Lasers in Medicine

Introduction to New
High Power High Dose
Class IV Laser Therapy
Bruce R. Coren, DVM, MS
Class IV Laser Therapy
High Dose – High Power Laser Therapy
• HPLT was first introduced to the medical field in
2002 by then CEO of Avicenna Laser Technology,
Inc, Bruce R. Coren, DVM, MS.
• The company invented and developed the
first High Power Therapeutic Laser to receive
FDA clearance in 2003.
• TMA – Technological Medical
Advancements is a spin off from
Avicenna and was founded not only to
advance the field of Laser Medicine
but also to bring other innovative
medical devices to the market place.
• TMA offers the most powerful laser
platforms in the world and thus
allowing physician's of all medical
disciplines the capability to heal
injuries previously refractive to
traditional medical care.
Design of the TMA Laser
• The TMA laser was
designed from the
ground up to be a
therapeutic medical
• It was developed using research
by our own biomedical
engineers and clinicians as
well as collaboration with a major
medical school and university
optics department.
• We investigated important
criteria such as wavelength,
power and power
density, optics and beam
delivery in order to afford the
greatest penetration and
delivery of a therapeutic dose
capable of stimulating tissue
healing in deep seated
LASER— an acronym for:
Amplification by
Emission of
It could well stand
for – Latest
Advance For
Surgeon to
Surgical Lasers in Medicine
Are used to cut,
coagulate, and
tissues. This type
of laser replaces
the scalpel
• The TMA Laser is the only
laser available on the market
that was designed to accomplish
both surgical and therapeutic
Lasers in Medicine
• Therapeutic Lasers are used for the
stimulation of cell function.
• The biological effect is photochemical not
thermal, as is the case with surgical lasers.
Comparison of “Class IV”
Surgical and Therapeutic Lasers
• Surgical lasers collimate high
amounts of laser energy into a
beam of high intensity
resulting in tissue destruction
• High Power Therapeutic Lasers
take a high amount of laser
energy but instead of beam
collimation you get beam
divergence resulting in tissue
Who is using Diowave
• Veterinarians
- Equine and Small Animal
• Human
- Physical Medicine and Rehab
- Pain Management
- Orthopedists, Neurologists,
- Family Practice
• Chiropractors and Physical Therapists
• Podiatrists, Naturopaths and DOM’s
• College Sports Teams
• Medical and Veterinary Colleges
• United States Military
• VA Hospitals
Biological Effects of
Therapeutic Lasers
• Laser therapy aims to bio-stimulate injured
and dysfunctional tissues.
• Clinical studies and trials of Class III & IV
laser technology indicate the following
beneficial effects of light therapy on tissues
and cells.
Cellular Effects of Laser Energy
are components of
molecules which
absorb light.
•The stimulation of
on mitochondrial
membranes incites the
production of ATP.
•Leading to a biological
cascade of events.
Increased Growth
factor response within
cells and tissue as a
result of increased ATP
and protein synthesis.
Accelerated cell
reproduction and
growth leading to
faster repair of
damaged tissues.
• Increased metabolic activity- via increase
in enzyme outputs, oxygen and nutrient
• Stem cell activation
Wound Healing Effects
of Laser Therapy
• Faster Wound Healing - Laser
significantly increases fibroblast and
collagen production which are essential
for tissue repair.
• Improved Vascular Activity - Increased
capillary production leads to faster
wound closure.
• Greater Tensile Strength - Surgical
repaired wounds heal with greater
tensile strength, including skin,
tendon, ligament and fascia.
• Scar Tissue Reduction - Wounds heal
with less scar tissue formation.
Wound Healing - Vet
Wound Healing- Human
Immune System Effects
of Laser Therapy
• Strengthening the immune
system response via
increasing levels of
lymphocyte activity and
through a newly researched
mechanism termed
photo-modulation of blood.
Acute Inflammation
Stabilization of cellular membrane
Lubart R, Friedman H, and Lavie R. Photobiostimulation as a
function of different wavelengths. The Journal of Laser Therapy.
Vol 12. World Association of Laser Therapy. 2000.
Karu T. et al. Changes in absorbance on monolayer of living cells
induced by laser irradiation. IEEE Journal of Selected Topics in
Quantum Electronics. IEEE Lasers and Electro-Optical Society.
December 2001. 7(6):982.
