1

Photobiomodulation Therapy (PBMT):

Laser Therapy for Pain Management –

A New Paradigm

Dr. Roberta Chow

Quantum Pain Management – Sydney, Australia

August 9, 2017

2

Roberta Chow, Disclosures

• I have no disclosures to report.

The contents of this activity may include discussion of off label or investigative drug uses.

The faculty is aware that is their responsibility to disclose this information.

3

Planning Committee, Disclosures

AAAP aims to provide educational information that is balanced, independent, objective and free of bias

and based on evidence. In order to resolve any identified Conflicts of Interest, disclosure information

from all planners, faculty and anyone in the position to control content is provided during the planning

process to ensure resolution of any identified conflicts. This disclosure information is listed below:

The following developers and planning committee members have reported that they have no

commercial relationships relevant to the content of this webinar to disclose: AAAP CME/CPD

Committee Members Dean Krahn, MD, Kevin Sevarino, MD, PhD, Tim Fong, MD, Tom Kosten,

MD, Joji Suzuki, MD; and AAAP Staff Kathryn Cates-Wessel, Miriam Giles, Carol Johnson, and

Justina Pereira.

All faculty have been advised that any recommendations involving clinical medicine must be based on evidence that is

accepted within the profession of medicine as adequate justification for their indications and contraindications in the care

of patients. All scientific research referred to, reported, or used in the presentation must conform to the generally

accepted standards of experimental design, data collection, and analysis. The content of this CME activity has been

reviewed and the committee determined the presentation is balanced, independent, and free of any commercial bias.

Speakers must inform the learners if their presentation will include discussion of unlabeled/investigational use of

commercial products.

4

Target Audience

• The overarching goal of PCSS-O is to offer evidence-based

trainings on the safe and effective prescribing of opioid medications

in the treatment of pain and/or opioid addiction.

• Our focus is to reach providers and/or providers-in-training from

diverse healthcare professions including physicians, nurses,

dentists, physician assistants, pharmacists, and program

administrators.

5

Educational Objectives

• At the conclusion of this activity participants should be able to:

Describe the most important characteristics of light as

medicine

Summarize the effect of light in the somatosensory nervous

system most relevant to pain relief

Describe the broad range of tissue effects initiated by light

which modulate pain

Evaluate the experimental and clinical evidence base for

application in clinical practice

Identify patients most likely to respond to PBMT

6

Photobiomodulation Therapy

(PBMT) – MESH definition NLM

“A form of light therapy that utilizes non-ionizing forms of light sources, including LASERS, LEDS and BROAD-BAND LIGHT in the visible and infrared spectrum.

It is a non-thermal process involving endogenous chromophores eliciting photophysical (i.e. linear and non-linear) and photochemical events at various biological scales.

This process results in beneficial therapeutic outcomes including but not limited to the alleviation of pain or inflammation, immunomodulation and promotion of wound healing and tissue regeneration.”

7

• Low level laser therapy

• Low reactive-level laser therapy

• Low intensity laser therapy

• Low level light therapy

• Low energy laser irradiation

• Low power laser

Synonyms

It is called “LOW” because of the comparison with surgical

“HIGH” power lasers, but it does not really describe the true

nature of the lasers.

• Photobiostimulation

• Biomodulation

• Biostimulation

• Cold laser

• Soft laser

• Laser therapy

8

Case Study

• Major SO 39 year Female Afghan Veteran

Nurse 17 years in military (special ops)

Severe widespread pain 24/7 for 1 yr

− Hypermobile

− Knee pain +++ (bilat tib osteotomy),

− L5/S1 back injury

− Thoracic pain - myofascial

− Rt ulnar nerve neuropathy

− etc.

PTSD (2009)

9

Treatment at presentation (09/2016)

Non-drug therapies

• Exercise physiology

(exercises made knee pain worse)

• Chiropractic – helped with mobility

• Pain psychologist

• Pain specialist

• Pain physiotherapist

• Psychiatrist

…..in hospital at the time she came to me (unable to cope at home)

• Buprenorphine sublingual tabs

• Morphine sulphate Pregabalin

150mg bd

• Venlafaxine 225mg daily

• Quetiapine 75mg at night

• Ketamine infusions

• Naprosyn 500mg daily (PRN)

• Celecoxib 200mg daily

• Diazepam 5-10mg prn

Despite all these therapies she

was not getting any better

Drug Therapies

10

PBMT

Where do we start with a patient like this?

