Higher power therapeutic lasers for neuromusculoskeletal therapy are becoming more common as a primary therapy device rather than an adjunctive treatment. Although high power lasers have a significant advantage for penetration in deep musculoskeletal tissues and shorter treatment times, the potential risk for injury is greater with high power lasers because of the greater energy density per unit area as compared to low power class III lasers. Class IIIb lasers are those ranging from 5-500mw. Class IV lasers have power ratings over 500mw in continuous wave or energy density of 10 J/cm2 in pulsed modulation. (1) In musculoskeletal therapy, however, the class IV laser power ranges from 500mw to 12,000mw. Regardless of power, providers must pay attention to laser safety.
As with all therapeutic procedures, some element of risk is present through negligence or accident. For example, additional musculoskeletal injury or exacerbation may occur from premature or excessive application of therapeutic exercise. Burns from hot packs and galvanic stimulation are known to occur. Deep tissue burns and tissue cavitation are possible from ultrasound and diathermy. Frostbite occurs from cryotherapy and excessive spray and stretch technique. Infection hazards are often overlooked from bacterial and fungal cross-contamination occurring with poorly sanitized equipment. These hazards are easily prevented or reduced with safety protocols for each application. Laser therapy is extremely safe when basic protocols are followed by the laser operator and support staff.
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The primary reason for following laser safety measures is the potential for thermal injury to the retina with direct or reflected laser. The lens of the eye effectively magnifies laser beam thus, a relatively low wattage of laser has the potential of damaging the retina with brief exposure. A laser beam of sufficient power can produce retinal damage when the beam enters the lens and is magnified on the retina surface. With higher power lasers, permanent blindness can be the result.
The blink reflex protects the eye when a visible light flash occurs however when the light source is an invisible high watt infrared source, the protective blink reflex is not elicited. Here in lies the primary caution with most therapeutic diode lasers; the laser beam generated is within the invisible infra-red spectrum. Thermal injury to the superficial skin is also a hazard with higher wattage lasers such as the class IV infrared therapy lasers, however, thermal skin injury is more common with surgical-type lasers.
Thermal damage may occur when a high degree of beam collimation is used. Modifying a laser tip to reduce the size of the beam also increases the energy density of the beam. Significant photonic energy is present with a class IV laser and a small spot size. Thermal injury to the skin may occur if contact with cutaneous tissues carelessly exceeds normal treatment parameters. A fire hazard may also be present with class IV lasers due to the high heat and fluence of the beam. However, when obvious sources of potential ignition are removed from the laser treatment area such as open volatile chemicals, fire hazards are only possible from highly unusual equipment failure or extremely careless laser usage. Never direct a class IV laser at, or toward dark surfaces, paper or plastic; they may catch fire or be damaged from the high temperatures generated by the laser beam.
Every clinic using a laser should have an individual trained in the safe operation of laser therapy and a daily safety checklist should be observed. This individual (usually the doctor), is the Laser Safety Officer (LSO).
The laser safety officer is the individual designated in a laser facility who has the authority to monitor and enforce measures that prevent laser injury. The LSO in a laser therapy center is usually the physician or medical director who is responsible for controlling access to the laser and prevention of injury from laser exposure. The LSO restricts all non-authorized use of the laser and performs the routine safety assessments of the facility and equipment. [Table 1] The LSO inspects all goggles for cracks or deterioration and inspects the integrity of the laser device for defects that may lead to safety component failure (housing, locks, optical fiber and probe).
The laser safety officer also provides oversight of the laser operator when laser use is delegated to another health care professional, therapist or registered chiropractic assistant. The LSO also must post laser warning signs outside of the treatment area. The LSO is responsible for managing and documenting all laser-related injuries as well as documenting any laser repair history.
Lasers should be operated in a closed room or curtained area with controlled access. Extra goggles should be kept outside the room should entry be necessary by authorized personnel during laser treatment. Glass, windows or shiny jewelry may reflect the incident beam and coverings for windows may be necessary.
Many states require registration of class IIIb and class IV lasers. It&#;s suggested you contact the appropriate state regulatory department, (Department of Nuclear Safety Division of Electronic Products, IDNS). In Illinois, laser registration is required. The registration form is titled Laser Registration it is free to register and the form is found online for download at https://www2.illinois.gov/iema/NRS/RadSafety/documents/laser.pdf The form is easy to complete and should be mailed to the IDNS after the purchase of any class IIIb or class IV laser.
