Position Statement on Laser Acupuncture

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

LASER ACUPUNCTURE

POSITION STATEMENT ON LASER ACUPUNCTURE

LASER, an acronym for   Light Amplification by Stimulated Emission of Radiation,  was developed in the early 60s. It is a form of  electromagnetic radiation, in the visible or infrared  region of the light spectrum, generated by stimulating a  medium, which may be solid or gaseous, under special  conditions. The beam of light thus generated has uses in  almost every area of technology which exist today. Laser was first used in the medical  field as a focussed, high power beam with photo thermal  effects in which tissue was vapourised by the intense  heat. During the early phase of its use as a surgical  tool, it was noted that there appeared to be less pain  and inflammation following laser surgery than  conventional surgery. It was postulated that this effect  was related to the use of surgical lasers with a Gaussian  beam mode (see fig) In this mode the power of laser is  highest at the centre of the beam with the power then  falling off in a bell-shaped curve with the weakest power  at the periphery of the beam diffusing out into the  undamaged tissues2. This phenomenon was called the  "alpha-phenomenon"35. Thus the "low  power" segment of the beam was postulated to be  responsible for the decreased pain and inflammation in  the wound. Workers in the field recognised this effect.  Laser devices were manufactured in which power densities  and energy densities of laser were lowered to a point  where no photo thermal effects occurred but the  photo-osmotic, photo-ionic and photo-enzymatic effects  were still operative. Thus the use of "cold"  laser or "soft" laser, as it was first known,  came into medical use. The earliest experimental   application of low power laser in medicine was first  reported in 1968 by Endre Mester in Hungary. He  described the use of Ruby and Argon lasers in the  promotion of healing of chronic ulcers. In 1974, Heinrich  Plogg of Fort Coulombe, Canada, presented his work on the  use of "needleless acupuncture" and pain  attenuation. The first clinical applications of the  GaAlAs diode laser appeared in the literature in 1981. Since then a multitude of  devices, from many different countries, generating a  variety of laser beams of varying power, wavelengths,  frequencies and claims of clinical effects have been  brought onto the market. Its use is now widespread  in almost every medical speciality, especially  dermatology, ophthalmology and medical acupuncture. Japan and several  Scandinavian countries are at the forefront of clinical  research work with laser. Low Level Laser Therapy (LLLT)  is also used in Australia, Canada, France, Korea, People's Republic of China, U.K. and many other  countries. A tissue repair research unit, examining the  effects of laser, now exists at Guy's Hospital, London. Many centres of research are now developing around the  world. It is to be noted that  lasers machines are used widely by physiotherapists,  veterinary surgeons3 as well as practitioners of  alternate therapies. It is unregulated by any authority  at the present time, apart from the need for the  equipment to conform to Australian standard safety  regulations. The aim of this  position paper is to present the current views, on the  use of laser, of the Australian Medical Acupuncture  College. The photo-chemical effects  of light in medicine are well known e.g. blue light is  absorbed by bilirubin and thus undergoes photo-chemical  change. This is the basis of the treatment of neonatal  jaundice. Another use is that of ultraviolet light to  treat psoriasis in PUVA treatment. The use of laser as a  mechanism to induce photo-chemical changes in tissues is  an extension of this effect. Laser has three  characteristics which make it different from ordinary  light. It is monochromatic, parallel and coherent. It is  the last characteristic which is the most significant  factor in skin penetration, thus allowing a  photo-chemical effect to occur in deeper tissues.  