The document discusses musculoskeletal laser therapy and its integrated clinical protocols, emphasizing the effectiveness of low-level laser therapy (LLLT) in enhancing cellular regeneration, reducing inflammation, and improving recovery from various injuries. It outlines how laser therapy works at a biochemical level, and it presents specific treatment protocols for conditions like carpal tunnel syndrome, rotator cuff injuries, and more. The author highlights the benefits of laser therapy for pain management and recovery in sports injuries, positioning it as a crucial tool in modern healthcare.

1. Dr. Robert G. Silverman
DC, DACBN, MS, CNS, CCN, CSCS, CIISN, CKTP, CES, DCBCN, HKC,
SFMA
www.DrRobertSilverman.com
info@drrobertsilverman.com
Musculoskeletal Laser
Therapy: Integrated Clinical
Protocols

2. Quote
“Let there be
light”.

3. Pathogenesis of the cumulative trauma disorder
Recovery
Cycle
Injury Cycle
Frequency of Insult
AmountofTissueInsult
Symptomatic
Injury Threshold
Pathogenesis of the cumulative trauma disorder
Injury Cycle
Frequency of Insult
AmountofTissueInsult
Insufficient Tissue
Recovery Between
Injury Cycles
Tissue Damage
Accumulates
Copyright Jerome M. True, DC

4. Integrating Laser into Practice
“The most versatile
healthcare tool of the 21st
century”.
Dr. Rob, January 2013
“No-pill pain buster”.
Dr. Oz, January 2013

5. Blue Print
• Find the cause
• Explain the source
• Determine effective treatment
• Shorten treatment time

6. What Comes First?
Injury Pain
Altered Motor
Control
We should diagnose this
FUNDAMENTAL QUESTION?

7. Abdominals
Gluteus maximus

8. For Your Pain
“Immediate pain reduction can be achieved by altering muscle
activation and movement patterns”
Spine, 8-6-2012. S. McGill, D. Ikede

9. Kinetic Chain =
Functional
Anatomy
Muscles act in
synergy not in
isolation
Muscular strain is
applied along
traceable
“Myofascial Lines”
Movement, not
muscles

10. The Search Is On

11. Laser Focus
• Laser: Light Amplification by Stimulated Emission of
Radiation
• A focused beam of light that emits photon energy
• All photons travelling same direction at same
wavelength = coherent light

12. Laser Focus
“The cell is a machine driven by energy…in every medical tradition
before ours, healing was accomplished by moving energy”.
Albert von Szent-Gyorgi, 1967

13. Well, the answer is best explained using the
basic principles of photochemistry
How Does it work?

14. Branched Chain Effect…
• A single photon can trigger a
reaction in one cell that
causes emission of several
photons
• These then trigger photon
emissions in other cells like a
chain reaction
• This accounts for the fact that
a tiny signal can be multiplied
to cause a rapid and
regenerating flow of energy
through a bio system
James Oschman, PhD. 2006

15. How It Works
• LLLT stimulates cell activation processes which, in turn, intensifies
physiologic activity
• Healing is essentially a cellular process
• Light energy initiates a cascade of reactions
• From cell membrane – cytoplasm – nucleus – DNA
• Cellular amplification

16. How can this “Star Trek” medicine benefit my
patients?
Photobiostimulation results in 2 basic responses:
Increased Cellular
Regeneration
Increased Cellular
Communication
ATP
Production
Nervous system
Living matrix
Phospholipid cell
membrane
Hydration
Due to
Due to

17. Cell Regeneration
Laser Therapy Causes Increased ATP
Production, a Precursor to Cell Division
Photons Absorbed by
Chromophores on Cell
Membrane
Absorption into Molecules
Leads to an Acceleration of
Electron Transfer Reactions
and ATP Production

18. Cell Communication
Integrins: Receptors on Cell Surface
Linking Cell to Surrounding Environment
Unique Bidirectional Transmembrane Signal
Transduction
Photons are
Absorbed and the
Integrin System Aids
in Transduction
Olsen, I.M. and French Constant, 2005, BMC Biology 3:25

19. Laser Therapy
3 components integral to beneficial outcome
LASER
1) Active
ingredient
2) Dosage
3) Delivery
Mechanism
Specific wavelength (color) is
component responsible for
influencing biochemical cascades
Intensity (power of light) determines
a response. Too little limits
response. Too much produces
adverse effect
Manner in which light is delivered
determines proper tissue response
and depth of penetration.
Coherent, focused light insures deep
tissue stimulation

20. Wavelengths
• Expressed in terms of color. Each wavelength has different
properties:
• 635 NM is the frequency of a healthy cell
• 635 NM is the absorbable dose
• 635 NM is visible light
• 635 NM is where DNA replication occurs (photobiostimulation)
• 20 times more effective than longer wavelengths