De Castro E Silva Jr. O, et al. Laser enhancement in hepatic
regeneration for partially hepatectomized rats. Lasers in Surgery
and Medicine. 2001. 29(1):73-77
Acute Inflammation Reduction
• Acceleration of leukocytic activity
• Increased Prostaglandin synthesis
• Reduction in Interleukin 1(IL-1).
• Enhanced lymphocyte response
• Increased angiogenesis
• Temperature modulation
Acute Inflammation Reduction
Laser Therapy
Cytochrome Activation
Cell Membrane
ATP Increase
Ros Production
Proton Gradient
Leukocyte Activity
PG Synthesis
Enhanced Lymphocyte
SOD Production
Ca, Na, K Ion
IL-1 Decrease
Summary of LT Biological Effects
Accelerated Tissue Repair
Accelerated Cell Growth
Faster wound Healing
Reduced Scar Tissue Formation
Anti-Pain (Analgesia)
Summary of LT Biological Effects
• Improved Vascular Activity
• Increased Metabolic Activity
• Improved Nerve Function
• Immunoregulation
• Trigger Point Resolution
• Acupuncture Pt. Stimulation
Summary of LT Biological Effects
• Improved Vascular Activity
• Increased Metabolic Activity
• Improved Nerve Function
• Immunoregulation
• Trigger Point Resolution
• Acupuncture Pt. Stimulation
High Power - High Dose Laser Therapy
as it Pertains to the Spine
• Decreased inflammation of disc, nerve
roots and the cauda equine
Increase microcirculation of spinal
Accelerate healing of annular defects
Decreased formation of abnormal/non
functional scar tissue
Decreased scar tissue and non-osseous
hypertrophic changes
Reduce pain associated with PRP –
prolotherapy injection
Decrease or even eliminate
need for epidurals
High Power – High Dose Laser Therapy
as it Pertains to the Lower Extremities
Decreased inflammation of nerve tissue
Accelerated Reinervation of nerve fibers
Increase blood flow and microcirculation
of tissue structures
• Accelerate healing of open wounds
Decreased formation of abnormal nonfunctional scar tissue
Increase synovial fluid and cartilage
Increase collagen and fibroblast
Increase osteoblastic activity and fracture
Decreased bony edema – osteochondral
bone bruise
Laser Safety Overview
• Safety Training begins with YOU!
• Class IV Laser Beams can cause
damage to the eyes
• Safety Glasses must be worn by
everyone in the treatment area AKA
Nominal Hazard Zone (NHZ)
Laser Safety
• Safety protocols must
ensure sufficient
precautions are taken to
protect the health and safety of
employees and patients. Use of
safety goggles to prevent retinal
exposure is paramount.
Laser Safety
• Laser safety eyewear is
not a primary mode of
• They do not replace
proper laser safety
education, training, and
careful clinical practice.
Laser Safety
Fluorescein angiography
of retina after laser irradiation
Laser Safety
• Training
• Equipment Purchase, Service, Quality
• Room Design
• Protective Equipment / Optical
Laser Safety
Routine Procedures
Administrative Controls/Management
Electrical Hazards
Laser Safety-Reflective Surfaces
• Medical Instruments (Reflex Hammers,
• Jewelry (Rings, Watches, Earrings)
• Treatment Table
• Mirrors, Door Knobs and other Fixtures
Optical Hazards
Optical Hazards
Optical Hazards
Optical Hazards
Laser Classifications
Laser Classifications
Class 1 Lasers
Compact Disc Players
Laser Printers
Laser Classifications
Class 2 Lasers
Laser Classifications
Class 3a Lasers
Office Depot Laser Pointers
Laser Classifications
Class 3b Lasers
Laser Classifications
Class 4 Lasers
Surgical Lasers
Therapeutic Lasers
Human Contraindications
• Pregnant Females
• Eyes
• Epiphyseal Lines In Children
• Carcinoma
• Pacemaker
• Hemorrhage
• Thyroid, Gonads, & Testicles
• Immuno-Suppressant Drugs
• Light Sensitive Medications
• Sympathetic Ganglia, The
Vagus Nerves & Cardiac
Region In Patients With Heart
• Corticosteroids
• Intolerance
All Lasers are Not Created Equally
• Although all therapeutic lasers biostimulate tissue, that is where the
similarities end.
• Laser Therapy is all about Physics!