• Establish a “hierachy” of the pain problems …. ….what is the most troublesome area?

• Look for nociceptive pain generators in the areas of pain – such as painful entheses or trigger points

• Is there a neuropathic component?

• Explain the “hardware” vs software nature of pain..

diagnostic imaging findings do not necessarily reflect clinical “pain” experiences

PBMT treats “software” – nerves, muscles, tendons etc. which cannot easily be imaged – “reprogramming software”

• Importantly – she wanted to get better

11

Light Based Therapies

• Greeks and Egyptians worshipped light

• Neils Finsen - Nobel Prize 1903

• Blue light for neonatal jaundice

• Red light for blindness of prematurity

• Light for depression (SAD)

• Vitamin D is synthesized in the skin by

UV light

• UV for psoriasis

Synthesis of Vit D in skin

Nobel Prize

Medicine 1903

12

Clinical Application of

Photobiomodulation Therapy

13

Principles of Treatment

• Apply the laser/light to tender areas in the region

of clinical interest

• Treat the lymphatics pertaining to the area

• Treat associated tender points in the associated

dermatomes and/or myotomes

• Treat the spine overlying the nerve roots

• +/- treat the tibia or sternum for stem cell

stimulation

• +/- treat “brain”

14

A Photon is:

• a discrete bundle (or quantum) of electro- magnetic (or light)

energy.

• always in motion at the constant speed of light

• can have particle-like interactions (i.e. collisions) with electrons

and other particles

• both a wave and a particle all the time

Q: What is the “medicine”? – A: photons

15

Light

Amplification by

Stimulated

Emission of

Radiation

Einstein

1916

16

Laser Characteristics

• Monochromatic i.e. single wavelength

• Coherence

the basis of speckle formation)

• Lack of divergence (original lasers)

diode lasers do have divergent beams

Laser Therapy - Tunér and Hode 2002

17

Laser Parameters

• Wavelength (nm) from 400 to 1064 nm

(red 650, 670 nm and infrared 810,

904 nm most commonly used)

• Power (W or mW) 1 mW to 500 mW

• Mode (pulsed or continuous)

• Time applied (seconds to minutes)

• Site applied (anatomical location)

• Area (localised or scanning)

From these we can calculate the dose of light delivered

– in Joules

18

The First Law of Photochemistry

states that

“for light to exert an effect it

must be absorbed”

…and something must absorb it

Primary effects of light in cells

Smith KC. The Photobiological Basis of Low Level Laser

Radiation Therapy. Laser Therapy. 1991; 3(1): 19-24.

19

How does it work?

Cytochrome C oxidase*

Porphyrins and Flavins

Adenine Nucleotides (NADH)

After absorption electromagnetic energy is transduced to electrophysical

and/or electrochemical energy. Not heat!!

Chromophores are molecules which are “light absorbers” in membranes

and the respiratory chain, which absorb photons

20

Cytochrome C oxidase in Mitochondrial

Membrane

• ATP synthesis/inhibition

• Induction of NF-κB

• Gene transcription

• Expression of growth factors

• bFGF, VEGF, TGF

• Increased inducible nitric oxide synthase

• Production of reactive oxygen species

21

• Reduces action potentials in nerves

• Reduces inflammation

• Reduces muscle spasm

• Reduces swelling/oedema

• Stimulates tissue repair/wound healing

• Modulates CNS neurotransmitter production

• Initiates systemic effects (abscopal effect)

Secondary cellular effects of light

absorption

22

Laser effects in the somato-

sensory nervous system

HUMAN STUDIES

18 human studies

Established the principle that transcutaneous laser can inhibit action potentials(block nerve conduction) in underlying nerves

ANIMAL STUDIES 25 animal studies Established the principle that laser selectively suppresses nociceptor (A and C fibre) action potentials Has specific anti- inflammatory activities

Chow R, Armati P, Laakso EL, Bjordal JM, Baxter GD. Inhibitory

effects of laser irradiation on peripheral mammalian nerves and

relevance to analgesic effects: a systematic review. Photomed

Laser Surg. 2011; 29 (6): 365-81.

23

Studies showing inhibition of neural stimuli

following noxious stimuli

Tsuchiya D, Kawatani M,

Takeshige C. Laser irradiation

abates neuronal responses to

nociceptive stimulation of rat-paw

skin. Brain Res Bull. 1994; 34(4):

369-74.

………………………..

