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A NASA discovery has current applications in orthopaedics Howard B. Cotler, MD, FACS, FAAOS ABSTRACT Low-level laser therapy (LLLT) has been actively used for nearly 40yr, during which time it has been known to reduce pain, inflammation, and edema. It also has the ability to promote healing of wounds, including deep tissues and nerves, and prevent tissue damage through cell death. Much of the landmark research was done by the National Aeronautics and Space Administration (NASA), and these studies provided a springboard for many additional basic science studies. Few current clinical studies in orthopaedics have been performed, yet only in the past few years have basic science studies outlined the mechanisms of the effect of LLLT on the cell and subsequently the organism. This article reviews the basic science of LLLT, gives a historical perspective, and explains how it works, exposes the controversies and complications, and shows the new immedi- ately applicable information in orthopaedics. Key Words Laser, LED, NASA, orthopaedic, injury BACKGROUND The pursuit of space travel has opened new areas for study and knowledge. Space medicine has had applications in various subspecialties. Although some think there is little application in orthopaedics, it may be that there has been much discovered but little appreciated. The National Aeronautics and Space Admin- istration (NASA) was established by the United States government in 1958 as a civilian space program for aeronautics and aerospace research.1 In 1959 the Astronaut Corps was founded. The insertion of humans into space presented many challenges from a biologic standpoint.2 Astronauts in space perform physically demanding work in a challenging environment that includes among other haz- ards, microgravity, which is known to have an adverse effect Financial Disclosure: Dr. Cotler is in private practice and owns Gulf Coast Spine Care Ltd., PA and Laser Health Spa, LLC. He received no financial suport for this manuscript. Correspondence to Howard B. Cotler, MD, FACS, FAAOS, 1200 Binz Street, Suite 970, Houston, Texas 77004 Tel: þ 713-523-8884; fax: þ 713-523-9075; e-mail: mgallegos@gulfcoastspinecare.com 1940-7041 r 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. 72 Current Orthopaedic Practice on bone and muscle to the extent that it places an increased risk for musculoskeletal injury. There is a threefold higher injury rate during mission periods than outside of mission periods for astronauts, and it has been observed that wounds heal more slowly in orbit.2 In 1993, Quantum Devices (Barneveld, WI) developed a light-emitting diode (LED) for NASA to use in their plant growth experiments.3 The experiments demonstrated that red LED wavelengths could boost plant growth, but coincidentally the scientist’s skin lesions began to heal faster as well. NASA subsequently began to study the use of LED to increase the metabolism of human cells and stem the loss of bone and muscle in astronauts. Dr. Harry T. Whelan, a professor of pediatric neurology at the University of Wisconsin, began the study of LEDs and lasers, receiving grants from NASA and and the National Institutes of Health. He determined that astronauts get four problems: immune deficiency, pituitary insufficiency, de- layed wound healing, and muscle and bone atrophy. He observed these results in the laboratory.4--7 MECHANISMS OF ACTION From a historical perspective we now know that light has a biologic effect, but what we need to know is how energy from lasers and LEDs work on a cellular level and what the optimal light parameters are for different uses.8 The power plant of cells is located in the mitochondria that are able to produce cellular energy or adenosine triphosphate (ATP) from pyruvate and oxygen.9--11 When tissues are stressed or ischemic, mitochondria make their own mitochondrial nitric acid (MtNO), which competes with oxygen. The MtNO bind to cytochrome C oxidase (CcO) that displaces oxygen. This subsequently reduces ATP synthesis and increased oxidative stress, which leads to inflammation.12--14 Hypoxic or stressed tissues are affected by LLLT in four stages: (1) light energy is absorbed by cytochrome C oxidase, triggering several downstream effects; (2) nitric oxide is released; (3) ATP is increased; and (4) oxidative stress is reduced.15 These biochemical inter- mediates affect components in the cytosol, cell membrane, and nucleus that control gene transcription, cell prolifer- ation, migration necrosis, and inflammation.16 Cells in blood and lymph, which have been light activated, can travel a distance for systemic effects.17,18 APPLICATIONS The four common targets for LLLT are: Volume 26 Number 1 January/February 2015 INNOVATIONSIN PRACTICEPDF Image | A NASA discovery has current applications in orthopaedics LLLT
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