21. Power and Wavelength
• LLLT accelerates tension healing, increasing fibroblast proliferation and
collagen synthesis
• LLLT effective at reducing post-injury inflammation and accelerated soft-
tissue healing
• LLLT increases ATP…stimulating DNA synthesis and cell proliferation
• 632.5-nm laser “produced a higher deposition of collagen, increasing the
tensile strength of completely severed and surgically repaired rat tendons
Comparative Study Using 685-nm & 830-nm Lasers in the Tissue Repair of Tenotomized Tendons in the
Mouse, Photomedicine and Laser Surgery, Dec. 2006, vol.24(6), p.754-758

22. KEY
• Wavelength (in NM) or color of the light should maximize
cytochrome-C-oxidase (CCO) absorption

23. KEY
• CCO – terminal enzyme of the mitochondrial respiratory chain,
catalyzing the transfer of electrons from reduced cytochrome c to
molecular oxygen
• CCO may be considered to be a mitochondrial photo-acceptor
• LLT at 635nm has ability to influence mitochondrial enzyme activity, in
particular CCO, leading to mitochondrial activity and ATP synthesis

24. Frequency
• Frequency is the blinking quality of the red line
• Frequency (in Hz) – the number of light flashes per second. Allows for
modulation of the light which can overcome clinical plateaus in
patients
• Frequency of 30 or less is visible to the naked eye
• Over 30 – the pulse/blink is too fast to see and it appears as a
continuous line

25. Dr. Rob’s Fab 5
Joint dysfunction
EC Matrix
Exercise/ergonomics/proprioception
Laser therapy
Nutrition:
a) Diet
b) Supplements

26. Laser/Pain Management
Dr. Rob’s take:
• By applying laser energy to affected areas, the frequency sensory
nerve firing is increased, which subsequently increases the frequency
of stimuli to the spinal cord, brainstem, and brain, in turn inhibiting
pain at the spinal cord and brain stem levels

27. Don’t you need a lot of power for the light to
penetrate?
Too much power – not low-level laser

28. Low level laser therapy effect are biochemical and not dermal and
cannot cause heating and thereby damage to living tissue
Low level laser therapy

29. Arndt-Schulz Law
• “Weak stimuli excite physiological activity, moderately strong ones
favor it, strong ones retard it, and very strong ones arrest it.”
• Biomodulation
Restoring the cell back to its natural frequency

30. IT’S ALL
CONNECTED

31. “Spontaneous
healing…all the circuitry
and machinery is there; the
problem is simply to
discover how to turn on
the right switches to
activate the process”.
Spontaneous Healing
Andrew Weil
Using laser light to
“turn on the right switches”

32. Muscle Test – Upper Body
• C1 – Flex/extension
• C2 – Flex/extension
• C3 – lateral flexion
• C4 – rotation
• C5 – deltoid
• C6 – bicep
• C7 – tricep
• C8 – finger flexors
• T1 – finger abductors

33. Low Back and Pelvis
MyotomesMuscles
L1-3 Iliopsoas
L2-4 Quadriceps
L3 Sartorius
L4,5 S1-3 Hamstrings
L4 TibialisAnterior
L5 Toe Extensors
L5 Glute Medius
S1 Peroneus L. & B.
S1 Glut Max/TFL

34. Laser Muscles
• SCM
• Scalenes
• Levator scap
• Trapezius
• Supraspinatus
• Lat dorsi
• Psoas
• Glute max
• Piriformis
• Erector spinae

35. Laser “Locomotor Lock-In”
• Resets NMS in 3D motion
• 4, 9, 33, 60
• Facilitated bodies global integration
• 5 sec.eyes open, 5 sec. eyes closed
• Cross-crawl: right arm – left leg, left arm – right leg
• Aim posterior midline-spine
• Repeat pointing at brain.

36. Core Lock-In
4, 9, 33, 60
30 sec. each side

37. Dr. Rob’s Magnificent 7
1) Posture/pain
2) Overhead squat
3) 1-legged squat
4) Trunk stability push-up
5) Valgus jump test
6) Upper/lower muscle firing patterns
7) Push-up
Functional Movement
Assessment

38. Functional Movement Assessment
(FMA)
• FMA will make the invisible visible very quickly
• Movement never lies
• It tells the unique story of each individual’s history,
compensations and adaptations
• Dysfunctional movement patterns lead to:
• Poor performance
• Increased injury
• Decreased durability and pain

39. Movement
Adhesions limit movement
limited movement creates
compensations
Compensations create stress
Chronic stress creates adhesions

40. Key Laser therapy
Protocols for
Musculoskeletal Injuries

41. Carpal Tunnel Treatment Protocol
• Laser at point/points of involvement (9,16,21,36) – 3
to 5 mins. max
• Laser during movement – 30-60 sec.
• Laser “locomotor lock-in”
• Nerve floss
• Corrective exercise
• Nutritional protocol: B vitamins (B5, B6), omega-3
fatty acids
• Mobilize, manipulate joint restrictions
• Myofascial release

