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M.sc (Biomedical Engineering) Thesis Presentation: EFFECTS OF LOW LEVEL LASER THERAPY ON HUMAN BONE REGENERATION (pdf):
Supervisor:

1Chairman,
Prof. and 2Course-coordinator
of International Co-operation.

Co- Supervisors:
Prof. F. H. Sirazee
3(Ex. Head of the Department ),
Associate Prof. P.C Debenath
3( Head of the Department ).




 1. Dept. of Medical Radiation Physics, Kreis-krankenhaus Gummersbach Teaching Hospital
    of the University of Cologne, 51643 Gummersbach, Germany.
2. Dept. of Medical Physics and Biomedical Engineering, GonoBishwabidyalay
    (Gono University), Nayarhat, Savar, Dhaka- 1344, Bangladesh.
3. Department of Orthopedic and Traumatology, ShaheedSuhrawardy Medical College
        Hospital, Dhaka-1207,Bangladesh.

                                                                                          2
Contents:




            3
Introduction:

Optimizing the results of fracture treatment
requires a holistic view of both patients and
treatment.
There is a perception, not least among fracture
surgeons themselves, that the mechanical issues
have been over-emphasized in the past.


                                                  4
Introduction:
The principles of AO treatment, drummed
into a generation of orthopedic
trainees, were anatomical open
reduction, rigid internal fixation and early
rehabilitation of soft tissues without
external splint.


                                           5
Introduction:
Now the science is taking another step, further in
the direction from mechanics to biology.
If the mechanical environment influences bone
regeneration and hence fracture healing, how, at
a cellular level, does it do so.




                                                     6
Introduction:
Low level laser acts on biological tissues on cellular
level.
The basic premise is that LLLT stimulates cell
activation processes which in turn, intensify
physiologic al activities.




                                                     7
Introduction:
Low Level Laser increases -
 Cellular ion-exchange,
 Tissue vascularization,
 Lymphatic circulation,
 Activates cytokines,
 Growth factors and
necessary hormonal activities for tissue healing
enhancement in the proliferative stage thereby
reduction of pain & inflammation.

                                                   8
Introduction:

And increases
 Fibroblast,
 Chondrocyte and osteoblast proliferation,
 Inhibition of osteoclast &
 Synthesis of bone collagen and bone matrix
that activities & enhances bone regeneration.


                                                9
How to Speed up
fracture healing !
                      Although there are no magical ways to fix a bone
                     fracture, but there are ways to help speed up the
                     healing process, and help fracture to heal properly/
                     faster.

                                Proper medical management.
                                Nutritional Support.
                                BMP/ Osteoblast cell injection
                                Electrical stimulation.
                                Magnetic stimulation.
                                Ultrasound therapy.
                                Gene-therapy
                                Low Level Laser therapy.
                                                                    10
Enhancement of Bone Union
(Cont.)
Among the current procedures of bone
fracture union enhancement, low level
laser therapy is superior to others in
contrast to-
  Patient Compliance,
  Length Of Healing Time,
  Less-invasive Procedure And
   Cost-effectiveness.

                                 11
Laser mechanism on biological
tissues can be explained by-
1. Physical mechanism
2. Bio-chemical mechanism
The primary (physical) mechanisms relate
to the interaction between photons and
molecules in the tissue, while the
secondary mechanisms relate to the
effect of the chemical (Bio-chemical)
changes induced by primary effects.


                                    12
Mechanism of action
   of LLLT on tissue (cont.):
   physical-

  There are two primary forms of physical effects
  generated by laser irradiation on biological tissues:
 Photon-absorption (the basis of photobiological
  action, and generated by all forms of light).
 Internal conversion & fluorescence of light also
  generates Speckle formation, which is unique to
  laser therapy.



