Journal of Cutaneous and Aesthetic Surgery
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   Table of Contents     
RESEARCH ARTICLE  
Year : 2014  |  Volume : 7  |  Issue : 1  |  Page : 14-17
Low-level laser therapy: An experimental design for wound management: A case-controlled study in rabbit model


1 Trauma Research Center, General Surgery Department, Shiraz University of Medical Sciences, Shiraz, Iran
2 General Surgery Department, Arak University of Medical Sciences, Arak, Iran
3 Pathology Department, Shiraz University of Medical Sciences, Shiraz, Iran

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Date of Web Publication2-Apr-2014
 

   Abstract 

Background: There is a wide array of articles in medical literature for and against the laser effect on wound healing but without discrete effect determination or conclusion. This experimental study aims to evaluate the efficacy of low-level laser therapy on wound healing. Materials and Methods: Thirty-four rabbits were randomly enrolled in two groups after creating a full thickness of 3 × 3 cm wound. The intervention group received low density laser exposure (4 J/cm 2 ) on days 0, 3 and 6 with diode helium-neon low-intensity laser device (wl = 808 nm) and in control group moist wound dressing applied. Finally, wound-healing process was evaluated by both gross and pathological assessment. Results: Fibrin formation was the same in the two groups (P = 0.4) but epithelialisation was much more in laser group (P = 0.02). Wound inflammation of the laser group was smaller than that of the control groups but statistical significance was not shown (P = 0.09). Although more smooth muscle actin was found in the wounds of the laser group but it was not statistically significant (P = 0.3). Wound diameter showed significant decrease in wound area in laser group (P = 0.003). Conclusion: According to our study, it seems that low-level laser therapy accelerates wound healing at least in some phases of healing process. So, we can conclude that our study also shows some hopes for low level laser therapy effect on wound healing at least in animal model.

Keywords: Experimental study, low level laser therapy, wound healing

How to cite this article:
Hodjati H, Rakei S, Johari HG, Geramizedeh B, Sabet B, Zeraatian S. Low-level laser therapy: An experimental design for wound management: A case-controlled study in rabbit model. J Cutan Aesthet Surg 2014;7:14-7

How to cite this URL:
Hodjati H, Rakei S, Johari HG, Geramizedeh B, Sabet B, Zeraatian S. Low-level laser therapy: An experimental design for wound management: A case-controlled study in rabbit model. J Cutan Aesthet Surg [serial online] 2014 [cited 2019 Jul 15];7:14-7. Available from: http://www.jcasonline.com/text.asp?2014/7/1/14/129962



   Introduction Top


Wound healing is one of the most challenging problems in today's medical issues especially in surgery field. For decades different methods for wound-healing acceleration and prophylaxis against infection has been suggeste. [1],[2] Beside chemical materials, some physical techniques such as electro-stimulation of wound, negative pressure wound therapy (NPWT) and also low-level laser therapy (LLLT) are suggested. [3] There is a wide array of articles in medical literature for and against the laser effect on wound healing [4] but without discrete effect determination or conclusion. In this study, we reviewed previous articles and also studied the effect of low-intensity laser in comparison to classical daily irrigation method on wound healing in rabbit model.


   Materials and Methods Top


In an animal model study, 34 male rabbits of the same race were randomly evaluated in two groups. This study was done in animal laboratory of Shiraz University of Medical Sciences, with permission of research ethics committee. All the rabbits received the same care and food during this study. In all rabbits, a full thickness of 3 × 3 cm wound was made with a surgical scalpel via a transparent measured tool. The intervention group received low density laser exposure (4 J/cm 2 ) on days 0, 3 and 6 with diode helium-neon low-intensity laser device, wl = 808 nm, Eufton, Italy. In this group after each session, wound dressing was done with sterile gauze that was sutured in the wound area. In the control group, the wound was irrigated with sterile normal saline solution, and wound dressing was done in the same way till crust formation. All the wounds were evaluated on days 0, 3, 6, 13 and 20 with the same transparent standardised instrument. For controlling of the observer bias, measurement of the wounds was done by three blinded observes from the Department of Surgery. The Mean of wound measurement of these three observers was applied in the final analysis. Digital photographs were made of the all wounds using the same camera, identical settings and lighting in each session. At the end of study, on the day 20, under general anaesthesia wound biopsy was taken for microscopic and immunohistochemistry (IHC) evaluation. The slides were reviewed by the same pathologist and grading of epithelialisation, inflammation and fibrosis was reported as grading from 1 + to 3+. Also, smooth muscle actin (SMA) reported with IHC method. During the study period, oral and intravenous antibiotics were not applied. For statistical methods in a blind manner in SPSS version 13, rational data were compared with Kruskal-Wallis test. Wound measurement was compared with repeated measure ANOVA. P-value less than 0 .05 was reported significant.