Kasai S, Kono T, Sakamoto T, Mito M. Effects of low-power laser irradiation on multiple unit discharges induced by noxious stimuli in the anesthetized rabbit. J Clin Laser Med Surg. 1994; 12(4): 221-4.

24

Neural blockade by direct application of light to

nerve following pro-inflammatory stimulus

Sato T, Kawatani M, Takeshige C, Matsumoto I . Ga-Al-As laser irradiation inhibits neuronal activity associated with inflammation.

Acupunct Electrother Res 1994 Jun-Sep 19(2-3) 141-51

25

Microtuble Polymerisation and Transport

Function

Images of microtubule arrays

(Alberts - Molecular Biology of

the Cell 4th edition)

Microtubule Associated Proteins

(MAPS) are ATPases

26

Transport within the nerve is temporarily

disrupted by disruption of the cytoskeleton

Chow R, David M, Armati P. 830-nm laser irradiation induces varicosity

formation, reduces mitochondrial membrane potential and blocks fast

axonal flow in small and medium diameter rat dorsal root ganglion

neurons: implications for the analgesic effects of 830-nm laser’. J

Peripher Nerv Syst. 2007; 12(1): 28-39.

27

Laser Causes Neural Blockade

• Depletes decreases mitochondrial membrane potential

• Decreases ATP

• Disrupts polymerisation of microtubules

• Disrupts function of ATPases e.g. Na+K+ATPase

• Disrupts fast axonal flow - organelles and mitochondria

• Affects small diameter, A and C fibre, nociceptors.

• Occurs within 5-10 mins in vitro and 10-20 mins in vivo

• Is reversible

• Represents neural blockade

• Blocks transmission of noxious impulses

A C fibre (nociceptors) lie

superficially in skin

(Peripheral Neuropathy Vol 1 2005 Eds

Dyck & Thomas)

28

Cascade of Neural Blockade

Laser blocks

conduction in

nociceptors

Reduces pain

Reduces nerve

excitability

Suppresses

peripheral

sensitisation

Reduces local

axon reflex

Suppresses neurogenic

inflammation

Reduces afferent

input to the

dorsal horn

Down regulates input to second order neurons

Reduces

oedema

Reduces progression

from acute to chronic

pain

Reduces anxiety

Improves mobility

Neuroplasticity

Reduces drug

intake

29

Anti-inflammatory Effects

Pathways for acute pain relief

by red or infrared LI

Local LLLT effects after first irradiation,

enhanced effect by repeated irradiation

Effects on biochemical inflammatory markers

Reduced PGE2

levels (5)

Reduced TNF

α levels (2)

Reduced IL1β

levels (3)

Reduced COX-2

mRNA levels (2)

Reduced plasminogen

activator levels (1)

Number of controlled laboratory trials verifying results

Effects on cells and soft tissue

Reduced

oedema

formation (7)

Reduced

hemorrhagic

formation (5)

Reduced

neutrophil cell influx

(4)

Enhanced local

microcirculation (4)

Anti-inflammatory

effects found in

21/24 laboratory

studies

Bjordal et al. 2006,

Photomed Laser Surg

30

Anti-inflammatory effects demonstrated in

human Achilles microdialysis study

31

Anti-inflammatory effects demonstrated in

human Achilles microdialysis study

In this study subjects with Achilles Tendinopathy were asked to jump

on the affected leg, activating the tendinitis. Microdialysis was

performed before and after the activation with and without laser

therapy.

Results: PGE2 levels were reduced in the laser group versus the

control group

Conclusion: This study demonstrated a direct inhibitory effect of

laser on local tissues to decrease response to pro-inflammatory

stimuli.

32

Laser therapy in rat paw edema

-0,2

0

0,2

0,4

0,6

0,8

1

1,2

1,4

0 1 2 3 4

Timer

mil

lili

te

r Kontroll (Carrageenan)

Laser 7.5 J/cm2

NSAID (diclofenac)

The anti-inflammatory effects of laser and anti-inflammatory drugs in animal studies are very similar

Aimbire F, Lopes-Martins R, Albertini R, Pacheco

M, Castro-Faria-Neto H, Martins P, et al. Effect of

low-level laser therapy on haemorrhagic lesions

induced by immune complex in rat lungs.

