Low Level Laser Therapy in therapy and performance

Written by Roger White on . Posted in Blog


IMG_1475An increasingly popular trend in sports performance programs has been increased attention to recovery and regeneration methods. Sports performance training, such as weight lifting, conditioning, and plyometrics, are methods that can help individuals improve their sports performance, but at the same, may result in fatigue, delayed onset muscle soreness (DOMS), and a potential decrease in future performance if recovery is not complete before the next strenuous training session. Athletes who recovery quickly may begin to train at higher intensities compared to those who are not fully recovered. Additionally, new technology for sports performance has become increasingly popular as well.

One technological advancement within the past ten years has been the use of low level laser therapy (LLLT). LLLT was approved for use by the FDA in 2002. LLLT has been found in 2500 articles and shown positive results in 120 double blind studies. It has become increasing popular in physical therapy and chiropractic practices to treat pain, reduce inflammation, and other issues specific to those practices. It was not until recently that research has begun to show LLLT has the potential to increase human performance in healthy subjects.

Light amplification by stimulated emission of radiation (LASER) has been used for a variety of medical purposes since the 1960s. Low level laser therapy, also referred to as cold laser, or phototherapy, is a low powered laser that is not able to cut through skin, unlike many surgical lasers. Lasers that are surgical are able to provide enough heat to the tissues to increase temperature over 50 C. LLLT is typically infrared light with wavelengths of 632.5-904 nm with power ranging from 5mW to 25,000mW. Some devices may also include light emitting diodes (LEDs), which have a scatter effect of light, compared to a narrow beam seen from a laser. Devices also come with options of continuous or pulsed light. Pulsed light is more powerful and can penetrate deeper depths in the tissues. It is able to achieve greater light intensity extending deep into the tissue.

Mechanisms of LLLT

LLLT can have a local effect and a systemic effect on an individual. The benefits from a local treatment include increased cell metabolism and collagen synthesis in fibroblasts, increase in action potential of nerve cells, increased immune function, stimulation of DNA and RNA synthesis in the nucleus, increased formation of capillaries by release of growth factors, and increased leukocyte activity..

Systemic effects occur when cells products substances that spread and circulate in blood vessels and lymphatic system. Acupuncture points, trigger points, blood irradiation, lymph nodes, and nerve roots may all be stimulated in order to get systemic effects. LLLT is safe when used properly. Individuals known to have cancer, are pregnant, and are sensitive to light are recommended to not use LLLT. Unlike ultraviolent light which has been shown to cause mutations, LLLT uses infrared wavelengths and are considered safe.

The laser provides photon energy to penetrate the skin, where cellular photoreceptors, more specifically within mitochondria, accept the energy and lead to increased speed on cellular processes. It’s been demonstrated that LLLT influences cytochrome C oxidase in the electron transport chain. Cytochrome C oxidase is the terminal enzyme of the electron transport chain, and when stimulated, increases adenosine triphosphate (ATP) production. ATP Is the main energy source of the cell, and an increase in its production would lead to enhanced cellular function.

During exercise, ROS is generated from contracting skeletal muscle, with nitric oxide (NO) and superoxide being the primary agents. The tissues have a well-developed system to regulate ROS and prevent potential harmful effects. Slow-twitch fibers have a higher concentration of these protective systems than fast twitch fibers. During the inflammatory response, ROS is produced by neutrophils to attack degenerated cells. This increase in ROS is one of the initial events in exercise induced muscle injury, often seen after intense exercise. Since the tissues may be damaged to some degree, these cells and tissues will need ATP to provide energy for the repair process.

When investigating muscle damage and fatigue, common blood markers include blood lactate, creatine kinase, and C reactive proteins (CRP). Blood lactate concentration is widely used to monitor performance and recovery, and it is also a surrogate marker of recovery after exercise. The CRP concentration is a very useful nonspecific biochemical marker of inflammation, measurement of which contributes importantly to (a) screening for organic disease, (b) monitoring of the response to treatment of inflammation and infection, and (c) detection of intercurrent infection in immunocompromised individuals, and in the few specific diseases characterized by modest or absent acute-phase responses.

