Laser therapy and wounds 1 - KEMP'S CLASS
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Running head: LASER THERAPY AND WOUND HEALING
Laser Therapy and Wound Healing
Sally Smith
Brock University
Laser therapy and wound healing 2
Laser Therapy and Wound Healing
Nurses regularly care for a variety of wounds to the skin, among them abrasions, burns, surgical incisions, and, perhaps most difficult to treat, ulcerations. Although the wounds may be different, the goal is always the same; to optimize wound care and promote healing.
Wound healing, the result of a complex tissue repairing process, is a continuing challenge in nursing. Despite some recent advances in understanding its basic principles, problems in wound healing continue to cause significant morbidity and mortality (Demir, Balay & Kirnap, 2004). In fact “venous ulcers are present in 0.2 to 0.4% of the population”(Gupta, Filonanko, Salansky & Sadder, 1998, p. 1383). More recent studies in wound healing have increased our knowledge and understanding of pressure ulcers as a significant clinical problem, however, they remain a frequent cause of death in patients. (Demir et al, 2004).
Wound healing can be the result of many diseases and conditions; most notably, diabetes. With diabetes, changes in the vascular system results in delayed wound healing, and approximately 15% of people with diabetes will develop foot ulcers, and 6% will require hospitalization. Even more impressive is that diabetes accounts for 50% of all non-traumatic amputations (Houreld & Abrahamse, 2005).
Low level laser therapy (LLLT) is a form of treatment that has had mixed results regarding wound healing. Studies have shown both positive and negative results in terms of wound healing. Lucas, Criens-Poublon, Cockrell & de Haan (2002, p.110) state that “this type of phototherapy should not be considered a valuable treatment”. Where as
LASER THERAPY AND WOUND HEALING 3
Demir et al, (2004, p. 147) stated that “laser treatment was found to be a significantly effective treatment”. The question is: is LLLT a valuable form of therapy for wound healing? This paper will attempt to summarize the positive effects of LLLT on wound healing, highlighting its benefits and worthy treatment effects.
The effects of low level laser therapy stems from the work of Hungarian surgeon Endre Mester. Mester started with experimental treatment of low level laser therapy in patients in the mid 1970’s and reported positive results of irradiation with LLLT in cell studies and animal experiments (Lucas, Criens-Poublon, Cockrell & de Haan, 2002, p. 111). Originally, Mester used blue-green lines of an argon laser, then switching to a helium-neon laser emitting red light. Mester wanted to find out if laser might cause cancer. He used mice, shaved the hair off their backs, divided them into two groups and gave a laser treatment with a low powered ruby laser to one group. They did not get cancer and to his surprise the hair on the treated group grew back more quickly than the untreated group. That was how "laser biostimulation" was discovered. Little was known about LLLT at the time, however, now we know that “low-level laser therapy (LLLT) is a form of phototherapy that involves the application of low power monochromatic and coherent light to injuries and lesions in order to stimulate wound healing” (Houreld et al, 2005, p. 182). “The exact mechanism of action of LLLT is not completely understood, however, it is known that during laser therapy, cells absorb photonic energy that is incorporated into chromosomes, which in turn, stimulates cellular metabolism. The chromosome is then able to transfer the absorbed energy to other molecules and thus cause chemical reactions in surrounding tissues” (Houreld et al, 2005, p. 182).
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Laser therapy has come a long way since the time of Mester and at present, lasers are used in a variety of medical and surgical settings, such as, dentistry, chiropractice, osteopathy, physiotherapy, cosmetic, pain therapy, wound healing, and acupuncture (Walsh, 1997).
Many people today are looking for time saving, quick and effective treatments. Alternative therapies are in high demand and with its low cost and ease of use, low level laser therapy as a treatment is a choice that appeals to many people. It is a simple and non-invasive treatment that offers pain relief and has no reported side effects. Therefore, it could be used as a complementary therapy in the treatment of wound healing (Houreld et al, 2005).
Several studies and clinical trials have show that LLLT does have a positive and healing effect on wounds. In one such study Khurshudian treated 174 people who had diabetes with suppurative diseases. Patients were exposed to a helium--cadmium laser beam of wavelength 441.6nm. A single exposure led to a rapid decrease in the inflammatory reaction, and there was a cleansing and acceleration of regeneration processes in the infected wounds (Khurshudian, 1989). This was supported by work conducted by Kuliev and Babaev (1991). They studied the immune status after laser irradiation in 152 people with diabetes with purulent soft tissue injuries. There was a rapid stabilisation of the immune system, thus reducing the duration of treatment. Potinen (1992) determined the stabilisation of the immune system by the observation of the increased release of various cytokines upon low level laser therapy. He also observed an increase in the leucocyte population and an arrest in bacterial growth.