   Results Top


During the study period, one rabbit of the control group died on the first day, and four rabbits in this group died on days 13-20. In intervention group, three rabbits died on days 13-20. Autopsy of all died rabbits ruled out wound infection in the two groups. Changes of wound area of died rabbits were calculated in the final analysis. In this study, three plus wound epithelialisation was shown in 38.6% of the laser group vs. in 0 percent of control group (P = 0.02) [Figure 1]. Fibrin formation was the same in the two groups (P = 0.4). Wound inflammation of the laser group was smaller than that of the control groups but statistical significance was not shown (P = 0.09). Also, more SMA was found in the wounds of the laser group but it was not statistically significant (P = 0.3) [Figure 2]. [Table 1] displays nominal data that were compared between the two groups. Changes of wound diameters showed significant decrease in wound area in laser group during study period (P = 0.003) [Table 2].
Figure 1: Histological sections of different stages of wound-healing process in study group: a) ulcer, (b) granulation tissue formation, (c) fibrosis, (d) scar formation

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Figure 2: IHC for smooth muscle actin

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Table 1: Comparison of pathologic finding between two groups

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Table 2: Comparison of wound area (cm2) changes during study period

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   Discussion Top


As mentioned in the introduction section, there is a wide array of studies on the effect of laser therapy on wound healing in comparison to previous methods and its affect assessment grossly and histopathologically. In clinical studies, many investigators have found contradictory results of the effects of LLLT on wound healing. In laboratory animals accelerated wound closure, increased wound epithelialisation and improved tensile strength of scars were seen. [5],[6],[7],[8] Many other studies showed no improvement of the healing process through LLLT and the above-mentioned affects could not be reproduced. According to experimental studies, low-level laser radiation activates individual cells via three principle effects:

  1. The photobiological action mechanism via activation of the respiratory chain: Primary photoacceptors are terminal oxidases as well as NADH-dehydrogenase.
  2. Activation of other redox chains in cells: In phagocytic cells irradiation initiates a nonmitochondrial respiratory burst (production of reactive oxygen species, especially superoxide anion) through activation of NADPH-oxidase located in the plasma membrane of these cells. The irradiation effects on phagocytic cells depend on the physiological status of the host organism as well as on radiation parameters.
  3. Indirect activation of cells via secondary messengers released by directly activated cells: Reactive oxygen species produced by phagocytes, lymphokines and cytokines produced by various subpopulations of lymphocytes, or NO produced by macrophages or as a result of NO-haemoglobin photolysis of blood cells. [9]


Also, in vitro data suggests that LLLT facilitates collagen synthesis [10] , keratinocyte cell motility [11] , and growth factor release. [12] and transforms fibroblasts to myofibroblasts. [13] However, the benefits of LLLT in wound healing are still controversial. Some animal studies has supported the use of LLLT to facilitate wound healing. [14],[15] Conversely, several studies have shown no advantage in healing with LLLT. [16],[17],[18],[19] These conflicting results are likely due to variations in treatment factors and limitations in experimental design, including comparison of heterogenous clinical wounds, lack of control groups and limited or no blinding of investigators. [20],[21]