Absorption spectra1 can be plotted for any chemical or  biological system. In any clinical setting the absorption  of laser and hence its biological effect depend upon skin  pigmentation, amount of fat, water and vascular  congestion of tissues. Penetration of laser into  tissues falls off at an exponential fashion. Thus  increase of laser power applied to tissues does not  result in a linear increase in biological effect. Once absorbed a  photochemical effect can be induced by the following  mechanisms 1. Neural: Laser causes in  vitro changes in nerve action potentials, conduction  velocities and distal latencies. Experimental evidence  includes Bishko's work in Vienna where he demonstrated  significant pain relief following low power HeNe and  infra-red laser stimulation of acupuncture points.  Walker demonstrated increased levels of serotonin in  chronic pain patients after treatment with low power HeNe  laser46. 2. Photoactivation of  enzymes: one photon can activate one enzyme molecule  which in turn can process thousands of substrate  molecules1. This mechanism provides a theoretical  framework in which a very small amount of energy can  cause a very significant biological effects. Primary photoacceptors,  which are activated by laser, are thought to be flavins,  cytochromes (pigments in the respiratory chain of cells)  and porphyrins 14,15. They are located in mitochondria.  They can convert laser energy to electro-chemical energy. It is postulated that the  following reaction is activated by laser1: Low doses of laser  stimulation ATP in mitochondria activation of the Ca++  pump Ca++ in the cytoplasm (via ion channels) cell  mitosis cell proliferation. Higher doses of laser  stimulation hyperactivity of the Ca++/ATPase pump and  exhaust the ATP reserves of the cell failure to maintain  osmotic pressure cell explodes. 3. Vibrational and  rotational changes in cell membrane molecules: Infra-red  radiation results in rotation and vibration of molecules  in the cell membrane leading to activation of the Ca++  pump as in the cascade above. Different wavelengths may  stimulate different tissue responses which may be  synergistic and thus produce better clinical effects. It is essential that basic  parameters of laser physics are understood by the  practitioner in order to achieve the best results in any  given clinical setting. Wavelength The wavelength  of a laser is determined by the medium from which it is  generated. Wavelengths of low power lasers in common  clinical use in Australia today are 632.8nm ( Helium  Neon, gas) in the visible light range, 810nm (Gallium/ Aluminium /Arsenide, diode) and 904 nm (Gallium/Arsenide,  diode) in the infra red region of the light spectrum.  Other wavelengths are used more commonly in surgical  settings. The wavelength is the prime determinant of  tissue penetration. Lasers which penetrate less deeply  are suitable for acupuncture point stimulation and  biostimulation. Infra red lasers penetrate more deeply  and are used in deeper tissue stimulation such as trigger  points. Energy Energy is a measure of the  dose of laser given in any treatment. Laser energy, in joules, is  calculated from the formula: Joules = Watts x Seconds It can be seen from this  formula that energy, expressed as joules, is related to  the power of the laser and the duration of irradiation so  that a higher power laser takes less time to generate the  required number of joules than a lower power laser. The  range of powers of laser devices used in Australia varies  from 1.5 to 100 mW. Principles of laser dosing should be  understood by users as some clinical effects, especially  with higher power lasers, appear to be dose related.  Acupuncture points are stimulated with energy ranging  from 0.01- 0.05 joules/point while trigger points may be  stimulated with 1-2 joules/point or higher, depending on  the tissue depth. Energy Density This  parameter is used in the calculation of doses for  biostimulation of wounds and is calculated as: Energy density (J/cm2) =  Watts x Seconds/Area of laser spot size (cm2) 4J/cm2 is regarded as the  optimal dose for biostimulation, based on empirical  findings. Power Density This is a  measure of the potential thermal effect of laser and is  fixed by the characteristics of the machine for any given  power output and spot size. It is calculated from the  formula: Power density (Watts/cm2) =  Watts/area of the