                                                  13
Mechanism of action of
LLLT on tissue (cont.):
Biochemical-
 Bio-chemical action of laser can be explained by
“Action of photon with mitochondrial respiratory
chain- Cytochromecoxidase enzyme”.
  Cytochromecoxidase mediated increase in ATP
   production.
  Cytochromecoxidase mediated singlet-oxygen
   production.
  Cytochromecoxidase mediated Reactive oxygen
   species (ROS) formation.
  Cytochromecoxidase mediated Photodiassociation
   and Nitric Oxide Production.
                                              14
Infrared laser radiation enhances bone regeneration/
  formation by two consecutive phases of cellular, intra
  cellular and tissue modulating cascades of inter-
  depended process.
• 1.Directly by simulation of osteoblast
  formation, inhibition of osteoclast
  activities, proliferation/differentiation of fibroblast and
  enhancement bone growth factors/ modulation of
  cytokines.
• 2. Indirectly by enhancing some specific bone formation
  modulation, and creating a friendly environment that
  fascinates bone formation /regeneration.
                                                         15
Mechanism of action
  of Laser on Bone union(Direct)-
• Studies of bone healing response to infrared
  light show acceleration of osteoblast
  formation as well as calcium salt deposition
  under the influence of infrared light.
• Osteoclast Inhibition Prevents Bone Mineral
  Resorption .
• Bone-matrix & collagen synthesis.

                                         16
Mechanism of action
   of Laser on Bone union(Indirect)-
• Laser promotes cellular/tissue ion exchange /
  transport and enhances Bone Mineralization.
• Laser therapy increases Nitric Oxide in tissues
  which increases vascularity, thereby helps in
  tissue healing and Bone Formation.
• Laser therapy increases lymphatic circulation
  in bone and enhances better tissue healing &
  regeneration.


                                             17
Effects Of Low Level Laser
(Ga-al-as, 830nm) On Human
Appendicular Bone Fracture
By
Assessing Parameters:
  Objective (Clinical) &
  Subjective (Radiological).

                                18
• Duration of study:
  The duration of this study was two years (from
  April- 2008 to March- 2010).
• Type of study:
• Prospective Randomized Case Control study.
• Place of study: The study was conducted at
  ShaheedSuhrawardy Medical College Hospital in
  the Department of Orthopedics and
  Traumatology, Sher-E-Bangla Nagor, Dhaka-
  1207, Bangladesh.

                                             19
Materials & Method (Cont.)
  Materials: sample
• The sample was collected randomly from admitted
  patients with appendicular bone fracture (superior and
  inferior extremity) at ShaheedSuhrawardy Medical
  College Hospital in the Department of Orthopedics and
  Traumatology, Dhaka-1207, Bangladesh.
• A total of 40 patients randomly collected; among
  which 20 were in the Laser group (L1,L2) and 20 were
  in the control group (C1,C2).



                                                    20
Materials & Method (Cont.)
Materials: Machine




Bio-Lux MD Ga- Al- As Laser
(830 nm) Machine with Probe.   21
Materials & Metho(Cont.)
Method:
Applied laser in the laser therapy group
was continuous infrared laser with BioLux
MD (Ga-Al-As-830nm).
The first session was started on the 5th day
after surgery/ incidence; based on previous
research work which proved that laser
works best on the proliferative stage of
tissue healing.
                                       22
Materials & Method(Cont.)
  Method:
• Procedure: LLLT was irradiated on the
  fracture- side, performed transcutaneously
  in pointing method, in 4 anatomical
  locations at 500 mW; 0.5 centimeter away
  from fracture line and, two points in each
  site of line/ day.
• Dose and duration:
  @ 8J/cm2 dose (energy) of
  total dose 8*4*9 J/cm2 for adult &
  @ 4 J/cm2 dose (energy) of
  total dose 4*4*9 J/cm2 for child.
                                        23
Materials & Method (Cont.)
Method:
Treatment Protocol (Cont.)
Laser Treatment Protocols used in
This work:

•   4- 8 joules /cm2
•   4 points/ session
•   Power-500mw
•   Point spacing is every 2-4 sq. cm.
•   Treatment schedule: daily for the first
    week, followed by alternate day in the
    second week (9 days total).           24
Materials & Method(Cont.)
   Method (Cont.)
• The data’s were routinely processed, by measuring
  the callus/ new bone formation. The best sets of
  weekly x-ray images of each patient from each
  group were selected for this analysis, and data’s are
  also shown in datasheets and graphs .
• Efficacies of treatment were evaluated with
  pain questionnaire,
  clinical assessment and
  serial weekly radiograph assessment starting from
  1st week up to 4th week and on the 6th week.