With this background in place, research by Junior et al. in 2010 found that LLLT pre-exercise LLLT helped increased endurance for repeated elbow flexion against resistance and decreased post-exercise levels of blood lactate, creatine kinase, and C reactive protein. This study is helps provide insight that LLLT has potential to provide performance enhancement benefits from a recovery and workout perspective. Strength and conditioning coaches looking to reduce post exercise fatigue may want to include LLLT into their warm-up and preparations for workouts.


Immune System Modulation

It has been established that a chronic dose of intensive training can decrease immune function. At this point, individuals are likely to become sick and may be required to miss training to recover from such an illness. Using LLLT, athletes may be able to boost immune function. According to Tuner & Hode, blood irradiation using LLLT, also called photohemotherapy, has been used in Russia for many years. When the blood is irradiated, there is improvement in immune system, microcirculation, decrease in blood viscosity, increased oxygenation, normalization of homeostasis, and activation of the proliferation processes. This area of study is still relatively new in research circles, however, the current literature exists to show that laser therapy plays a role in activating and boosting the normal reaction of the immune system components.

From a sports performance perspective, this technique has many important applications. First, intense exercise has been shown to decrease immune function. Decreased immune function is an attribute of intensive training and will eventually lead to decreased performance and potentially illness. Following intensive exercise, the body may see elevated temperatures, cytokines, and stress-related hormones may lead to depression of the body’s immune defenses. Fighting this is important in order to maintain optimal performance.


Photohemotherapy Application

Immunomodulation through blood irradiation (applying laser to a highly vascular area of the body) is important during an athlete’s basic training period, also called general preparation phase. Further, immunomodulation may take place during later phases of training following the basic training phase. According to Potemkin’s protocols, athletes may receive treatment on the apex beat of the heart and on the cubital fossa for a course of 10 days and may be repeated later on in training. During the specialized training phase, additional areas may be treated and include the liver and spleen, which both play an important role in blood physiology. Protocols during strength training include treating specific muscles for short periods of time.

Another benefit from regular photohemotherapy is an increase in microcirculation. Microcirculation includes small blood vessels in the body consisting of the capillary network, the arterioles, and the venules. Microcirculation is responsible for regulation of blood flow in individual organs and for exchange between blood and tissue. Approximately 80% of the total pressure drop between the aorta and the vena cava occurs in these vessels.

An increase in microcirculation improves the body’s self-healing capacity due to increased blood flow to tissues. In a recent study, they found treating areas around the knee led to increased microcirculation. Nitric oxide (NO) is one of the most important physiological regulators of the microcirculation, which activates vasodilatation via activation of cGMP-dependent pathway. Further, it appears blue wavelengths of light might have additional benefit when it comes to blood irradiation.

Blood viscosity, which is the resistance to blood flow, plays an important role in oxygen delivery to the cells. Increased viscosity leads to a decreased on oxygen delivery to the cells. Since LLLT has been shown to decrease viscosity, there would be an increase in oxygenation to the cells. Photohemotherapy would be used during general and intensive training periods.

Treatment Times

A common concern using LLLT is the recommended treatment times to achieve results. According to Potemkin’s recommendations using a 25,000 mW super pulsed laser with a 905 nm wavelength required treatment times of 1-2 minutes for most sites per athlete. Devices with smaller wavelengths and less power might require more time to achieve similar results. Additionally, many treatments can be done multiple times a day, as recommended in the table below.