Table 1: Laser Safety Checklist
Laser safety checklist for the laser operator and Laser Safety Officer
&#; Appropriate warning signs posted
&#; Access to the laser and treatment area is secure and controlled
&#; Visually inspect and clean all optical connectors for dirt, debris, etc.
&#; Inspect laser for proper function
&#; Visually inspect and clean all safety goggles
&#; Goggles available for all persons in Nominal Hazard Zone
&#; Extra goggles placed outside the treatment room if necessary
&#; Sources of potential laser beam reflection and scatter controlled
&#; Treatment protocol established for the patient
&#; Laser injury management protocol in place for accidental injury
&#; Document laser treatment and post-treatment outcome
The three most important points in laser safety are maximum permissible exposure (MPE), nominal hazard zone (NHZ), and the optical density (OD) of protective eyewear. These values must be known by the laser safety officer and laser operator. Laser manufacturers usually provide this information in the specification page of the laser operation manual.
The MPE is the level of laser radiation to which a person may be exposed without hazardous effects or adverse biological changes in the eye or skin. This is a time-based calculation versus wattage level. There is a ¼-second, 10-second, 600-second, and 30,000-second limits for manufactured devices used in industrial settings. There are 28,800 seconds in an 8-hour day. This is rounded up to 30,000 seconds. The NHZ describes a space or distance in which the level of direct, reflected, or scattered radiation during normal operation of the laser exceeds the maximum permissible exposure. The area outside the NHZ is the distance from the laser source that does not exceed the MPE. Some high powered lasers may have a nominal hazard zone exceeding 20 to 30 meters. Specular reflections from class IV lasers are hazardous if they directly enter the eye. [Figure 1]
Figure 1 A) Specular and B) Diffuse reflections
Optical density (OD) is a logarithmic calculation for optical attenuation of laser provided by protective eyewear. The OD value for various lasers is computed based on the amount of attenuation needed and exposure time with the specific laser wavelength and wattage. Knowing the appropriate exposure time and distance from direct or scatter radiation, along with wattage and wavelength considerations, allow the laser safety officer to select the appropriate protective eyewear. Treatment applications with laser also determine the shape of the lens and the need for extra protection. For example, patients with smaller faces may require smaller goggles, or using the laser for sinus drainage application requires a tighter fitting goggle that seals tight against the eye socket. All personnel and patients in the nominal hazard zone must wear protective eyewear with the operation of class IIIb and IV lasers. (1)
Contraindications to laser therapy may be absolute, relative or anecdotal/ unproven. Precautions to use are also important to consider where patients may develop side effects from laser therapy because of specific disorders or conditions.
High power laser is harmful to eyes and protective eyewear is essential for the operator and all persons present in the room. In a study of all reported laser injuries (including all laser uses), there were 339 laser accidents between the years -. (2)With reference to surgical and industrial lasers, the vast majority of all eye injuries reported have resulted from failure to wear protective eyewear. A recent study of laser eye injury within facilities using lasers for the U.S. Department of Energy reported seven cases of eye injury since ; all of which resulted from lack of personal protective eyewear. (3)Although thermal damage is possible to the superficial skin when excessive laser wattage is used or from prolonged skin contact, the injury is self-limited. Biostimulative hazards are possible with laser exposure to the thyroid and various cancers. There are many theoretical biostimulative as well as over-stimulation hazards to tissues of the body from laser exposure that has not been scientifically confirmed or recognized.
Absolute contraindications to therapeutic laser are those exposures where known tissue damage may occur. [Table 2] Relative contraindications to laser use are based on specific patient status and conditions and should be decided on a case by case application. [Table 3] There are generalized precautions and unproven or anecdotal precautions. The absolute contraindications are as follows: Direct eye exposure is damaging to the retina and cornea. Permanent blindness may result. Laser should not be used directly over cancer or tumor.
The laser should not be used over the thyroid gland or over a gravid uterus. However, the use of laser away from the abdomen and uterus in the pregnant mother is safe. Relative contraindications include laser hypersensitivity and photosensitizing medications or skin creams, although there are many that react with the UV spectrum, very few react with infrared. Some autoimmune disorders and severe Lupus may cause a hypersensitivity to laser therapy.