                                                   25
Materials & Method(Cont.)
Method (Cont.)
The patients were analyzed by-
Clinical Assessment
 Pain & inflammation level.
 Stability of fracture side.
 Movement of fracture side.
 Immobilization duration.
 Patient compliance.          26
Densitometer
used in this   Radiological Assessment
work.

                Radiographic Scoring System (by
               Lane and Sandhu) of fracture
               site, done weekly.
                Densitometer assessment of Callus in
               the radiograph of fracture site, taken
               weekly.
                                                    27
• Clinically the laser group showed better
   stable fracture site,
   earlier movement of limb and
  removal of cast/plaster was performed.
• Pain & inflammation also
   subsided much earlier in the laser group
  (L1 & L2) than the control group (C1 & C2).


                                                28
Observation &
  Result(Cont.)
• Radio-logically, this study compared degree
  of callus formation, callus density changes by
  weeks, and assessment of bone/ callus
  formation/ union, pain & inflammation
  parameters changes, with and without laser
  radiation (LLLT) in the post laser therapy
  period, starting from 1st week up to 4th week
  and on 6th.
                                             29
Observation
                 & Result (Cont.)                                    Patient on
                                                                         LLLT




                      Before starting
                      of treatment.

L1-2. Patient Name:
Md DalilUddin
Age: 95 Years
Sex: Male
Diagnosis: Fracture
Lt. Humerus (Shaft)
Study group: L1       At 1st week       At 2nd week   At 3rd week




                      At 4th week       At 6th week   At 12th week            30
Observation & Result(Cont.)
      C1-1.. Patient Name: Halima Begum
      Age: 55 Years
      Sex: Female
      Diagnosis: Fracture Rt. Shaft of Femur
      Study group: C1                    Patient Name: Ms Halima Begum
                                           Week Vs Bone Density: Non-fracture side(Cortex, Medulla) & fracture Side
                                                                    ( Cortex, Medulla).

              Non-fracture site, Medulla          fracture site, Medulla                  Non-fracture site, Cortex              fracture site,Cortex


                                                                                                                      2.0033




                                                                                 1.7767                               1.7567

                                                                                                                                                   1.43

               1.0167
                                                                                 1.2267                               1.8133
                                            1.1667
                                                                                                                                                   1.0167
               1.0033
                                                                                 1.2867
                                            0.8333
                                                                                                                                                   1.14
               0.87                                                                                                   1.8233
                                            0.8367
                                                                                 1.1033
               0.9267                                                                                                                              0.9333
                                            0.5633
                                                                                                                                                        31
At the end of the 1st week   At the end of the 2nd week      At the end of the 3rd week             At the end of the 4th week     At the end of the 6th week
Observation & Result(Cont.)
      L1-1. Patient Name: Ms Anowara
      Age: 55 Years
      Sex: Female
      Diagnosis: Fracture Rt. Shaft of Radius
      Study group: L1


                                                                  Patient Name: Ms Anowara
                                 Week Vs Bone Density Change: Non-fracture side (Cortex, Medulla) & fracture side ( Cortex, Medulla)

              Non-fracture site, Medulla              fracture site, Medulla                 Non-fracture site, Cortex                 fracture site, Cortex



                                                                                     2.0267




                                               0.9067                                                                                                     0.9033
                                                                                     1.2333
               0.9667
                                                                                                                           1.1667
                                               1.1733                                                                                                     1.1767

                                                                                     1.3067
               0.78
                                                                                                                           0.8333
                                               0.88                                                                                                       0.88
               0.9033
                                                                                     1.39                                  0.8367
                                               1.0933                                                                                                     1.0967
               0.8967
                                                                                                                           0.5633

                                                                                                                                                               32
At the end of the 1st week   At the end of the 2nd week          At the end of the 3rd week            At the end of the 4th week         At the end of the 6th week
• The result of this study reveals a better bone
  healing after irradiation with 830nm diode
  laser (Ga-Al-As).
• This study result also concludes that better
  bone healing after irradiation with Ga-Al-
  As, 830nm diode laser in human model as an
  adjunctive to regular fracture management
  that accelerates bone union significantly and
  enhances patient compliances.