Table: Applications of Low Level Laser Therapy on Sports Performance

 Before ExerciseDuring ExerciseAfter ExerciseOther
Muscle FatigueXX
Joint PainXX
ImmunomodulationAM & PM
Strength TrainingXXX



 For the strength and conditioning coach, there are many ways to implement laser therapy into a training program. The easiest and fastest protocol would be photohemotherapy administered prior to workout. The laser would be applied to the athlete’s cubital fossa, carotid artery region, or to the apex beat of the heart, all for a period of one to two minutes total treatment time. Ideally this would be done before a workout begins. In a team setting, laser treatment might be included as part of a warm-up station that allows all athletes to participate in a warm-up sequence while getting benefits of laser. Additional lasers would reduce the logistical issues associated with treatment. This treatment would be best suited during the general preparation phases of a yearly training plan.

Laser may also be applied during the strength training segments of workouts. Ideally, the athlete would laser the targeted muscles prior to the session. In larger group settings, applying laser during rest can help keep workout tempo quick, since a treatment time of about one minute is usually required. A three person group may rotate in a spot-lift-laser sequence. It has become increasingly popular for exercise routines to incorporate multiple sets per exercise. In exercises such as squats where multiple muscle groups are involved, the athlete may apply laser to the quadriceps on the first and second sets, the hamstrings on the third and fourth sets, and other areas such as lower back on any additional sets that may be required. In a program that requires only one set of an exercise, such as squats or deadlifts, the athlete can split the treatment time in half. Using this technique would appear to work well in programs that utilize a maximum strength phase that incorporates longer rest periods between sets, compared to shorter rests and lighter loads often seen in the general preparation phases. Since a maximum strength phase would have a limited number of lifts, each athlete would have the potential to utilize the rest time with laser treatments on various muscle groups.

In early 2014, Oregon Project coach Alberto Salazar publically discussed the teams use of LLLT


IMG_1477During therapy sessions, LLLT can be used depending on the athletes status during the session. For example, a runner comes to see me with tightness in the hamstrings and a painful sensation in the Achilles region. I would use the laser for a few minutes on both inguinal regions aiming for the femoral artery and nerve, as they can be reached with larger wavelength lasers. This serves to increase blood flow in a major circulation “highway” that transports blood down through the entire lower leg. Depending on how large of an area, I would move the laser the impaired muscles. Often a trigger point can be done, or a larger scan of the entire muscle. For the Achilles, I would first treat the popliteal fossa, for the same reason we did the inguinal region. Then I would scan the Achilles on the sides, not directly on top of it. I would expect the Achilles pain decreased, if not eliminated following the session, and a sense of looseness in the muscle regions. There is a time delay as a result of the reactions that occur. I would then begin manual massage work as needed on the athlete.



LLLT shows tremendous potential as an innovative and effective recovery and performance enhancement option. As more research is done, LLLT will continue to show promising uses in sports performance. It’s short treatment times allow many athletes to receive treatment in a short time, which is so important in settings such as collegiate environments where time for training is limited based on time of year. Sports performance coaches should explore the possibility of incorporating LLLT into their training plans and joining efforts with their athletic training staff to ensure each athlete performs at their optimal level.

Recommended Reading

Phototherapy 101. Douglas Johnson (2007)

Ernesto Cesar Pinto Leal Junior et al. Effects of Low-Level Laser Therapy (LLLT) in the Development of Exercise-Induced Skeletal Muscle Fatigue and Changes in Biochemical Markers Related to Postexercise Recovery J Orthop Sports Phys Ther 2010;40(8):524-532.

C-reactive protein: a critical update. Mark B. Pepys and Gideon M. Hirschfield  J. Clin. Invest. 111:1805–1812 (2003).

Low-Intensity Light Therapy: Exploring the Role of Redox Mechanisms Joseph Tafur, M.D. and Paul J. Mills, Ph.D. Photomedicine and Laser Surgery Volume 26, Number 4, 2008 Pp. 323–328

The Laser Therapy Handbook.  Jan Tuner & Lars Hode (2004)

Biomedical Support and Quantum Medicine of Top Achievement Sport. Leonid Potemkin (2001)

Lenz et al (2008) Blood viscosity modulates tissue perfusion. Transfus Altern Transfus Med 9(4) 265-272.