Holding a laser over a tattoo will cause a rapid thermal effect, because of the absorption of laser on dark colors. Laser therapy in immuno-suppressed patients particularly AIDS may produce an adverse response. Patients with renal failure on dialysis may suffer side effects of nausea resulting from vasodilatation and the release of toxins into the bloodstream that cannot be eliminated. Patients with severe collagen vascular diseases should be treated in a small region for a test response, before initiating a whole body scanning technique. Laser therapy in encephalopathy; meningitis; or neuronopathy may have the potential for exacerbation when the organism or pathological process is unknown.
Treatment/precautions include hairline sensitivity; using laser through dark clothes because of thermal heating of dark fabrics; patients on anticoagulant therapy, because of the greater potential for bruising; iodine treated wounds, because of the potential for increased absorption of laser by Betadine&#;; steroid therapy, and dark skin (high power red laser only). [Table 4]
Unproven contraindications for laser therapy have anecdotal evidence or an assumption of harm because of inappropriate association with another known hazard associated with a different physical therapy device. Unless the anecdotal contraindication has been disproved, some level of caution or avoidance is nevertheless suggested when using laser therapy. Unproven contraindications include using laser over ununited fontenelles and epiphyseal growth plates because of the potential for asymmetric closure.
The contraindication associated with laser and systemic infections is the potential for biostimulative growth of the organism. According to Navratil et al. (4), some of the contraindications to laser therapy that have been misreported are as follows: fever and infectious diseases; certain blood diseases; heavy blood losses; neuropathies; and irradiation in the region of gonads. Laser use in multiple sclerosis, has an anecdotal/unproven contraindication because of the potential for exacerbation from heat and the biostimulative effect on the immune system.
The contraindication of laser with epileptics is an assumed risk because of the association of photic flicker producing seizures in photosensitive individuals. Although this is known to occur with 15-65 hz flicker and pattern-based visual stimulation in susceptible individuals, it has not been shown to occur with continuous wave or high frequency modulated laser. Patients with highly unstable epilepsy should not receive laser therapy because of the risk of seizure. It is doubtful that a photosensitive stimulation risk to mild epileptic patients using high-frequency modulation or continuous wave laser would cause a seizure. The use of a class IV laser directly over a pacemaker is contraindicated; however, the surrounding use of laser in patients with a pacemaker is appropriate and demonstrated to be without risk. The contraindication to laser therapy in patients with pacemakers only remains in the literature, because of an inappropriate assumption of risk similar to ultrasound and diathermy.[Table 5]
Mild adverse reactions with normal treatment protocols may occur.Rarely, some patients have reported increased pain; this may be more common in patients after steroid injection. Occasionally, patients may describe a bruised sensation in muscles the following day. Mild bruising also may occur from pressure of the laser wand into cutaneous tissues using the laser tip in conjunction with deep tissue myofascial techniques. Mild temporary dizziness may rarely occur, most likely from the peripheral vasodilatory effect and a possible drop in blood pressure.
Safe operation of higher power class IIIb and IV lasers is not difficult when the laser operator has basic training in laser safety. The laser operator and Laser Safety Officer should follow a laser safety check list each day before treating patients as a simple method to avoid equipment failure as a source of laser injury. Wavelength specific protective goggles are mandatory for all individuals in the nominal hazard zone or treatment room. An adequate history should be taken from the patient to determine if any contraindications to treatment are present. Following preset timed protocols for laser dosage will prevent some if not all of the potential adverse responses to treatment.
Jerome M. True, D.C., DABCN is a board-certified chiropractic neurologist practicing in Stuart, FL. He has extensive experience with laser therapy and neuromusculoskeletal disorders. Dr. True is the co-author of the textbook: Myelopathy, Radiculopathy and Peripheral Entrapment Syndromes, CRC Press: . He has recently completed a chapter titled: &#;Nerve Injuries in Competitive Sports&#;, for the second edition of Conservative Management of Sports Injuries, Jones and Bartlett: . He has also contributed to and/or illustrated many published articles on Chiropractic Neurology.
For the majority of people, laser hair removal has long been accepted as a safe and effective treatment in achieving long-term results. However, like all laser treatments, certain contraindications need to be considered for your own safety.
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Although there&#;s no evidence to suggest that laser hair removal isn&#;t safe for your unborn baby, it is generally not recommended. It&#;s advisable that you wait until after you&#;ve had your child before considering the procedure.
This can be frustrating, especially as women often find themselves becoming hairier during pregnancy. The good news is that this usually disappears after birth or once breastfeeding has finished. If it doesn&#;t, laser hair removal could be an option.
Laser hair removal should generally be avoided while breastfeeding. Your hormones will likely cause changes to hair growth, meaning the procedure might not be as effective as you would have liked.