Therapeutic Laser Classifications
• Therapy lasers are classified based on
their power output
• Class IIIa = lasers 1 to 5mw of power
(laser pointers)
• Class IIIb = lasers 6 to 500mw in power
• Class IV = lasers above 500mw of power
• TMA Laser Platforms = 1,000 – 60,000
mw maximum continuous wave output
Clinical Laser Medicine
• What we would like to do is find a
volunteer with knee pain to demonstrate
the efficacy of high dose laser therapy
• While we finish the lecture we will treat
the patient and have him/her give you
feed back as to how the pain level and
range of motion have changed.
The Technology
Laser Therapy 101
Rule #1:
You Cannot Treat a Target
That You Cannot Reach.
The Technology
X-Ray Physics = Laser Physics
Rule # 2
The Technology
Laser Therapy 101
Rule #3:
Overstimulation With Laser
Energy Only Exists in
a Petrie Dish
The Technology
Laser Therapy 101
Rule #4:
Understimulation and Lack of
Penetration are the #1
Reasons for Poor Clinical
Energy Medicine and
Therapeutic Laser Physics
• The therapeutic dosage of laser energy is
measured in Joules
• Dosage is a function of the lasers power
• For every one watt of continuous laser
power output, one joule of laser energy is
delivered per second of time
• For a pulsed laser the energy delivery
depends on the duty cycle. Duty cycle tells
us what percentage of time the laser is on
or actively firing. If the duty cycle is 50%
then the laser at 1 watt only delivers 0.5
Joules / Second.
• For any given time period a continuous
wave laser delivers twice as much energy
than laser with a 50% duty cycle
Laser Physics
The shorter the
wavelength, the more
readily the energy is
absorbed in the body.
The higher the
wavelength, the deeper
the penetration of photon
Absorption Curve
980 nm: Low melanin, low water, low hemoglobin absorption thus an optimal
wavelength to choose when designing a therapy laser for stimulating tissue at greater
depths of penetration.
Laser Tissue Interactions
Physiological Effects
Light – Tissue Interactions
65% of laser energy is absorbed in the
skin and subcutaneous tissue layers with
the following having a high affinity for
• Hemoglobin in blood
• Melanin in skin, hair, moles, etc.
• Water (present in all biological tissue)
How Laser Light Penetrates Tissue
• As light energy hits the surface of the skin and
subsequent deeper layers, some of it is
scattered and some of it is absorbed and some
is reflected
• At each tissue interface less energy is available
to pass further through to the next layer
because of the effects of absorption,
reflectance and transmission
Laser Penetration
• Laser Energy is just another form of energy
on the electromagnetic spectrum.
• Depth of penetration is determined by
wavelength and energy density.
• Just like with x-rays when deeper
penetration is required, more energy must
be delivered to reach the target tissues.
Clinical Therapeutic
Laser Penetration
Prime Determinants of Laser Penetration
and Concomitant Tissue Stimulation are:
Power – measured in Watts or
• Wavelength – measured in
• Power Density – measured in
/ cm2
• Frequency – continuous wave versus
Importance of Power Density
• Since approximately 65% of the energy
delivered is lost in the epidermis
• If you don’t start with enough energy on
the skin, there will not be enough to
stimulate cell healing in deeper tissues
• If you do not have sustained power
density over a long enough period of
time treatments may be ineffective
Single Wavelength, Multiple Wavelength,
Continuous or Pulsed Wave Laser
• A laser with two or more wavelengths only has the
ability to penetrate as deep as each individual
wavelengths allows
• Most class iv lasers that pulse or have a high duty cycle
coupled with multiple wavelengths of energy emission
will not penetrate as deep as CW lasers of a single
wavelength or lasers that can pulse but still maintain a
high average power output
• Continuous wave lasers = 100% duty cycle,
laser is always delivering energy which is
needed to overcome absorption in the
superficial layers
• Newer generation of TMA lasers can now
pulse yet still maintain a high average
power output allowing for greater tissue
saturation with less thermal effects
In Laser Medicine 1 + 1
Does Not Equal 2
• Dual wavelength lasers
only penetrate as deep
as each wavelength
individually. Penetration
is not additive. There is
no validated clinical
benefit to this scenario.
It is more of a marketing
• For purposes of penetration it is more
advantageous to have one wavelength of
greater power that stimulates cell
metabolism and tissue regeneration at all
tissues densities in its pathway
Is There A Magical
• Throughout our 13 years of clinical
experience using a 980nm treatment
beam, we have experienced stellar results
with both superficial and deep
• We still feel once you are treating within
the infrared spectrum, power, power
density and dosage are the key to better
clinical outcomes.