                                            33
This study has demonstrated the
 potential of low level laser
 therapy in the treatment of –
“ Enhancement Of
  Human Bone Fracture Union”.

                              34
Future
Recommendations(Cont.)
A large multi- centric study pointing
important subjective (i.e.
   • mechanical,
   • biochemical and
   • Histological , as well as objective
     (clinical) parameters.

                                      35
Future
  Recommendations (Cont.)
  Including -
 laser protocol (dose, duration, type of laser
   & mode of operation),
 patient selection criteria and
 procedure of therapy,
  is highly desirable to make this non-
   invasive method of bone stimulation
   applicable in medical science.

                                          36

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M.sc (Biomedical Engineering) Thesis Presentation: EFFECTS OF LOW LEVEL LASER THERAPY ON HUMAN BONE REGENERATION (pdf):

  • 2. Supervisor: 1Chairman, Prof. and 2Course-coordinator of International Co-operation. Co- Supervisors: Prof. F. H. Sirazee 3(Ex. Head of the Department ), Associate Prof. P.C Debenath 3( Head of the Department ). 1. Dept. of Medical Radiation Physics, Kreis-krankenhaus Gummersbach Teaching Hospital of the University of Cologne, 51643 Gummersbach, Germany. 2. Dept. of Medical Physics and Biomedical Engineering, GonoBishwabidyalay (Gono University), Nayarhat, Savar, Dhaka- 1344, Bangladesh. 3. Department of Orthopedic and Traumatology, ShaheedSuhrawardy Medical College Hospital, Dhaka-1207,Bangladesh. 2
  • 4. Introduction: Optimizing the results of fracture treatment requires a holistic view of both patients and treatment. There is a perception, not least among fracture surgeons themselves, that the mechanical issues have been over-emphasized in the past. 4
  • 5. Introduction: The principles of AO treatment, drummed into a generation of orthopedic trainees, were anatomical open reduction, rigid internal fixation and early rehabilitation of soft tissues without external splint. 5
  • 6. Introduction: Now the science is taking another step, further in the direction from mechanics to biology. If the mechanical environment influences bone regeneration and hence fracture healing, how, at a cellular level, does it do so. 6
  • 7. Introduction: Low level laser acts on biological tissues on cellular level. The basic premise is that LLLT stimulates cell activation processes which in turn, intensify physiologic al activities. 7
  • 8. Introduction: Low Level Laser increases -  Cellular ion-exchange,  Tissue vascularization,  Lymphatic circulation,  Activates cytokines,  Growth factors and necessary hormonal activities for tissue healing enhancement in the proliferative stage thereby reduction of pain & inflammation. 8
  • 9. Introduction: And increases  Fibroblast,  Chondrocyte and osteoblast proliferation,  Inhibition of osteoclast &  Synthesis of bone collagen and bone matrix that activities & enhances bone regeneration. 9
  • 10. How to Speed up fracture healing ! Although there are no magical ways to fix a bone fracture, but there are ways to help speed up the healing process, and help fracture to heal properly/ faster.  Proper medical management.  Nutritional Support.  BMP/ Osteoblast cell injection  Electrical stimulation.  Magnetic stimulation.  Ultrasound therapy.  Gene-therapy  Low Level Laser therapy. 10
  • 11. Enhancement of Bone Union (Cont.) Among the current procedures of bone fracture union enhancement, low level laser therapy is superior to others in contrast to-  Patient Compliance,  Length Of Healing Time,  Less-invasive Procedure And  Cost-effectiveness. 11
  • 12. Laser mechanism on biological tissues can be explained by- 1. Physical mechanism 2. Bio-chemical mechanism The primary (physical) mechanisms relate to the interaction between photons and molecules in the tissue, while the secondary mechanisms relate to the effect of the chemical (Bio-chemical) changes induced by primary effects. 12
