Chapter 7 Rehabilitation Physical Modalities 159plastic, metal and/or cement implants, though
low doses should be delivered if a heating laser
is used over implants. Finally, aseptic technique
should be used when treating wounds by either
applying clear plastic wrap over the probe or
by maintaining a small space over the wound
surface.
Multiple techniques are commonly described
for delivering LLLT. One technique, gridding or
point‐to‐point, is achieved by holding the probe
in one place for a duration of time to deliver a
specific dose and then moving the probe to the
next spot to be treated. The benefit of this treat
ment is that photons of energy saturate or
photo‐bleach the tissue, allowing deeper pene
tration of the beam. Depending on the unit
involved, these treatment spots may be the size
of the probe or the distance between the probe
locations may be centimeters apart. Space is
needed due to refraction. Some laser probes
adjust for this by having a large probe with
only a small diode. Other companies have mul
tiple diodes inside the probe, close to the edges,
requiring further probe placement on the tis
sue. A second technique, surround, is primarily
used with wounds; the periphery of the wound
is treated with a higher dose of energy than the
area directly over the wound. The granulation
tissue requires less energy as there is no mela
nin to attenuate the photon beam. Angiogenesis
is desired at the area of the granulation tissue as
is reduction of bacteria. Deep penetration is not
needed, reducing the need for higher doses.
Scanning, or continuously moving the probe, is
another method of treating the tissue. This is
essential when using a heating laser to prevent
thermal damage. When using a nonheating
laser, scanning can also be used to treat tissue.
Scanning allows lower doses of energy to be
applied to the tissue multiple times rather than
one larger dose. In this author’s (L.M.) experi
ence, scanning works better for muscle issues
and wounds whereas point‐to‐point is more
effective on deep tissue, joints, and when pain
control is the goal.
Mode of operation of the laser may be con
tinuous, pulsed wave, or combined depending
on the unit, each with different biological
effects. Pulsed wave may be more beneficial in
treating deeper tissues (Keshri et al., 2016),
wound healing, and post‐stroke management.
Continuous wave may be more efficacious in
the treatment of nerve regeneration. Further
research is needed to delineate the benefits of
each mode.
When considering dosage, specific recom
mendations have not been fully established.
The effects of LLLT are believed to be biphasic
in that low doses appear to stimulate healing
while higher doses may inhibit it (Huang et al.,
2009; Gagnon et al., 2016). The authors recom
mend referring to the manufacturer’s recom
mendations for each unit. Information can also
be found on the World Association of Laser
Therapy (WALT) website.Precautions and contraindicationsLLLT is not recommended for use in patients
with epilepsy that can be triggered by a photo
sensitivity. Lasers that cause tissue to heat
should not be used over open epiphyseal plates,
over the gonads, or in proximity to surgical
implants. Precautions should be considered
when using laser over an area of skin that has a
tattoo as skin heating can occur, and over the
injection site of long‐acting steroids as a pain
response has been noted (Laurie McCauley,
unpublished finding, 2017). Contraindications
include treatment over the cornea, over the
endocrine glands, in areas of active bleeding,
over the pregnant uterus, and over neoplasia.
Laser may be used in areas of neoplasia as a
palliative form of pain control, with the under
standing that tumor growth may escalate with
the laser therapy, as long as there is clear, writ
ten, informed consent.Figure 7.18 Patient receiving low‐level laser therapy
(LLLT) of the elbow joint.