42. Carpal Tunnel

43. Rotator Cuff Injury Treatment Protocol
• Laser at point/points of involvement:
• Muscle/joint/scapular (9,16,42,53)
• Laser during movement – 30-60 sec.
• Laser “locomotor lock-in”
• Corrective exercise
• Nutritional protocol: see 3 Phases of Care
• Mobilize, manipulate joint restrictions
• Myofascial release

44. Exercise and LLLT for
Subacromial Impingement
• Conclusion: This double-blind, randomized control trial showed that
LLT and exercise therapy is more effective than exercise therapy alone
for the purposes of improving pain and active/passive ROM in
patients with subacromial syndrome
Clinical Rheumatology 2011; 30: p1341-46

45. Supraspinatus

46. Intervertebral Disc Tx Protocol (cont’d)
• Core “lock-in”
• Nutritional protocol:
• Glucosamine chondroitin MSM complex
• Omega-3 fatty acids
• Turmeric, ginger, boswelia
• Mg/calcium
• Outer annulus – ca, mg, vit. D, boron, horsetail aerial parts, silica
• Myofascial release
• Mobilize, manipulate, flx/distraction, joint restrictions

47. Intervertebral disc

48. Lat/Medial Epicondylopathy Tx Protocol
• Laser at point/points of involvement: (9,16,42,53)
• Laser during movement: 30-60 sec.
• Laser “locomotor lock-in”
• Corrective exercise
• Core “lock-in”
• Nutrition protocol
• Myofascial release
• Mobilize, manipulation, joint restrictions

49. Lateral
Epicondylopathy:
Laser Protocol

50. Medial
Epicondylopathy:
Laser Protocol

51. Non Surgical Interventions for Rheumatoid
Arthritis
Christie et al
PT Journal December 2007
• LLLT reduces Pain and improves function!!
• Higher Quality of evidence than US, TNS, Heat,
Exercise, ES, Acupuncture.

52. The low-level laser therapy application improves the
healing process of the Achilles tendon of rats
Conclusion: the laser treatment is effective during the
healing process in tendons since there is more
presence of gags and collagen types I and III in tendons
submitted to low-level laser than in tendons without
treatment. With respect to the active isoform of MMP-
2, the low-level laser with a pulsed emission is more
effective than low-level laser continuous
2012 Fascial congress abstract. FR Guerra, CP, Vieira AA Aro, EP Pimentel

53. Effects of LLLT in the development of exercise-
induced skeletal muscle fatigue and changes
in biochemical markers related to post-
exercise recovery
Conclusion: pre-exercise irradiation of the biceps with
an LLLT dose of 6 J per application location, applied in 2
locations, increased endurance for repeated elbow
flexion against resistance and decreased post-exercise
levels of blood lactate, creatine kinase, and C-reactive
protein
J Orthop Sports Phys Ther, 2010 Aug;40(8):524-32

54. Low-Level Laser Therapy for Sports Injuries
Conclusion: LLLT is an effective treatment for sports injuries,
particularly jumper’s knee, tennis elbow, and Achilles tendinitis
Y. Morimoto, A. Saito, Y. Tokuhashi, Low level laser therapy for sports injuries. Laser Ther. 2013;
22(1):17-20

55. Getting Athletes Back in The Game: Low-Level Laser
Therapy For Sports Injuries
“Most athletes with chronic ankle sprains have a proprioceptive deficit
in that injured ankle. Proper proprioceptive exercises coupled with
laser therapy have enabled many of my athletes to avoid the
recurrence so commonly seen with the injury.”
Dr. Robert Silverman
Dynamic Chiropractic, Aug. 1, 2014

56. Low level laser therapy (LLLT) in the
management of neck pain
Conclusion: LLLT reduces pain immediately after
treatment in acute neck pain and up to 22 weeks after
completion of treatment in patients with chronic neck
pain
Lancet, Nov. 13, 2009

57. LLLT Effectiveness
• The International Association for the study of pain found “strong
evidence” for LLLT on myofascial pain syndrome

58. A meta-analysis of the efficacy of laser
phototherapy on pain relief
Conclusion: These findings warrant the conclusion that
laser phototherapy effectively relieves pain of various
etiologies; making it a valuable addition to
contemporary pain management
Fulop AM, Dhimmer S., et al. Clin J Pain. 2010 Oct; 26(8):729-36

59. Frozen Shoulder: The Effectiveness of Conservative and
Surgical Interventions
Conclusion: Strong evidence for
the effectiveness of laser therapy
British Journal of Medicine 2011, Jan. 45(1), p.49-58