  • 13. Mechanism of action of LLLT on tissue (cont.): physical- There are two primary forms of physical effects generated by laser irradiation on biological tissues:  Photon-absorption (the basis of photobiological action, and generated by all forms of light).  Internal conversion & fluorescence of light also generates Speckle formation, which is unique to laser therapy. 13
  • 14. Mechanism of action of LLLT on tissue (cont.): Biochemical- Bio-chemical action of laser can be explained by “Action of photon with mitochondrial respiratory chain- Cytochromecoxidase enzyme”.  Cytochromecoxidase mediated increase in ATP production.  Cytochromecoxidase mediated singlet-oxygen production.  Cytochromecoxidase mediated Reactive oxygen species (ROS) formation.  Cytochromecoxidase mediated Photodiassociation and Nitric Oxide Production. 14
  • 15. Infrared laser radiation enhances bone regeneration/ formation by two consecutive phases of cellular, intra cellular and tissue modulating cascades of inter- depended process. • 1.Directly by simulation of osteoblast formation, inhibition of osteoclast activities, proliferation/differentiation of fibroblast and enhancement bone growth factors/ modulation of cytokines. • 2. Indirectly by enhancing some specific bone formation modulation, and creating a friendly environment that fascinates bone formation /regeneration. 15
  • 16. Mechanism of action of Laser on Bone union(Direct)- • Studies of bone healing response to infrared light show acceleration of osteoblast formation as well as calcium salt deposition under the influence of infrared light. • Osteoclast Inhibition Prevents Bone Mineral Resorption . • Bone-matrix & collagen synthesis. 16
  • 17. Mechanism of action of Laser on Bone union(Indirect)- • Laser promotes cellular/tissue ion exchange / transport and enhances Bone Mineralization. • Laser therapy increases Nitric Oxide in tissues which increases vascularity, thereby helps in tissue healing and Bone Formation. • Laser therapy increases lymphatic circulation in bone and enhances better tissue healing & regeneration. 17
  • 18. Effects Of Low Level Laser (Ga-al-as, 830nm) On Human Appendicular Bone Fracture By Assessing Parameters:  Objective (Clinical) &  Subjective (Radiological). 18
  • 19. • Duration of study: The duration of this study was two years (from April- 2008 to March- 2010). • Type of study: • Prospective Randomized Case Control study. • Place of study: The study was conducted at ShaheedSuhrawardy Medical College Hospital in the Department of Orthopedics and Traumatology, Sher-E-Bangla Nagor, Dhaka- 1207, Bangladesh. 19
  • 20. Materials & Method (Cont.) Materials: sample • The sample was collected randomly from admitted patients with appendicular bone fracture (superior and inferior extremity) at ShaheedSuhrawardy Medical College Hospital in the Department of Orthopedics and Traumatology, Dhaka-1207, Bangladesh. • A total of 40 patients randomly collected; among which 20 were in the Laser group (L1,L2) and 20 were in the control group (C1,C2). 20
  • 21. Materials & Method (Cont.) Materials: Machine Bio-Lux MD Ga- Al- As Laser (830 nm) Machine with Probe. 21
  • 22. Materials & Metho(Cont.) Method: Applied laser in the laser therapy group was continuous infrared laser with BioLux MD (Ga-Al-As-830nm). The first session was started on the 5th day after surgery/ incidence; based on previous research work which proved that laser works best on the proliferative stage of tissue healing. 22
  • 23. Materials & Method(Cont.) Method: • Procedure: LLLT was irradiated on the fracture- side, performed transcutaneously in pointing method, in 4 anatomical locations at 500 mW; 0.5 centimeter away from fracture line and, two points in each site of line/ day. • Dose and duration: @ 8J/cm2 dose (energy) of total dose 8*4*9 J/cm2 for adult & @ 4 J/cm2 dose (energy) of total dose 4*4*9 J/cm2 for child. 23
  • 24. Materials & Method (Cont.) Method: Treatment Protocol (Cont.) Laser Treatment Protocols used in This work: • 4- 8 joules /cm2 • 4 points/ session • Power-500mw • Point spacing is every 2-4 sq. cm. • Treatment schedule: daily for the first week, followed by alternate day in the second week (9 days total). 24