Sponge Theory
• In order to achieve penetration one must create
significant energy density to overcome
absorption in the superficial layers of the skin.
• With low power or pulsed lasers it is like
pouring small amounts of water onto a large
sponge (the dermis and subcutaneous tissues)
and expecting the water to leak through.
In order to do so you must saturate the
superficial layers of the sponge- with
enough water-energy to soak the
sponge-superficial tissue structures
• So as you pour more water-energy over
the sponge it will start to penetrate or
leak through.
This it what is needed to penetrate
and why it is important to deliver a
high amount of laser energy/dosage
on the skin
• Especially if you want to reach deep
seated pathologies.
How Much is Enough
• 49-73 mw/cm2 for cell stimulation1
Mark D. Skopin and Scott C. Molitor, Department of
Bioengineering, University of Toledo, Toledo OH
• This study shows an optimal wavelength (980 nm) and
power density range for wound healing and tissue stimulation
Laser & Tissue Powers
Tissue Layer
Dermis Layer
Dermis Plexus Super.
2nd Dermis Layer
Dermis Plexus Prof.
Muscle Tissue
Max Power (mw/cm2)
Power Setting 5 Watts, 3.0cm spot size, 980nm
This is a snapshot in time. Calculated using computer models
by U of Toledo.
• Translation – As laser light or energy
penetrates through the body more and
more energy is absorbed so by the time
you start reaching deeper structures there
is not enough therapeutic energy to cause
adequate tissue stimulation
• Thus the reason why low power lasers as
well as pulsing lasers cannot effectively
treat deep seated pathologies.
Other Factors Affecting Lasers Penetration
• Duty Cycle – 100%
• Laser is firing continuously
• Duty Cycle – 50%
• Laser is firing 50% of the time. This
will not only cut energy delivery but it
will also affect ability to penetrate.
• Pulsing – Lasers that pulse also do not
emit continuous energy
• Lasers that can operate at 100%
continuous wave output or pulse the
laser energy while still maintaining a
high average power output is key to
treating deep seated pathologies and
better clinical outcomes.
Class III vs. “Class IV” Laser
With a high power output the laser beam can easily penetrate
deeper joints especially when compared to a class iii laser which at
best only offers superficial penetration.
Why Therapeutic Lasers Fail
• Under penetration - The typical low level
or cold laser or weak or pulsed class iv
laser does not concentrate the laser
energy sufficiently to allow for adequate
• Under-dosage – The typical low level or
cold laser or weak or pulsed class iv laser
does not deliver enough energy to
adequately stimulate deep seated
inflammatory conditions
• TMA protocols are successful because
they call for delivery of significantly
larger amounts of therapeutic energy
than industry standard protocols.
TMA-Diowave Philosophy
• TMA’s goal has always been to build the
most efficacious laser available to deliver
the best outcomes.
• Our lasers are built from the ground up and
are designed to get patients who have
failed traditional therapy better
• Many other lasers are built based on
economic factors or from taking laser
from other markets like dentistry and
converting them into weak class iv
• There are no shortcuts to treating
deep seated pathologies and one must
deliver the correct dosage of laser
energy in order to get the best
“The Key to Better Outcomes”
• Higher the power output of laser
• The Greater The Penetration and
• The Faster the Therapeutic
•The Quicker the Patient Returns to Normal
•This is the main reasons we keep
advancing our technology and developing
more powerful lasers.
Why More Power is Better
• More power equates to deeper
penetration, faster delivery of the proper
therapeutic dosage, and ultimately better
• A 30 watt laser will not only penetrate
deeper, it will put more therapeutic energy
to the target pathology
• It will do this 3X faster than a 10 watt laser
and 5X faster than a 12 watt laser with a
duty cycle of 50%
Recommendations for
High Dose Laser Therapy
• Small Joint – 25-50 lb. Pet = 6,000 Joules
• Small Joint – 50-100 lb. Pet = 9,000 Joules
• Large Joint - 25-50 lb. Pet = 9,000 Joules
• Large Joint- 50-100 lb. Pet 12-15,000
• Equine Dosages are typically Double the
Small Animal Dosage for Large Joints
• Even more for back pathologies
Evidence Based Medicine
• The effects of HPLT can easily be documented
• Clinician’s can measure results using outcome
assessment tools:
Pressure Algometer
Inclinometer , Goniometer
Thermal Imaging and Doppler Studies
VAS, PDQ – Pain Disability Questionnaire
Lasers vs. Standard Modalities Currently Used
to Treat Neuromusculoskeletal Pathologies
(In watts)
TMA - Diowave 60
TMA - Diowave 30
TMA - Diowave 15
TMA - Diowave 10
Litecure 15
Litecure 10
Klaser 12
Klaser cube 15
Cutting Edge 1.1
Cutting Edge 3.3
Class iii lasers
60 w
30 w
15 w
10 w
7.5 w
5.0 w
3.0 w
2.5 w
<1.0 w
<1.0 w
3 yr
3 yr
3 yr
3 yr
2 yr
2 yr
2 yr
2 yr
not published
not published
1-3 yr
1. MDO = Maximum Diode Output
2. Duty Cycle = Average Time
Diodes Are Firing
3. MPTD = Maximum Penetrating
Therapeutic Dosage.