probe tip (cm2) 10,000mW/cm2 will  produce a sensation of heat A wide range of conditions  are amenable to management by laser2,3,4,5, 42. Many of  these include conditions not amenable to or unresponsive  to current drug or physical therapies such as  osteoarthritis16,18, back pain17, post-herpetic  neuralgia19,20 , chronic pelvic inflammation44 and  rheumatoid arthritis22,31. Laser may be used in three  different ways 1. To stimulate acupuncture  points Laser is used to stimulate  acupuncture points using the same rules of point  selection as needle acupuncture. Laser acupuncture may be  used solely or in combination with needles for any given  condition over a course of treatment. 2. To treat trigger points In some musculo-skeletal  conditions higher doses of laser may be used for the  deactivation of trigger points. Trigger points may be  found in muscles, ligaments, tendons and periosteum.  Direct irradiation over tendons, joint margins, bursae  etc may be effective in the treatment of conditions in  which trigger points may play a part. Children and the  elderly may require smaller doses. Areas of thick skin or  muscle may require higher doses for penetration than  finer skin areas e.g. ear. 3. To promote healing The biostimulatory effects of laser have been widely investigated both in vivo and  in vitro . In vitro experimental  evidence has demonstrated acceleration of collagen  synthesis in fibroblast cultures due to acceleration of  mRNA transcription rate of the collagen gene. Superoxide  dismutase activity is increased (this decreases  prostaglandins). This is postulated as one mechanism of  pain and oedema reduction. Other effects are: inhibition  of procollagen production in human skin keloid fibroblast  cultures and stimulation of phagocytosis by  macrophages, increased fibroblast  proliferation, as well a wide variety of cellular  responses. In vivo effects  demonstrated in animals include increased formation of  granulation tissue and increased rates of  epithelialisation in laser irradiated wounds, stimulation  of suppressor T-cells, increased collateral nerve  sprouting and regeneration of damaged nerves in rats and  tendon and ligament repair in race horses. Bio-stimulatory effects of  laser are governed by the Arndt-Schultz Law of Biology  i.e. weak stimuli excite physiological activity, strong  stimuli retard it. The implication of this for wound  healing is that, as treatment of a wound is continuing  and there appears to be a slowing down of healing, a  reduction of the laser dosage may be needed. By virtue of  the Arndt-Schultz Law and the changed responsiveness of  the tissues, what was originally a stimulating laser dose  may have become an inhibitory dose of laser. The optimal  energy density for biostimulation, based on current  clinical experience, is 4J/cm2. Dose must be adjusted  according to individual response. Biostimulatory effects of  laser may be used in the following conditions: 1. the promotion of healing  of wounds e.g. venous and arterial ulcers, burns,  pressure sores. 2. treatment of skin  infections such as herpes zoster, labialis and genitalis. 3. treatment of apthous  ulcers. Laser may have an enhancing  effect on healing wherever inflammation is present. Bio-inhibitory effects of  laser may occur at higher doses e.g. 8J/cm2. Treatment of  keloid scars has been successful at these doses. Class 4  Lasers are used. Reprinted with permission  of Standards Australia from Australian Standard: Laser  Safety AS 2211-1991 References 1. Smith K.C. Light and  Life: The Photobiological Basis of the Therapeutic Use of  Radiation from Lasers. Progress in Laser Therapy.  Selected Papers from the first meeting of the  International Laser Therapy Association, Okinawa, 1990.  Ed. Oshiro T and Calderhead R.G. pp 11-18. 2. Oshiro T. An  introduction to LLLT. Progress in Laser Therapy. Selected  Papers from the first meeting of the International Laser  Therapy Association, Okinawa, 1990. Ed. Oshiro T and  Calderhead R.G. pp 36-47. 3. Motegi M. Low Reactive  Laser Therapy in Japan. Progress in Laser Therapy.  Selected Papers from the first meeting of the  International Laser Therapy Association, Okinawa, 1990.  Ed. Oshiro T and Calderhead R.G. pp75-80. 