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Low-level laser irradiation induces wound healing in conditions of reduced microcirculation. Schindl, Heinze, Schindl, Pernerstorfer & Schindl (2002) investigated the effect of LLLT in patients with diabetic microangiopathy by infrared thermography on skin blood circulation. In the first study, 30 people with diabetic ulcers or gangrene received either a single low-intensity laser irradiation, or a sham irradiation over both forefoot regions. At 20 minutes of laser irradiation, there was a significant rise in skin temperature in the forefoot area. This shows that LLLT causes a significant increase in skin circulation in both feet and points to the possibility of systemic effects. However, the issue of significant thermal change is contovesial. It is concluded in some texts that low level laser energy does not produce significant tissue temperatre changes (Demir et al, 2004). Consequently, more research is needed in this area.
Schindl et al (2002) conducted another study on a pateint with diabetes with sensory neuropathy, macroangiopathy and microangiopathy. The patient was exposedto low level laser therapy as well as conventional treatments such as using dressings and antibiotics. There was complete healing of the ulcer with no recurrence after 9 months, despite the patient's unstable metabolic condition. Despite the fact that LLLT was not applied alone, LLLT may be a useful alternative treatment modality for the induction of wound healing of ulcers in people with diabetes which is free of side effects.
From the previous information, it is obvious that the benefits of low level laser therapy are numerous. Houreld et al (2005, p. 182) concluded that, not only does LLLT encourage wound healing but, “LLLT has been shown to increase the speed, quality and tensile strength of tissue repair, resolve inflammation and provide pain relief”. Demir et
LASER THERPY AND WOUND HEALING 6
al (2004, p. 150) noted that “laser therapy had a positive effect on the proliferation phase, increasing the fibroblast number and hydroxyproline level, and stimulating the synthesis and organization of collagen” as well as the fact that laser treatment was reported to have an antibacterial effect, by inhibiting proliferation of bacteria in cultures and stimulating the phagocytic activity of leukocyes” (Demir et al, 2004).
Added beneficial effects include things such as “wound epithelialisation, reduction of oedema and inflammation, and re-establishment of arterial, venous and lymph microcirculation. Increased rates of ATP, RNA and DNA synthesis are also observed” (Houreld et al, 2005, p. 184).
Major changes seen in wounds treated with LLLT include: “increased granulation tissue, early epithelialisation, increased fibroblast proliferation, increased extracellular matrix synthesis and enhanced neovascularisation, all of which lead to better tissue oxygenation and nutrition, and in turn, enhanced wound healing” (Houreld et al, 2005, p. 184). Walsh (1997) agrees with these positive findings, stating that it has been shown that low level irradiation of fibroblasts stimulates the production of basic fibroblast growth factor and stimulates the transformation of fibroblasts into myofibroblasts. Table 1 summarizes beneficial effects of LLLT.
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[pic]
Table 1. Summary of events during wound healing and the effects of low level laser therapy adapted from Pearl & Kanat, (1988). Houreld et al (2005).
Not only does LLLT encourage changes at a cellular level but also in whole body systems as Ribeiro, Silva, Maldonado, de Rossi, & Zezell, D (2002) found. They stated that LLLT has been shown not only to affect immune cells, but also act directly and selectively on the immune system. Stimulation of the immune system means that infected wounds can be cleared more easily. The use of low level lasers in wound healing has
been shown to speed up the healing of leg ulcers and burn wounds, it has also been shown to improve skin healing capabilities. () sums up the effects of LLLT quite nicely by stating that the effects of LLLT on the three overlapping phases of wound healing (inflammation, proliferation, and remodeling) are such that acute injuries heal more rapidly and that healing can be induced in chronic lesions such as venous
LASER THERPY AND WOUND HEALING 8
ulcers/pressure sores and diabetic ulcers. The duration of acute inflammation can be reduced by LLLT, the proliferation phase of repair, during which granulation tissue is
formed, beginning earlier and the rate of wound contraction can be altered and angiogenesis increased.
The implications for nursing in regards to LLLT are numerous. The first and most obvious would be faster healing time. Faster healing time means less time either in hospital or with home care. With faster healing time comes a decrease in pain and pain
medication. Not only will the quick healing time cause less pain, but, the LLLT procedure itself is quick and painless. Patients would not have to rely on pain medication for the horrible pain endured during most wound care procedures. Nurses should also be aware that quicker treatment and faster healing would be beneficial to the federal government. With health care spending always in the public eye, LLLT could potentially save money.
If nurses are aware of LLLT as a form of alternative therapy, they can then be advocates for their patients when conventional treatments are failing. A few things that nurses should be aware of when advocating for their patients are cost and availability. The cost of LLLT can be substantial if you do not have employment benefits and at the
moment there are not a large number of locations where LLLT is performed. Advocacy of this treatment would have to be patient specific.
Phototherapy in medicine is of great curiosity to many. There is a growing interest in the use of lasers for the treatment of various conditions and disorders, including the treatment of wounds. Using lasers as a source of photobiostimulation looks to be an
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attractive branch of medicine for the future (Houreld et al, 2005). Future research needs to be conducted regarding LLLT and wound healing to be able to conclude, for certain,
that it is an effective and valuable treatment option. As nurses know, the treatment of wounds can be difficult at best. Low level laser therapy can be an excellent addition to conventional treatment modalities in a nurses wound care repertoire.
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