Photomedicine and Laser Surgery. 2007; 25(2):

112-7. Laser (650nm) dose 7.5 Joules

Anti-inflammatory Effects

Albertini R, Aimbire F, Correa FI, Ribeirob W, Cogob JC,

Antunesc E, et al. Effects of different protocol doses of

low power gallium–aluminum–arsenate (Ga–Al–As) laser

radiation (650 nm) on carrageenan induced rat paw

oedema. Journal of Photochemistry and Photobiology B:

Biology 2004; 27(2-3): 101-7.

33 Marcos et al 2011 LLLT in collagenase-induced Achilles Tendinitis in rats:

Analysis of biochemical and biomechanical aspects.

J Orth Res Dec 2012 1945-1951

mRNA gene expression of COX-2 vs reduction

in PGE2

Figure 3. PGE2 derived from COX-2 2 h after tendinitis

induction. The values are represented by mean, error

bars are SDs.

**p < 0.01 versus control, #p < 0.05

and ##p < 0.01 versus collagenase group.

Figure 2. mRNA gene expression of COX-2.

The samples were collected 2 h after the

collagenase-induced tendinitis. *p < 0.05 and

**p < 0.01 versus control;

##p < 0.01 versus collagenase group.

34

Muscle Effects

Laser (at the right dose) has direct effects

on muscle to cause relaxation and change in

algometry pressure

within 10 to 15 minutes

Airaksinen O, Rantanen P, Pertti K, Pontinen P. Effects of the infrared

laser therapy at treated and non-treated trigger points. Acupuncture &

Electro-therapeutics Research International Journal. 1989; 14: 9-14.

35

Effects of 635 NM LLLT On Exercise Induced

Skeletal Muscle Fatigue

Photomed & Laser Surgery Vol 26, 5, 2008 p 419-424

36

Effect of 830 NM LLLT On Muscle Recovery

Applied Pre-Exercise

Lasers Med Sci (2009) 24: 857-863

Leal Junior et al

37

Tissue Repair

• Burns

• Pressure sores

• Traumatic wounds

• Post-op wounds

• Leg ulcers

• Any conditions in which

there is swelling,

inflammation and pain.

38

Examples of Effects of Phototherapy on

Immune Cells

Changes have been reported in:

• Neutrophils

• Monocytes

• Macrophages

• Lymphocytes

• Mast cells

• e.g.

• LLLT (830 nm, continuous, 150 mW/cm2) decreases reactive oxygen species (ROS) production by human neutrophils, modulating inflammation. Effect greater in smokers, who heal slowly and produce more ROS, than in non-smokers.

Fujikami Y et al J Clin Laser Med Surg 21(4):165-170 2003.

39

Macrophages

LLLT

• (a) increases soluble protein mediators production by macrophages directly which

• (b) increases fibroblast proliferation indirectly

Effective Ineffective

660, 820, 870 nm 880 nm

Young SR, Bolton P & Dyson M (1989) Lasers Surg Med 9:497-505

40

Lymphatic System Effects

41

0.88 J/cm2 628-nm

HS27 human fibroblasts

74 genes up > 2-fold

37 genes down > 0.5 fold

J Invest Dermatol. 2003 May;120(5):849-57. Zhang Y, Song S, Fong CC,

Tsang CH, Yang Z, Yang M.

42

Laser and mechanotransduction in collagen...

.....Laser makes tendons stronger

Neves et al 2011 Different

power settings of LLLT on the

repair of the calcaneal tendon.

Photomed Laser Surg 29 (10)

663-668

43

What painful conditions can be treated?

• OA

• RA

• Myofascial pain

• Tendnopathies

• Back pain

• Neck pain

• Sciatica

• Pudendal Neuralgia

• Shingles

• Post-herpetic

neuralgia

• TMD

• Migraines and

cervicogenic

headache

• wound healing

44

WALT Guidelines

45

So how did we treat Major SO?

• PBMT

Start treatment twice a week

Selected the primary area to treat at each visit – up to two areas

20-30 mins treatment (nurse or physio* or doctor)

Aim is to reduce pain, relieve muscle spasm, treat trigger points, improve inflammation, reduce swelling and stimulate tissue repair

Total Rx time – 30 mins

TLC = a

large

cluster

LED probe

– red and

infrared

904nm

super

pulsed

laser

Large

scanning

laser to left

knee

Prone – 15 mins

Supine – 5 mins

46

Further Treatment

• Stopped exercise physiology

• Continued physiotherapy Rx 1/week– mobilisation, strapping, exercise, manipulative techniques – 1 physio