• Because wavelength and power determine
penetration, and each wavelength penetrates
independently, the maximum penetrating dose
is no greater than the maximum power output
of each diode. With a 50% duty cycle
penetration of each diode gets cut in half.
4. JPM = Joules Per Minute
5. CPW = Cost Per Watt
(Continuous Power Output)
• Maximum power output per wavelength is one
of the most important factors in favorable
treatment outcome.
• With a dual wavelength laser, laser beam
penetration is reduced by 50%; with a 50% duty
cycle setting and dual wavelengths, laser
penetration is equal ¼ of the stated power
output of the laser.
• With multiple-wavelength lasers (2-3) beam
penetration is reduced even more significantly.
If a 50% duty cycle setting is paired with a
three-wavelength laser, beam penetration is
equal to 1/6 of the stated laser power output.
• A 10W CW Diowave laser has a stronger
maximum diode power output of any therapy
laser currently produced.
A New Trend in Pain
• Profound anti-inflammatory and analgesic effects
• Pain relief typically immediate
• Non-invasive and no side effects
• Profound tissue regeneration of all tissue types
• Overall contraindications minimal
Evidence Based Medicine
• The effects of HPLT can easily be documented
• Clinician’s can measure results using outcome assessment tools:
• Pressure Algometer
• Inclinometer , Goniometer
• Thermal Imaging and Doppler Studies
• VAS, PDQ – Pain Disability Questionnaire
• These tools are vital to document outcomes which ultimately
lead to adequate reimbursement
Applications of Laser Therapy
• Disc Pathologies, Spinal Stenosis, Radicular Pain,
spondylolesthesis, and sacroiliac dysfunction
• Failed surgical back syndrome
• Accelerated Post Surgical, Soft and hard Tissue healing
• Arthritis (Degenerative Joint Disease)
• Foot Pain and Neuropathies
• Muscle, Ligament and Tendon Injuries
• Ulcerations and Open Wounds
What to Look For When
a Class IV Therapy Laser
• Single wavelength laser
• True CW (Continuous Wave). Laser will
operate all day on CW without issues
• Highest CW Power
Introducing the 2012 TMA
Suite of Laser Platforms
• A technological advancement in energy output and delivery
• The TMA suite of laser platforms offer the world’s most
powerful and advanced therapeutic laser system ranging in
power output from 10 – 60 watts or 10,000mw -60,000mw.
• As a veterinary based company we have treated or will know
how to treat any condition you are confronted with, the
ultimate result being a better outcome
• With the superior training and clinical support we provide
veterinarians, the above goal will readily be achieved
Introducing the 2012 TMA
Diowave Laser Platforms
10 -15 Watt Laser Platform
20 - 30 and 60 Watt Laser Platform
Marketing High Power Laser
Therapy in Veterinary Medicine
• Laser Therapy is by far the most exciting new clinical
treatment to advance veterinary medicine in the 21st
• It can also become one of your most significant profit
centers in your practice
• All that’s need to be done to accomplish is to follow the
Diowave Turnkey marketing plan that comes with every
laser purchase
• For further information on bringing the a Diowave Laser
into your practice you will find our contact information in
the next page
• In summary my recommendation is to bye
the most powerful single continuous
wavelength therapy laser you can afford
over the next 5 years
• 15-30 watts for SA
• 30-60 watts for Equine or Mixed
Introducing the
2014 TMA-Diowave
High Power – High Dose Lasers
10-15 Watt Laser Platform
20-30 and 60 Watt Laser Platform
For More Information
Contact the Company by:
• Email – [email protected]
• Phone – 866-862-6606
Better Outcomes Are Only a
Phone Call or Email Away

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