60. Treating TMJ Pain with Low-Level Laser
Patients with functional TMJ pain reported significantly reduced pain scores
(pain Visual Analog Scale) following five treatments with low-level laser therapy
0 5 10 15 20 25 30
Before laser
therapy
After laser
therapy
27.5
4.16
Dostalova T, et al. Effectiveness of physiotherapy and GaA/As laser in the management of
temporomandibular joint disorders. Photomed Laser Surg, 2012;30(5):275-80

61. Low-level light stirs in vivo stem cells to
regenerate tissue
• Researches have demonstrated for the first time that non-invasive,
low-power light therapy can prompt stem cells inside the body to
reconstruct tissue
• Research promises a broad range of clinical applications in wound
healing and bone growth
• Led by Dr. David Mooney of Harvard University – the team used a
low-power laser to trigger human dental stem cell to form dentin
(hard tissue that is similar to bone and makes up bulk of teeth)
P.R. Arany, Sci. Trans Med 6, 238 (2014)

62. Low-level light stirs in vivo stem cells to
regenerate tissue (cont’d)
• They outlined the precise molecular mechanism involved and
demonstrated its abilities using multiple laboratory and animal
models
P.R. Arany, Sci. Trans Med 6, 238 (2014)

63. Neurodynamic test – Lower Extremity
• Sciatic: slump or add neck flexion
(SLR) – piriformis
• Tibial: df/ev/SLR - posterior to
the knee
• Peroneal: pf/in/SLR – head of
fibula/medial to b. femoris
• Sural: df/in/SLR – bottom of
calve
• Femoral: prone knee bent –
inguinal ligament

64. Laser Nerves
• Brachial plexus – scalenes
• Median – pronator teres, flexor retinaculum
• Ulnar – olecranon and medial epicondyle
• Radial – triangular space between T minor, LH triceps and humerus
• Sciatic – piriformis muscle
• Femoral – psoas
• Tibial – posterior to knee
• Peroneal – medial biceps femoris/head of fibula
• Sural – calve region
• Tarsal tunnel –at tunnel

66. Cell membrane Health
Alpha-Linolenic Acid (ALA)
(e.g., green vegetables, flaxseed oil)
Steridonic Acid
Eicosatraenoic Acid
delta-5 desaturase
EPA/DHA
(e.g., fish oils)
Cyclooxygenase Lipoxygenase
Delta-4 desaturase
(DHA critical)
PGE3 LTB5
(anti-inflammatory) (anti-inflammatory)
Linoleic Acid (LA)
(e.g., corn, safflower, sunflower oil, grains)
Gamma-Linolenic Acid (GLA)
(e.g., evening primrose, borage, black currant seed oils)
Dihomo-Gamma-Linolenic Acid (DGLA)
delta-5 desaturase
Arachidonic Acid (ArA)
(e.g., grain-fed meat)
Cyclooxygenase Lipoxygenase
PGE2 LTB4
(pro-inflammatory) (pro-inflammatory)
Competing
Delta-6
desaturase
Blocked by insulin,
trans fats, alcohol,
Stress
OMEGA-3 EFA
PGE1
(anti-inflammatory)
OMEGA-6 FA
Competing
B3, B6, C, zinc,
mg. (nutrient
co-enzyme)
Ginger,
turmeric,
bioflavonoids,
boswelia (co-
enzyme)
Cell membrane

67. Laser directed to affected site
Photon Enters Tissue
Alters Cell Permeability
Cellular Photochemical Reaction
Absorbed into Mitochondria  ATP+
Resulting Effects
Rapid Cell Growth  Increased Metabolic Activity
Increased Angiogenesis  Vascular Activity
Suppression of COX-2 Pathway  Decreased Inflammation

68. Simple strategies first!

69. Choosing Your Next Laser
• Regulating considerations – FDA-cleared
• Therapeutic factor – laser light parameters:
• Dose and frequency
• Wavelength
• Power
• Modulation (pulsing) of light
• Non-therapeutic factors:
• Portability
• Size and weight
• Corded or cordless operation

70. What does the low-level laser do
• Laser therapy – stimulates both the nervous system
and site of tissue injury
• Clinically proven to:
• suppress inflammation
• Increase oxygen and blood flow
• Promote muscle calcium update
• Increase neurotransmitter release
• Key – by addressing the injury with a diverse tool it is
possible to resolve the condition more effectively by
suppressing not one but all contributors

71. Dr. Rob’s Sexy Six
1) Laser delivers light energy
2) Lasers can stimulate cell activity
3) Laser is classified based on its power supply
4) Wavelength (color) is the length of the wave of the light energy
5) The kind of tissues treated depends on wavelength and power
supply
6) Laser companies do not always agree

72. Quote
“A mind once stretched by
a new idea never regains
its original dimensions”
Oliver Wendell Holmes

73. Q & A