  • 25. Materials & Method(Cont.) Method (Cont.) • The data’s were routinely processed, by measuring the callus/ new bone formation. The best sets of weekly x-ray images of each patient from each group were selected for this analysis, and data’s are also shown in datasheets and graphs . • Efficacies of treatment were evaluated with pain questionnaire, clinical assessment and serial weekly radiograph assessment starting from 1st week up to 4th week and on the 6th week. 25
  • 26. Materials & Method(Cont.) Method (Cont.) The patients were analyzed by- Clinical Assessment  Pain & inflammation level.  Stability of fracture side.  Movement of fracture side.  Immobilization duration.  Patient compliance. 26
  • 27. Densitometer used in this Radiological Assessment work.  Radiographic Scoring System (by Lane and Sandhu) of fracture site, done weekly.  Densitometer assessment of Callus in the radiograph of fracture site, taken weekly. 27
  • 28. • Clinically the laser group showed better stable fracture site, earlier movement of limb and removal of cast/plaster was performed. • Pain & inflammation also subsided much earlier in the laser group (L1 & L2) than the control group (C1 & C2). 28
  • 29. Observation & Result(Cont.) • Radio-logically, this study compared degree of callus formation, callus density changes by weeks, and assessment of bone/ callus formation/ union, pain & inflammation parameters changes, with and without laser radiation (LLLT) in the post laser therapy period, starting from 1st week up to 4th week and on 6th. 29
  • 30. Observation & Result (Cont.) Patient on LLLT Before starting of treatment. L1-2. Patient Name: Md DalilUddin Age: 95 Years Sex: Male Diagnosis: Fracture Lt. Humerus (Shaft) Study group: L1 At 1st week At 2nd week At 3rd week At 4th week At 6th week At 12th week 30
  • 31. Observation & Result(Cont.) C1-1.. Patient Name: Halima Begum Age: 55 Years Sex: Female Diagnosis: Fracture Rt. Shaft of Femur Study group: C1 Patient Name: Ms Halima Begum Week Vs Bone Density: Non-fracture side(Cortex, Medulla) & fracture Side ( Cortex, Medulla). Non-fracture site, Medulla fracture site, Medulla Non-fracture site, Cortex fracture site,Cortex 2.0033 1.7767 1.7567 1.43 1.0167 1.2267 1.8133 1.1667 1.0167 1.0033 1.2867 0.8333 1.14 0.87 1.8233 0.8367 1.1033 0.9267 0.9333 0.5633 31 At the end of the 1st week At the end of the 2nd week At the end of the 3rd week At the end of the 4th week At the end of the 6th week
  • 32. Observation & Result(Cont.) L1-1. Patient Name: Ms Anowara Age: 55 Years Sex: Female Diagnosis: Fracture Rt. Shaft of Radius Study group: L1 Patient Name: Ms Anowara Week Vs Bone Density Change: Non-fracture side (Cortex, Medulla) & fracture side ( Cortex, Medulla) Non-fracture site, Medulla fracture site, Medulla Non-fracture site, Cortex fracture site, Cortex 2.0267 0.9067 0.9033 1.2333 0.9667 1.1667 1.1733 1.1767 1.3067 0.78 0.8333 0.88 0.88 0.9033 1.39 0.8367 1.0933 1.0967 0.8967 0.5633 32 At the end of the 1st week At the end of the 2nd week At the end of the 3rd week At the end of the 4th week At the end of the 6th week
  • 33. • The result of this study reveals a better bone healing after irradiation with 830nm diode laser (Ga-Al-As). • This study result also concludes that better bone healing after irradiation with Ga-Al- As, 830nm diode laser in human model as an adjunctive to regular fracture management that accelerates bone union significantly and enhances patient compliances. 33
  • 34. This study has demonstrated the potential of low level laser therapy in the treatment of – “ Enhancement Of Human Bone Fracture Union”. 34
  • 35. Future Recommendations(Cont.) A large multi- centric study pointing important subjective (i.e. • mechanical, • biochemical and • Histological , as well as objective (clinical) parameters. 35
  • 36. Future Recommendations (Cont.) Including -  laser protocol (dose, duration, type of laser & mode of operation),  patient selection criteria and  procedure of therapy, is highly desirable to make this non- invasive method of bone stimulation applicable in medical science. 36