Instead, wait until you have finished breastfeeding before starting laser hair removal. This will give your body chance to return to normal and ensure the effects are as good as they can be.
There are some health conditions that are widely considered to be contraindications to laser hair removal. Among them are:
If you suffer from any of these conditions, you may not be suitable for treatment. Your laser practitioner will advise the best course of action in a consultation
Many medications come with side-effects, including those that will make your skin more photosensitive. This means that your skin might react more negatively to change &#; such as laser hair removal.
If this is the case, you might want to think of ways to get around the issue. For example, taking a break from the problematic medication may be an option or switching to an alternative treatment. Having a discussion with your GP will help determine the right course of action for your needs.
The sun will cause your skin to create more melanin, which is there to protect your skin from damage. However, this can cause your skin colour to become patchy and uneven, which isn&#;t the best start for laser hair removal.
As a result, your consultant will have to change lasers depending on the condition of your skin at the time of your treatment. This can make it difficult to maintain uniform hair removal and may affect the quality of the results.
In the event of an active or severe sunburn, the procedure cannot go ahead. You&#;ll be expected to allow the skin to fully heal before returning for your treatment. You should always be given guidance on sun rules with a consultation.
People with dark skin shouldn&#;t be prevented from seeking laser hair removal treatment. However, if you also have a sun tan, it&#;s important that it fades before any work can get underway.
All the consultant will need to do is change the laser they are using for the procedure. They will know which is most suited to your skin type and, if you&#;re still unsure, a patch test can be carried out on a less obvious part of your body.
Keloid scarring occurs when wounds do not heal properly, and they can be especially hazardous to anyone seeking laser hair removal. The skin is usually raised, which can make it vulnerable during the procedure.
There are some cases where your consultant might still be able to perform laser hair removal. However, it&#;s essential that you are aware of the risks and fully informed before coming to a final decision.
Areas of the skin where there is a tattoo should be avoided during laser hair removal. This is to minimise skin irritation, as well as any potential aesthetic changes to your tattoo.
Laser hair removal can be especially painful in areas of the body where there are lesions or open wounds. It&#;s therefore a good idea to postpone the procedure until they&#;ve fully healed.
The beams can potentially slow down the healing process and lead to additional discomfort. Many consultants will refuse to carry out laser hair removal until the lesions have disappeared.
Laser hair removal is possible once the herpes virus is kept under control. However, bear in mind that you will be required to make sure that prescription medication has been taken, and that the condition is in remission before a consultation.
Herpes and cold sores are treated as contagious skin diseases, so don&#;t be surprised if you&#;re initially turned away. Once the problem has disappeared, you should be able to undergo the procedure.
If you have a mole, you can still undergo laser hair removal. The beams used aren&#;t on the UV spectrum, so there is so far no evidence to suggest they can change a mole and make it cancerous.
However, it is important to keep an eye on any visual alterations that may occur. If you do see anything suspicious, make sure you inform your GP of the treatment and have it checked as soon as possible.
Any laser hair removal treatment requires there to be a follicle to target. If you&#;ve recently plucked or waxed your body, there won&#;t be any. It&#;s usually recommended that you wait two weeks before attempting laser hair removal. Alternatives like shaving or depilatory creams are great to bridge that gap between hair and laser results!
Depilatory creams work by dissolving the hair in a chemical substance. This is achieved using keratinocytes, which will not only kill keratin in the hair, but also in the skin.
However this act&#;s as a great alternative to use in between laser treatments so that the hairs are still available for treatment. Your consultant will advise you individually.
Light induced epilepsy sufferers are usually advised against laser hair removal, unless they have a note authorising the procedure from their GP. If you do decide to go ahead, you should be provided with eye protection that blocks out the light to minimise the likelihood of a seizure.
Hirsutism is a genetic condition that sees women experiencing excessive hair growth. The hairs are generally thick and dark, making them easy to see.
Laser hair removal can be an effective way of getting rid of these unwanted hairs. It is worth bearing in mind that the procedure can take longer for hirsutism sufferers &#; potentially several months &#; and it is generally most effective on women with pale skin and dark hair.
If you have any questions about laser hair removal and the contraindications, don&#;t hesitate to get in touch by calling us on or filling in our contact form.
Contact us to discuss your requirements of Low Level Laser Therapy For Hyperviscosity. Our experienced sales team can help you identify the options that best suit your needs.