4. Chow R.T. Results of  Australia-wide survey into Laser use. The Journal of the  Australian Medical Acupuncture Society: Vol 12, No 2,  1994: 28-32 5 .Greenbaum, G.M. The  Bulletin of the Australian Medical Acupuncture Society ;  Volume 6, No.2, 1987. 6. Cassar E.J. LLLT in  Australia. Progress in Laser Therapy. Selected Papers  from the first meeting of the International Laser Therapy  Association, Okinawa, 1990. Ed. Oshiro T and Calderhead  R.G. pp 63-65. 7. McKibbin L.S. and Downie  R. LLLT in Canada. Progress in Laser Therapy. Selected  Papers from the first meeting of the International Laser  Therapy Association, Okinawa, 1990. Ed. Oshiro T and  Calderhead R.G. pp 66-70. 8. Goepel Roland, MD. Low  Level Laser Therapy in France. Progress in Laser Therapy.  Selected Papers from the first meeting of the  International Laser Therapy Association, Okinawa, 1990.  Ed. Oshiro T and Calderhead R.G. pp 71-74. 9. Motegi Mitsuo Low  Reactive-level Laser Therapy in Japan. Progress in Laser  Therapy. Selected Papers from the first meeting of the  International Laser Therapy Association, Okinawa, 1990.  Ed. Oshiro T and Calderhead R.G. pp 77-80 10. Professor Jae Kyu  Cheun. Progress in Laser Therapy. Selected Papers from  the first meeting of the International Laser Therapy  Association, Okinawa, 1990. Ed. Oshiro T and Calderhead  R.G. pp 81-82. 11. Professor Yo-cheng  Zhou. Progress in Laser Therapy. Selected Papers from the  first meeting of the International Laser Therapy  Association, Okinawa, 1990. Ed. Oshiro T and Calderhead  R.G. pp 85-89. 12. Moore, Kevin C. Low  Level Laser Therapy in the United Kingdom. Progress in  Laser Therapy. Selected Papers from the first meeting of  the International Laser Therapy Association, Okinawa,  1990. Ed. Oshiro T and Calderhead R.G. pp 94-101. 13. Dyson, M. Cellular and  Subcellular aspects of Low Level Laser Therapy. Progress  in Laser Therapy. Selected Papers from the first meeting  of the International Laser Therapy Association, Okinawa,  1990. Ed. Oshiro T and Calderhead R.G. pp 221-224. 14. Lubart, R., Friedmann,  H., Faraggi, A. and Rochkind, S., (1991). Towards a  mechanism of low energy phototherapy. Laser Therapy,  1991; 3: 11-13. 15. Smith, Kendric C.  (1991). The photobiological basis of low level laser  radiation therapy. Laser Therapy, 1991; 3: 19-24. 16.Gartner, C (1992). Low  reactive-level laser therapy (LLLT) in rheumatology: a  review of the clinical experience in the author's  laboratory. Laser Therapy, 1992; 4: 107-115. 17.Ohshiro, T. and Shirono,  Y. (1992). Retroactive study in 524 patients on the  application of the 830nm GaAlAs diode laser in low  reactive-level laser therapy (LLLT) for lumbago. Laser  Therapy, 1992; 4: 121-126. 18.Trelles, M. A., Rigau,  J., Sala, P. Calderhead, G. and Oshiro.T. (1991).  Infrared diode laser in low reactive-level laser (LLLT)  for knee osteoarthrosis. Laser Therapy, 1991, 3: 149-153. 19.Kemmotsu, O., Sato, K.,  Furumido, H., Harada, K., Takigawa, C., Kaseno, S.,  Yokota, S., Hanaoka, Y. and Yamamura, T. (1991). Efficacy  of low reactive-level laser therapy for pain attenuation  of postherpetic neuralgia. Laser Therapy, 1991; 3: 71-75. 20. McKibbin, Lloyd S. and  Downie, Robert. (1991). Treatment of post herpetic  neuralgia using a 904nm (infrared) low incident energy  laser: a clinical study. Laser Therapy, 1991, 3: 35-39. 21. Rigau, J., Trelles,  M.A., Calderhead, R.G.and Mayayo, E. (1991). Changes on  fibroblast proliferation and metabolism following in  vitro Helium-neon laser irradiation. Laser Therapy, 1991;  3: 25-33. 22. Asada, K., Yutani, Y.,  Sakawa, A. and Shimazu, A. (1991). Clinical application  of GaAlAs 830nm diode laser in treatment of rheumatoid  arthritis. Laser Therapy, 1991; 3: 77-82. 23. Zheng, H., Qin, J-Z,  Xin H.and Xin S-Y. (1993). The activating action of low  level Helium neon laser radiation on macrophages in the  mouse model. Laser Therapy, 1993, 4: 55-58. 24.Lubart, R., Friedmann,  H., Peled, I. and Grossman, N. (1993). Light effect on  fibroblast proliferation. Laser Therapy, 1993; 5: 55-57. 25. Karu, T. (1992).  Derepression of the genome after irradiation of human  lymphocytes with He-Ne laser. Laser Therapy, 1992, 4:  5-24. 