Although, there are human studies that have shown that LLLT is effective in burn scar healing [22] and superficial wound healing [23] , Atabey et al. studied on effect of helium-neon laser on wound healing in rabbits and on human skin fibroblasts in vitro but their data did not show significant benefit. [24] In a recent study, the effects of topical tripeptide copper (TTC) complex and helium-neon laser on wound healing has been evaluated in rabbits in which clinical and histopathological effects of TTC and two different doses of laser application (helium-neon laser, 1 and 3 J/cm 2 ) on wound healing with untreated control wounds is compared. [25] In this study, the median time for the first observable granulation tissue was shorter in the low and high-dose laser groups than in the control group, but was not different between the TTC and control groups. Filling of the open wound to skin level with granulation tissue was faster in the TTC and high-dose laser groups than in the control group, but was not different between the low-dose laser and control groups. The average time for healing was shorter in the TTC and high-dose laser groups, but was not different between the low-dose laser and control groups. Histopathologically, wound healing was characterised by a decrease in the neutrophil counts and an increase in neovascularisation. The TTC and high-dose laser groups had greater neutrophil and vessel counts than in the control group, suggesting a more beneficial effect for wound healing. But Kana et al. has shown that the maximum effect of LLLT is with an energy density of 4 J/cm 2 . [26] In another study, Nunez et al. assessed He-Ne laser effects on blood microcirculation during wound healing with laser Doppler flowmetry in vivo. [27] They found out flow alterations and inflammatory response. There were no statistical differences between the groups and the results did not show any significant sustained effect on microcirculation with helium-neon in their study. Gál et al. showed that LLLT at 670 nm positively influenced all phases of rat skin wound healing by studying both irradiated and control wounds. [28] Some studies such as Moore et al. revealed the effect of laser wave length on cell proliferation response and showed that fibroblast proliferate was faster than endothelial cells in response to laser irradiation and most proliferation response occurs in 665 and 675-nm light. [29] So as discussed above the effect of LLLT on wound healing is very controversial. In our study with low-level laser ( wl = 808 nm with 4 J/cm 2 of wound ) as mentioned in the results, effect of laser therapy on wound healing assessed both clinically and histopathologically. Our clinical assessment of wound healing was done in double blinded gross assessment method which confirmed statistically better wound healing in laser group in comparison to control group. But according to our pathological findings, just accelerated epithelialisation of the wound, as the effect of LLLT, was found to be statistically significant. Therefor, according to our study it seems that low-level laser therapy accelerates wound healing at least in some phases of healing process. Hence, we can conclude that our study also shows some hopes for low-level laser therapy effect on wound healing at least in rabbit model.

 
   References Top

1.Mani R. Wound healing at the crossroads. Int J Low Extrem Wound 2007;6:5.  Back to cited text no. 1
    
2.Ravari H, Modaghegh MH, Kazemzadeh GH, Johari HG, Vatanchi AM, Sangaki A, et al. Comparision of vacuum-asisted closure and moist wound dressing in the treatment of diabetic foot ulcers. J Cutan Aesthet Surg 2013;6:17-20.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Hess CL, Howard MA, Attinger CE. A review of mechanical adjuncts in wound healing: hydrotherapy, ultrasound, negative pressure therapy, hyperbaric oxygen, and electrostimulation. Ann Plast Surg 2003;51:210-8.  Back to cited text no. 3
    
4.Simhon D, Halpern M, Brosh T, Vasilyev T, Ravid A, Tennenbaum T, et al. Immediate tight sealing of skin incisions using an innovative temperature-controlled laser soldering device: In vivo study in porcine skin. Ann Surg 2007;245:206-13.  Back to cited text no. 4
    
5.Halevy S, Lubart R, Reuveni H, Grossman N. 780 nm low power laser therapy for wound healing in vivo and in vitro studies. Laser Ther 1997;9:159-64.  Back to cited text no. 5
    
6.Inoue K, Nishioka J, Hukuda S. Altered lymphocyte proliferation by low dosage laser irradiation. Clin Exp Rheumatol 1989;7:521-3.  Back to cited text no. 6
    
7.Mester E, Spiry T, Szende B, Tota JG. Effects of laser rays on wound healing. Am J Surg 1971;122:532-5.  Back to cited text no. 7
[PUBMED]    
8.Yamamoto Y, Kono T, Kotani H, Kasai S, Mito M. Effect of low-power laser irradiation on procollagen synthesis in human fibroblasts. J Clin Laser Med Surg 1996;14:129-32.  Back to cited text no. 8
    
9.Karu TI. Low-power laser therapy. In: Vo-Dinh T, editor. Biomedical photonics handbook. Vol. 48. London: CRC Press; 2003. p. 7-20.  Back to cited text no. 9
    
10.Abergel RP, Meeker CA, Lam TS, Dwyer RM, Lesavoy MA, Uitto J. Control of connective tissue metabolism by lasers: Recent developments and future prospects. J Am Acad Dermatol 1984;11:1142-50.  Back to cited text no. 10
[PUBMED]    
11.Haas AF, Isseroff RR, Wheeland RG, Rood PA, Graves PJ. Low-energy helium-neon laser irradiation increases the motility of human keratinocytes. J Invest Dermatol 1990;94:822-6.  Back to cited text no. 11
    