• Continued 1x/week Rx PBMT

• Was able to leave hospital after 1 month and live at home (with two flights of stairs)

• Meds: by Jan 2017

• Ceased oral morphine

• Reduced Buphrenorphine 0.2mg – 0.2mg – 0.2mg

• Ceased celecoxib took PRN naproxen

• Reduced pregabalin to 75 mg bid

• No diazepam

47

Further Developments

• Experienced exacerbations at times when under

stress – had to increase medication at times

• Had several trigger point injections to glut medius

at times

• March 2017 – medically discharged from the army

• Continued treatment –

• Started photography as a business

• June 2017 went to Paris for 3 months (arranged

physio and laser therapy while away)

48

Summary of Effects

• In complex and chronic patients laser therapy laser therapy can be used as an adjunctive treatment to:

• Reduce pain - Neural blockade leading to reduction in central sensitisation; Anti-inflammatory effects especially at sites of enthesitis and in joints (knees); Reduce trigger point activity to facilitate more effective exercise; Improve lymphatic flow to promote healing and reduce interstitial oedema associated with chronic inflammation; Stimulate tissue repair to improve tissue healing at injured sites and strengthen ligaments and tendons with gradual reduction in medication.

These changes take time – months (to years)

49

Rewiring a brain with light

Chapter 4

Rewiring a Brain with Light Using Light to Reawaken Dormant Neural Circuits

It is the unqualified result of all my experience with the sick

that second only to their need of fresh air is their need of

light; that, after a close room, what hurts them most is a

dark room, and it is not only light but direct sun-light that

they want.....People think the the effect is upon the spirits

only. This is by no means the case. The sun is not only a

painter but a sculptor.

Florence Nightingale, Notes on Nursing, 1860

50

Transcranial Low Level Laser (Light) Therapy for

Traumatic Brain Injury

51

Laser Therapy for Neck Pain

52

Over 300 (RCT) clinical trials

Over 3000 laboratory studies

Over 30 new research papers a month

53

National Health and Medical Research Council

(Australia)

Science to

Art Prize

2013

Effects of

laser on

nerves

Thank you

54

References

1. Smith KC. The Photobiological Basis of Low Level Laser Radiation Therapy. Laser Therapy. 1991;

3(1): 19-24.

2. Chow R, Armati P, Laakso EL, Bjordal JM, Baxter GD. Inhibitory effects of laser irradiation on

peripheral mammalian nerves and relevance to analgesic effects: a systematic review. Photomed

Laser Surg. 2011; 29(6): 365-81.

3. Tsuchiya D, Kawatani M, Takeshige C. Laser irradiation abates neuronal responses to nociceptive

stimulation of rat-paw skin. Brain Res Bull. 1994; 34(4): 369-74.

4. Kasai S, Kono T, Sakamoto T, Mito M. Effects of low-power laser irradiation on multiple unit

discharges induced by noxious stimuli in the anesthetized rabbit. J Clin Laser Med Surg. 1994; 12(4):

221-4.

5. Chow RT, Johnson MI, Lopes-Martins RA, Bjordal JM. Efficacy of low-level laser therapy in the

management of neck pain: a systematic review and meta-analysis of randomised placebo or active-

treatment controlled trials. Lancet. 2009; 374(9705): 1897-908.

6. Sato T, Kawatani M, Takeshige C, Matsumoto I. Ga-Al-As laser irradiation inhibits neuronal activity

associated with inflammation. Acupunct Electrother Res. 1994; 19(2-3): 141-51.

7. Wakabayashi H, Hamba M, Matsumoto K, Tachibana H. Effect of irradiation by semiconductor laser

on responses evoked in trigeminal caudal neurons by tooth pulp stimulation. Laser Surg Med. 1993;

13(6): 605-10.

55

References (continued)

8. Bjordal JM, Lopes-Martins RAB, Iversen VV. A randomised, placebo controlled trial of low-level

laser therapy for activated Achilles tendinitis with microdialysis measurement of peritendinous

prostaglandin E2 concentrations. Brit J Sport Med. 2006; 40: 76-80.

9. Marcos RL, Leal-Junior EC, Arnold G, Magnenet V, Rahouadj R, Wang X, et al. Low-level laser

therapy in collagenase-induced Achilles tendinitis in rats: analyses of biochemical and

biomechanical aspects. Journal of orthopaedic research : official publication of the Orthopaedic

Research Society. 2012; 30(12): 1945-51.