26.Calderhead, R. Glen  (1991). Watts a Joule: on the importance of accurate and  correct reporting of laser parameters on low  reactive-level laser therapy and photobioactivation  research. Laser Therapy, 1991; 3: 177-182. 27. Bolton, P., Young, S.  and Dyson, M. (1991). Macrophage responsiveness to light  therapy with varying power and energy densities. Laser  Therapy, 1991; 3:105-111. 28. Matsumura, C.,  Murakami, F. and Kemmotsu, O. (1992). Effect of  Helium-Neon laser therapy (LLLT) on wound healing in a  torpid vasculogenic ulcer on the foot: a case report.  Laser Therapy, 1992; 4: 101-105. 29. Smith, Kendric C.  (1991). The photobiological basis of low level laser  radiation therapy. Laser Therapy, 1991; 3: 19-24. 30. Wolbarsht M.L. &  Sliney D.H.: Safety in LLLT. Progress in Laser Therapy.  Selected Papers from the first meeting of the  International Laser Therapy Association, Okinawa, 1990.  Ed. Oshiro T and Calderhead R.G. pp 31-35 31. Asada K., Yasutaka, Y.,  Kenjirou Y., Shimazu A. Pain Removal of Rheumatoid  Arthritis and Application of Diode Laser Therapy to Joint  Rehabilitaion. Progress in Laser Therapy. Selected  {Papers from the first meeting of the International Laser  Therapy Association, Okinawa, 1990. Ed. Oshiro T and  Calderhead R.G. pp 124-129. 32. T., Wang Li-shi, and  Yamada H. A Review of Clinical Applications of LLLT in  Veterinary Medicine. Progress in Laser Therapy. Selected  Papers from the first meeting of the International Laser  Therapy Association, Okinawa, 1990. Ed. Oshiro T and  Calderhead R.G. pp 162-169. 33. Terashima y., Kitagawa  M., Takeda O., Sago H., Onda T and Nomuro K. Clinical  Application of LLLT in the Field of Obstetrics and  Gynaecology. Progress in Laser Therapy. Selected Papers  from the first meeting of the International Laser Therapy  Association, Okinawa, 1990. Ed. Oshiro T and Calderhead  R.G. pp 191-196 34. Pontinen Pekka J. Low  Level Laser Therapy as a Medical Treatment Modality. Art  Urpo Ltd. pp 37-38 1992 35. Calderhead R. Glen.  Simultaneous Low Reactive-Level Laser Therapy in Laser  Surgery: the alpha-phenomenon" explained. Progress  in Laser Therapy. Selected Papers from the first meeting  of the International Laser Therapy Association, Okinawa,  1990. Ed. Oshiro T and Calderhead R.G. pp 209-213. 36.Mikhailov, V.A.,  Skobelkin, O.K., Denisov, I.N., Frank, G.A. and  Voltchenko, N.N. (1993). Investigations on the influence  of low level diode laser irradiation on the growth of  experimental tumours. Laser Therapy, 1993; 5: 33-38 37. Schindl, L., Kainz, A.  and Kern, H. (1992). Effect of low level laser  irradiation on indolent ulcers caused by Buerger's  disease; Literature review and preliminary report. Laser  Therapy, 1992, 4: 25-29. 38. Matsumura, C.,  Ishikawa, F., Imai, M. and Kemmotsu, O., (1993). Useful  effect of application of Helium-neon LLLT on an early  stage case of Herpes Zoster: a case report. Laser  Therapy, 1993; 5: 43-46. 39. Mester Andrew F. M.D.  and Mester Adam M.D. Laser Biostimualtion in Wound  Healing. Lasers in General Surgery. Williams &  Williams Publ. 40. Mester Endre et al. The  Biomedical Effects of Laser Application. Lasers in  surgery and Medicine 5:31-39 1985 41. Bischko Johannes J.  M.D. Use of the Laser Beam in Acupuncture. Acupuncture  & Electro-therapeut. Res. Int. J.. Vol 5, pp. 29-40,  1980. 42. Choi Jay J. M.D. A  Comparison of Electro-acupuncture, TENS and Laser  Photo-Biostimulation on Pain Relief and Glucocorticoid  Excretion. A Case Report. Acupuncture &  Electro-therapeut. Res. Int. J.. Vol 11, pp. 45-51, 1986. 43. Kreczi T. M.D.,  Klingler D. M.D. A Comparison of Laser Acupuncture vs  Placebo in Radicular and Pseudoradicular Pain Syndromes  as Recorded by Subjective Responses of Patients.  Acupuncture & Electro-therapeut. Res. Int. J.. Vol  11, pp. 207-216, 1986 1980. 44. Xijing Wu & Yulan  Cui. Observations on the effect of He-Ne laser Acupoint  Radiation in Chronic Pelvic Inflammation. Journal of  Traditional Chinese Medicine 7(4): 263-265, 1987. 45. Walker J. Relief from  Chronic Pain by Low Power Laser Irradiation. Neuroscience  Letters, 43 (1983) 339-344. Prior to any laser  acupuncture treatment an initial consultation, including  history, examination and appropriate investigations of  the presenting complaint, is necessary to arrive at a  diagnosis. 