Behind the scenes interview: Terrel Hale, Sports Massage Therapist

Written by Roger White on . Posted in Blog

terrelatNBI had time to catch up with Terrel Hale, one of the top sports massage therapists, located in Washington D.C.  Terrel also has had the unique experience working some top events in the US.  He just returned from working the weekend at the Nike Prefontaine Classic in Oregon and had time to answer a few of my questions.





Terrel, how long have you been involved in sports massage?  Do you have a sport of focus?

I have been practicing since 2004, when I went to the summer games in Athens as a volunteer sports massage therapist. I work mostly with runners and triathletes, but have tennis players and winter sports athletes like bobsled and skeleton. Mostly though, it is runners!

Since 2004, has your therapy techniques evolved? 

My work has evolved from my training at the Potomac Massage Training Institute, my study of gross anatomy and my training in both active isolated stretching and active release techniques. I combine all of these to form a holistic session and approach to recovery and injury prevention.

Would you say you have a philosophy for your treatments?

My philosophy in treatment is the integrated approach of mind and body that Plato believed in.  I started a PhD program in Mind Body Medicine with an emphasis on practice.  The program at Saybrook University in San Francisco espouses these same principles of integration I believe in and try to practice with the athletes I work with. I have started using the mental aspect of training with my clients that includes both motivation and imagery. I am currently writing a paper on elite performance and imagery.

What might a session with you be like for an athlete who comes to your clinic in DC

I use the same skill set and principles for ordinary weekend warriors as I do with the elites I've worked with or am working with. There is no difference. A good principle or technique is a good principle or technique!

You have been involved with many races across the country, including the Athens Olympics, Pre Classic, Cherry Blossom, and Boston Marathon to name a few.  How did you get involved in those events? 

Like a lot of things my own involvement with the races I go to comes from the ground up, from the people I know or have met. One thing leads to the next. In the world of sports massage at the races I work at most the therapists know each other. The bigger races like Boston have a place in their web page for massage volunteers.

How do you know which athletes you get to work with and how much time do you have with them?

Usually there is a point person to greet the athletes and point them to the available table. This is common at most of the bigger races like Iron Man

In your experience with runners, is there a common treatment request you get from them?

Most of the runners have issues with their hip flexors and tensor fascia latae and or gluteus medius. I worked on Joanie Bennet Samuelson at one Cherry Blossom race.  She had an issue with her gluteus medius and I used the ART protocol for that and she set a course record for her age group. After the race, I was able to locate ART providers in and around Portland, Maine for her.

Many athletes have limited therapy access due to funds, or other reasons.  In these big race events when you have limited time with the athlete, how do you handle situations where more work is needed on areas? Do you alter your treatment at all?

Usually there is limited time so I focus on what the runner asks me to work on.  I alter my treatment based on the runner's need as any other therapist world. Most often the runner knows her or his body best.

At big events, are any post-race treatments provided? 

Usually there is post race or event massage offered for athletes.

I notice you have a twitter (@TerrelHale), Facebook, and a website (www.Georgetownsportsmassage.biz).  Do you keep in touch with athletes after working with them? 

I have a social media presence.  The runner may choose to they stay in touch with me on either twitter or Facebook. Social media for me is a way for these runners to contact me and make appointments.

Terrel, thanks so much for your time.  It was great to hear about some behind the scenes info that is often not publicized.

For more information on Terrel, check him out on Facebook, Twitter @TerrelHale, and www.Georgetownsportsmassage.biz



Is dynamic warm-up really that good?

Written by Roger White on . Posted in Blog

Dynamic Warm-up

Nearly 15 years ago, published research started appearing discussing the concept of a dynamic warm-up. For many years, athletes and recreational exercise enthusiasts performed stretches held for several seconds. Teams would often sit and count aloud in unison during these stretches. A dynamic warm-up is made up of exercises that are often quick and move various body segments in large ranges of motion.