12.Yu W, Naim JO, Lanzafame RJ. The effects of photo-irradiation on ht secretion of TGF and PDGF from fibroblasts in vitro. Lasers Surg Med Suppl 1994;6:8.  Back to cited text no. 12
    
13.Pourreau-Schneider N, Ahmed A, Soudry M, Jacquemier J, Kopp F, Franquin JC, et al. Helium-neon laser treatment transforms fibroblasts into myofibroblasts. Am J Pathol 1990;137:171-8.  Back to cited text no. 13
    
14.Dyson M, Young S. Effect of laser therapy on wound contraction and cellularity in mice. Lasers Med Sci 1986;1:126-30.  Back to cited text no. 14
    
15.Mester E, Jaszsagi-Nagi E. The effect of laser radiation on wound healing and collagen synthesis. Studia Biophys 1973;35:227-30.  Back to cited text no. 15
    
16.Allendorf JD, Bessler M, Huang J, Kayton ML, Laird D, Nowygrod R, et al. Helium-neon laser irradiation at fluences of 1, 2, and 4 J/cm2 failed to accelerate wound healing as assessed by wound contracture rate and tensile strength. Lasers Surg Med 1997;20:340-5.  Back to cited text no. 16
    
17.Hunter J, Leonard L, Wilson R, Snider G, Dixon J. Effects of low energy laser on wound healing in a porcine model. Lasers Surg Med 1984;3:285-90.  Back to cited text no. 17
[PUBMED]    
18.Lundeberg T, Malm M. Low-power HeNe laser treatment of venous leg ulcers. Ann Plastic Surg 1991;27:537-9.  Back to cited text no. 18
    
19.Saperia D, Glassberg E, Lyons RF, Abergel RP, Baneux P, Castel JC, et al. Demonstration of elevated type I and type III procollagen mRNA levels in cutaneous wounds treated with helium-neon laser: Proposed mechanism for enhanced wound healing. Biochem Biophys Res Commun 1986;138:1123-8.  Back to cited text no. 19
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20.Basford JR. Low-energy laser therapy: Controversies and new research findings. Lasers Surg Med 1989;9:1-5.  Back to cited text no. 20
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21.Baxter GD. Therapeutic lasers: Theory and practice. Edinburgh Churchill Livingstone; 1994.  Back to cited text no. 21
    
22.Gaida K, Koller R, Isler C, Aytekin O, Al-Awami M, Meissl G, et al. Low level laser therapy-a conservative approach to the burn scar? Burns 2004;30:362-7.  Back to cited text no. 22
    
23.Hopkins JT, McLoda TA, Seegmiller JG, David Baxter G. Low-level laser therapy facilitates superficial wound healing in humans: A triple-blind, sham-controlled study. J Athl Train 2004;39:223-9.  Back to cited text no. 23
    
24.Atabey A, Karademir S, Atabey N, Barutçu A. The effects of the helium neon laser on wound healing in rabbits and on human skin fibroblasts in vitro. Europ J Plast Surg 1995;18:99-102.  Back to cited text no. 24
    
25.Gul NY, Topal A, Cangul IT, Yanik K. The effects of topical tripeptide copper complex and helium-neon laser on wound healing in rabbits. Veterin Dermatol 2008;19:7-14.  Back to cited text no. 25
    
26.Kana JS, Hutschenreiter G, Haina D, Waidelich W. Effect of low-power density laser radiation on healing of open skin wounds in rats. Arch Surg 1981;116:293-6.  Back to cited text no. 26
[PUBMED]    
27.Núñez SC, Nogueira GE, Ribeiro MS, Garcez AS, Lage-Marques JL. He-Ne laser effects on blood microcirculation during wound healing: A method of in vivo study through laser Doppler flowmetry. Lasers Surg Med 2004;35:363-8.  Back to cited text no. 27
    
28.Gál P, Vidinský B, Toporcer T, Mokrý M, Mozes S, Longauer F, et al. Histological assessment of the effect of laser irradiation on skin wound healing in rats. Photomed Laser Surg 2006;24:480-8.  Back to cited text no. 28
    
29.Moore P, Ridgway TD, Higbee RG, Howard EW, Lucroy MD. Effect of wavelength on low-intensity laser irradiation-stimulated cell proliferation in vitro. Lasers Surg Med 2005;36:8-12  Back to cited text no. 29
    

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Correspondence Address:
MD Hamed Ghoddusi Johari
Trauma research center, General Surgery Department, Shiraz University of Medical Sciences, Shiraz
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2077.129962

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