1 - as determined by  accreditation 2 - as determined by peer  review Australian Medical  Acupuncture College Doctors are required to  comply with the Australian Standard requirements  regarding the use of eye protection. Please refer to the  appropriate appendices for specific information. Power  alone is only one parameter used to determine the class  of laser. Do not rely on power alone. A laser with power  as low as 10mW may be classed as a 3B laser. Side-effects Patients may  experience: Dizziness •  fainting • nausea • tiredness • headache  • change in the site of pain • increased  pain...."treatment reaction". Warn patients  that they may get more pain in the first 24 hours of  treatment. This reaction tends to diminish with  subsequent treatments. Some studies have shown an  exacerbation between the third and fifth treatment.  Paracetamol is usually sufficient for analgesia. Precautions Do not shine laser  through pupils when treating around eyes • no  laser to fontanelles of infants Conditions which may be  treated but requiring experience and caution •  tumourous tissues • pregnancy • unstable  epilepsy Appendix 1 CLASSIFICATION OF LASERS Introduction: Because of the wide ranges  possible for the wavelength, energy content and pulse  characteristics of a laser beam, the hazards arising in  their use vary widely. It is possible to regard laser as  a single group to which common safety limits can apply. Description of laser  classes: Laser products are grouped  into four general classes for each of which accessible  emission limits are specified. CLASS 1: lasers are those  that are inherently safe (so that the maximum permissible  exposure level cannot be exceeded under any condition) or  are safe by virtue of their engineering design (please  refer to Table 1, Australian Standard: AS 2211-1991 for  specific details). CLASS 2: are low power  devices which emit visible and invisible radiation and  which may operate in either CW or pulsed mode. (please  refer to Table 1 and 11, Australian Standard: AS  2211-1991 for specific details). Note: These lasers are not  intrinsically safe but eye protection is normally  afforded by aversion responses including the blink  reflex. CLASS 3 A: are lasers that  emit higher levels of radiation than Class 11. For  example, in the visible range (400-700nm) they may have a  CW output power up to 5mW, provided the maximum  irradiance at any point in the beam does not exceed  25W.m.-2. (please refer to Table 111, Australian  Standard: AS 2211-1991 for specific wavelength and time  dependent limits) CLASS 3 B (Restricted): are  lasers that operate at the same power levels as Class 3A,  but have higher levels (less than or equal to 50W.m.-2)  of irradiance. They may be used in daylight conditions,  where the pupil diameter will not be greater than 5mm,  under the same controls as for Class 3A. where used in  conditions of lesser illuminance, the appropriate safety  controls as those specified for Class 3B. Class 3B lasers may emit  visible and/or invisible radiation at levels not  exceeding the accessible emission limits specified in  Table IV of the Australian Standard, Laser Safety.  Continuous wave lasers may not exceed 0.5W and the  radiant exposure from pulsed lasers must be less than 105  J.m.-2 (please refer to Table IV, Australian Standard: AS  2211-1991 for specific wavelength and time dependent  details) Eye wear shall be available  in all hazard areas where Class 3B, other than Class 3B(restricted) LASER UNITS ANDERTRON Narrow Band Non-Coherent Light Emitting Diode (N.B.N.C.L.E.D.) Power Output 1MW/sq.cm Modulation Frequency 1618  Hz Battery Voltage 9V Average Current Consumption  28MA Multiple Wavelengths  available Infra - red 820 - 904 nm  ...............Visible red 660 nm Optional Orange 635  nm....................Yellow 585 nm Green 565  nm.........................................Blue 470 nm Address for Purchase Dr. M.E. Anderson P.O. Box 6273 Dunedin North. N.Z. Comments: Lightweight,  economical Range of different  wavelengths Adjustable timer Economical enough for  patients to purchase SPECIFIC ARTICLES The use of Lasers in Medical Acupuncture - Geoff Grenbaum January 1997 Low Level Lasers have been  in use in Medical Acupuncture now