Early research revealed traditional sit and stretch routines lead to decreased performances in speed and power. Recently, a study investigated the effects on 10K times.

Ten years ago in my graduate school studies as an Exercise Physiology major, I had a sit down talk with my advisor and we started discussing basketball and soccer players who do not start the games and matches, have limited warm-up time. Add baseball for that matter, as guys sit on the bench or stand in the outfield, and yet are then required in a split second, to begin sprinting. As I looked into the research, the common theme in all the testing was the researchers had the test subjects perform a warm-up and then immediately do the testing sequences. It is hard to think of any sport where that reality takes place. This eventually led to my master’s thesis idea.

What would happen if subjects rested upon completion of their warm-up? Would we see the same results? And if so, how long would they last? My study had 4 groups, static and dynamic tested immediately, dynamic with a 5 minute wait, and dynamic with a 15 minute wait. Results favored dynamic warm-up in the immediate and 5 minute rest groups. However, at 15 minutes, test results were no different than the static stretch group. My conclusion is somewhere between 5 and 15 minutes (following the specific warm-up we designed), the performance enhancement leveled off and returned to static levels. So does a dynamic really matter?

Think about the basketball player who does a pre-game dynamic stretch and warm-up at 5:30pm, with a 7pm game, and is not a starter. He might go in the game at 7:45pm. Was all the dynamic stretching beneficial? Compared to soccer, where players can be seen during matches doing various warm-up movements on the sidelines minutes prior to entering, basketball players have no warm-up time. Likewise for the baseball players. When it comes to runners, few perform static stretches or even dynamic stretches and immediately run. Some races, athletes are held up in call rooms or wait areas. Then they are ushered to starting line areas where they strip down to their race uniforms. Sure, you might see an athlete or two do a leg swing or toe touch, but you never see a full out stretch routine prior to racing. Have we ever? Go back years, did anyone do their seated stretches and head out to play? Not that I have witnessed. Usually they would then go do position sport specific activities for a time period until the national anthems and then would start their game/match/race.

In the research on dynamic warm-up, one of my favorite studies included a group who did a static stretch AND then followed immediately with dynamic stretch, and their results were no different than the group who did dynamic alone. (3 groups: static, static and dynamic, dynamic only). To me, this is huge! This gives insight that the static can be done without performance enhancement, as long as some dynamic movements were done.

As a coach and massage therapist, my experience shows few people possess adequate flexibility and mobility. I feel it’s an error to eliminate traditional stretching from pre-workout/race routines. One of my coaching mentors, Charlie Francis, would say athletes should do enough stretching to feel loose, not to improve flexibility. This would be followed by drills and strides. Yet Runners World, twitter feeds and running blogs promote dynamic warm-up in favor of stretching. I bite my lip for not publishing my studies in a paper, as I only presented it at ACSM national conferences as a poster.

To the weekend marathoner who can’t touch his toes and others like him, use some common sense and work to improve your muscle movement abilities. I’ve seen professional and college athletes lack these abilities as well, and that is the first thing I address with them. Any therapist will tell you that lack of movement somewhere leads to compensation somewhere else, and eventually you will get hurt from this. Even when I see athletes perform dynamic arm-up movements, there is often a lot of compensation going on, usually involving the pelvic region.

I love research, but too often the results are used to create guidelines without looking deeper and missing important details. Athletes I coach do both static and dynamic stretching. In 6 years of coaching, I’ve had one muscle pull out of hundreds of kids. Coaches and athletes need to use some common sense when it comes to trends, and dig deeper to the original sources, instead of re-using the same information everyone else is claiming.

Athletes who see me for treatment always get stretched following treatment. I hate giving things names, (as I feel the therapy world is filled with techniques) but it’s a combination of what some call a muscle energy technique combined with PNF and MIMG_1446icrostretching. I don’t care what it’s called, but I do know that it works.

Runners Massage Studio - 2013