10. Leal Junior EC, Lopes-Martins RA, Baroni BM, De Marchi T, Taufer D, Manfro DS, et al. Effect of

830 nm low-level laser therapy applied before high-intensity exercises on skeletal muscle

recovery in athletes. Lasers Med Sci. 2009; 24(6): 857-63.

11. Baxter GC, Walsh DM, Allen JM, Lowe AS, Bell AJ. Effects of low intensity infrared laser

irradiation upon conduction in the human median nerve in vivo. Exp Physiol. 1994; 79: 227-34.

12. Chow R, David M, Armati P. 830-nm laser irradiation induces varicosity formation, reduces

mitochondrial membrane potential and blocks fast axonal flow in small and medium diameter rat

dorsal root ganglion neurons: implications for the analgesic effects of 830-nm laser’. J Peripher

Nerv Syst. 2007; 12(1): 28-39.

13. Kennedy W, Wendelschafter-Crabb G, Polydefikis M, McArthur J. Ch 34 Pathology and

quantitation of cutaneous innervation. In: Dyck P, Thomas P, editors. Peripheral Neuropathy. 4 ed.

Philadelphia: W.B Saunders; 2005. p. 873.

56

References (continued)

14. Albertini R, Aimbire F, Correa FI, Ribeirob W, Cogob JC, Antunesc E, et al. Effects of

different protocol doses of low power gallium–aluminum–arsenate (Ga–Al–As) laser radiation

(650 nm) on carrageenan induced rat paw oedema. Journal of Photochemistry and

Photobiology B: Biology 2004; 27(2-3): 101-7.

15. Aimbire F, Lopes-Martins R, Albertini R, Pacheco M, Castro-Faria-Neto H, Martins P, et al.

Effect of low-level laser therapy on haemorrhagic lesions induced by immune complex in rat

lungs. Photomedicine and Laser Surgery. 2007; 25(2): 112-7.

16. Marcos RL, Leal Junior EC, Messias Fde M, de Carvalho MH, Pallotta RC, Frigo L, et al.

Infrared (810 nm) low-level laser therapy in rat achilles tendinitis: a consistent alternative to

drugs. Photochem Photobiol. 2011; 87(6): 1447-52.

17. Airaksinen O, Rantanen P, Pertti K, Pontinen P. Effects of the infrared laser therapy at

treated and non-treated trigger points. Acupuncture & Electro-therapeutics Research

International Journal. 1989; 14: 9-14.

18. Leal Junior EC, Lopes-Martins RA, Dalan F, Ferrari M, Sbabo FM, Generosi RA, et al. Effect

of 655-nm low-level laser therapy on exercise-induced skeletal muscle fatigue in humans.

Photomed Laser Surg. 2008; 26(5): 419-24.

19. Leal Junior EC, Lopes-Martins RA, Vanin AA, Baroni BM, Grosselli D, De Marchi T, et al.

Effect of 830 nm low-level laser therapy in exercise-induced skeletal muscle fatigue in

humans. Lasers Med Sci. 2009; 24(3): 425-31.

57

References (continued)

20. Fujimaki Y, Shimoyama T, Liu Q, Umeda T, Nakaji S, Sugawara K. Low-level laser irradiation

attenuates production of reactive oxygen species by human neutrophils. J Clin Laser Med Surg.

2003; 21(3): 165-70.

21. Young S, Bolton P, Dyson M, Harvey W, Diamantopoulos C. Macrophage Responsiveness to Light

Therapy. Lasers in Surgery & Medicine. 1989; 9: 497-505.

22. Zhang Y, Song S, Fong CC, Tsang CH, Yang Z, Yang M. cDNA microarray analysis of gene

expression profiles in human fibroblast cells irradiated with red light. The Journal of investigative

dermatology. 2003; 120(5): 849-57.

23. World Association of Laser Therapy (WALT). Laser dosage table for musculoskeletal disorders

using 904 nm laser. 2010.

24. Johnstone DM, Coleman K, Moro C, Torres N, Eells J, Baker GE, et al. The potential of light

therapy in Parkinson's Disease. ChronoPhysiology and Therapy. 2014; 4: 1-14.

25. Huang YY, Gupta A, Vecchio D, de Arce VJ, Huang SF, Xuan W, et al. Transcranial low level laser

(light) therapy for traumatic brain injury. Journal of biophotonics. 2012; 5(11-12): 827-37.

58

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