for at least the last  twenty years. There is still a lot of confusion as to  whether they work, ie. is it just placebo, and also the  physical parameters of the various lasers available as to  which is the ideal or correct laser to use. Much of the  comment is ill-informed, and driven by commercial  interests. The other use of LLLT for physical therapy,  and wound healing not using Acupuncture techniques, will  not be discussed in this overview. Thus we need to discuss  these two factors. There are a plethora of  scientific papers describing the use of LLLT in  acupuncture for a variety of problems. Unfortunately most  of these papers, although showing positive results, are  not scientifically sound. Our own experience in the  clinic at PANCH has shown in a continuing audit of  patients, comparable results with needle acupuncture,  using a simple visual analogue scale to provide results.  This study has now been in progress for twelve years. It  is however not useful for a scientifically based comment. It is therefore good to  note that a scientifically based study of LLLT used for  acupuncture stimulation done in Melbourne in 1996 by Dr.  Gordon Wallace as a basis for his thesis for his  Masters' of Family Medicine-Monash University, has  shown a very positive result. I believe that we can rest  assured that this modality of stimulation in acupuncture  therapy does work, as all of us who use it extensively  have always felt. The other problem is more  difficult, and as yet has no answers. My personal  experience has been with very low output lasers, with  satisfaction, but others feel that higher power and  modulation of the wave form is necessary. Naturally this  adds to the expense of the device and this needs to be  considered in the purchase of any machine. A major factor as far as  Australia is concerned is maintenance and repair and for  this reason I would strongly recommend buying an  Australian made Laser. There are three or four varieties,  all of which appear to be well made and adhering to the  necessary "Standards". Do we use HeNe gas lasers,  or one of the many laser diode devices, either in the  visible range or the infra-red. They all appear to work  well in the clinical situation. Hence the appearance, and  physical qualities of the machine will affect your  decision to purchase one or the other variety. My  preference has always been for the HeNe 1.5mw gas laser,  but these are becoming obsolete, probably due to  commercial factors, as the Laser Diode is much cheaper to  produce. So visible light at about 670nm, or infrared at  about 830nm?? They both work, but I  prefer the red light as I can see it, and for the times  when I want to direct the laser over skin, or in the  mouth or nose, I prefer to see where the beam is. Also  there is the problem of damage to the retina if the beam  is inadvertently shone through the pupil, as there is no  protective blink reflex, with infra-red. I doubt that in the context  of medical acupuncture, that an output greater than 10mw  is desirable, and probably 4-5mw is very satisfactory. The parameters that you  need to know are the output in milliwatts, the spot size  in mm, and the time in seconds. If the machine produces  modulation then we need to know if the output is  continuous or at what frequency the modulation is set.  For the purposes of acupuncture stimulation I do not  believe modulation is required, but that is open to  question. It has been postulated that a minimum of 1mw  and 10-12seconds are required to produce any sort of  reaction What would I buy now? After  years of using many of these machines, I would choose the  cheapest laser which had a visible red light, in the  order of 5-10mw, and had an inbuilt timer. The physical  characteristics of those currently available in Australia  will determine which is the one for me!! I use the laser instead of  the needle. There is no need to detail any treatment  schedules, as they are dictated by your use of  acupuncture. Suffice to say that somewhere between 0.03  and 0.5 Joules of energy per point should be used. For a much more detailed  discussion on LLLT in medical acupuncture see the AMAC  "Laser Position Statement" 1995.

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