1. Wavelengths and emissions
Nd:YAG LASER
Wavelengths and emissions

2. Nd:YAG (λ = 1064 nm) WAVELENGTH
980
808
Therapeutic window
Absorption coefficient
CO₂
Source with a very low absorption coefficient in the tissue

3. Biological effects Emitted energy
Nd:YAG (λ = 1064 nm) EFFECTS
Biological effects Emitted energy
Tissue heating
The energy density or fluence (J/cm2) is the energy per unit area
I (W/cm2) x t (s)

4. Nd:YAG (λ = 1064 nm) EMISSION MODALITY
Continuous emission
Chopped emission
Pulsed emission
Time
Power
Power
Time
Power
Time
Continuous: the average power is equal to the peak power.
Chopped: pulse duration ton is comparable to the period T.
Pulsed: the average power is far lower than the peak power.

5. Nd:YAG (λ = 1064 nm) EMISSION MODALITY
Continuous emission
Chopped emission
Pulsed emission
Fluence (J/cm2): I (W/cm2) x t (s)
In order to avoid thermal damage, emissions are
characterized by low intensities for long times:
Low Efficiency!

6. Nd:YAG (λ = 1064 nm) EMISSION MODALITY
Countinuous emission
Chopped emission
Pulsed emission
(Hilterapia only)
Fluence (J/cm2): I (W/cm2) x t (s)
Excessive thermal increase is avoided thanks to pulses
with very high intensity and very short duration:
High Efficiency!

7. continuous and pulsed systems
Comparison between
continuous and pulsed systems
CW:
Pm = 1,5 W
Spot = 0,3 cm2
Fluence in 10 s = 50 J/cm2
Incident Intensity = 1,5 W / 0,3 cm2 = 5 W/cm2
PW:
Pp = 1500 W
τ-on = 100 μs
Freq.= 10 Hz
Pulse Incident Intensity = 1500 W / 0,3 cm2 = 5000 W/cm2
The Intensity of incident radiation is 1000 times higher in pulsed system respect to continuous system!!

8. Pp Pm=Pp ton toff Pm Diode Laser 632,780, 810, 980, 1064 nm
Tempo
Power
Pm=Pp Pm Pp
ton
toff
Power
Time
PW Emissione
CW Emission
Time Pp Pm
Power
CW-I Emission
Diode Laser 632,780, 810, 980, 1064 nm
Pulsed Nd:YAG 1064nm (only Hilterapia®)

9. Comparison CW/CW-I emission and Hilt®
Pm = 10 W
Spot = 0,2 cm2
Time = 10 sec
Energy = 100 J
HILT® PULSE SH1 :
Pm = 6 W
Spot = 0,2 cm2
Time = 10 sec
Energy = 60 J
Pp = 1000 W
τ-on = 150 μs
Freq = 40 Hz
Intensity= 10W/0,2 cm2 = 50 W/cm2
CW- I:
Pm = 10 W
Spot = 0,2 cm2
Time = 10 sec
Energy = 100 J
Pp = 20 W
τ-on = 10 ms
Freq = 50 Hz
Intensity=1000 W/0,2 cm2 =5000 W/cm2
HILT® PULSE HIRO 3.0:
Pm = 10 W
Spot = 0,2 cm2
Time = 10 sec
Energy = 100 J
Pp = 3000 W
τ-on = 120 μs
Freq = 28 Hz
Intensity =20 W/0,2cm2 = 100 W/cm2
Intensity=3000 W/0,2 cm2 =15000 W/cm2

10. Technical characteristics
Hilterapia®
Technical characteristics

11. Hilterapia® Patented in USA (U.S. Patent n°6,527,797 B1)
Approved by FDA-USA 510 (k) n. K051537

12. Unicity of Hilterapia®
INTENSE
DEEP
SAFE

13. Hilterapia®: why?
Because pulsed technology is able to increase the intensity of incident radiation without increase the total quantity of energy delivered to the tissue, with consequently:
Deeper action, high peak power promote penetration inside the tissues
Elevated efficacy, due to the ability of producing biological effects even in deep tissues.
Higher safety of treatment (to minimize risk of thermal damage during laser treatment).

14. TECHNICAL CHARACTERISTICS of HILTERAPIA®
Nd:YAG source (λ = 1064 nm)
Pulsed emission
Very high peak power (1-3 KW)
Veru high intensity ( W/cm2)
High energy content ( mJ)
Short duration ( µs)
Low repetition frequency (10-40 Hz)
Duty cycle 0,1 % - 0,6 %

15. Vertical delivery of energy!
Power
Time
Vertical delivery of energy!
High peak power pulse, up to 3 kW
Short duration ( µs) and long pulse interval (ms)

16. Power
Time
Low frequency: Hz
Low frequencies minimize damaging thermal effects
It is known that many cell types are more responsive to low frequency stimulations

17. High energy contents delivered in deph
LASER PULSATO
High energy contents delivered in deph
respecting thermal relaxation time of tissues

18. Laser-Tissue Interaction
HILTERAPIA®
Laser-Tissue Interaction

19. HILT PULSE PHOTOTHERMAL INTERACTION: PHOTOMECHANICAL INTERACTION
Increase of kinetic energy
Localized increase of temperature
Formation of temperature gradients
PHOTOMECHANICAL INTERACTION
(resulting from photothermal effect):
Temporary deformation of ECM (extracellular matrix)
Reorganization of cellular cytoskeleton
Induction of specific intracellular signals

20. ACTION ON CELLS OF CONNECTIVE TISSUES:
Induction of cell differentiation (maturation process in which cells specialized themselves to perform the characteristic function of the tissue they belong to) observed in chondrocytes and stem mesenchymal cells.
Exaltation of inflammatory cytokines signaling pathway, promoting reparative, regenerative and remodeling processes in tissue
Increase of ECM production by fibroblasts and chondrocytes
Induction of formation of very ordered arrays of fibronectin fibrils.
Fibronectin is a protein that connects ECM components each other and with cell surface and constitutes a template for collagen fibres assembling.

21. ACTION ON ENDOTHELIAL CELLS :
Promotion of ordered cell monolayers formation, with important consequences on angiogenesis (formation of new vessels) and on endothelial function (in particular, blood-tissue exchange)

22. ACTION ON NERVE FIBERS :
Action on conduction mechanism of peripheral nerve fibers, inducing a dose-dependent reduction of action potential.
In soft tissue can decrease sensitivity to pain

23. HILT PULSE PHOTOTHERMAL INTERACTION PHOTOMECHANICAL INTERACTION
ACTION ON CELLS OF CONNECTIVE TISSUES
ACTION ON ENDOTHELIAL CELLS
ACTION ON NERVE FIBRES
THERAPEUTIC EFFECT
REPARATIVE, REGENERATIVE, REMODELING EFFECT
ANTI-INFLAMMATORY EFFECT
ANTI-OEDEMA EFFECT
ANTALGIC EFFECT

24. Indications, contraindications
HILTERAPIA®
Indications, contraindications
and warnings

25. THERAPEUTIC INDICATIONS
Acute pathologies
Tendinopathies
Muscle lesions
Distortions and dislocations
Post-traumatic edemas
Synovitis and bursitis
Osteochondral lesions
Degenerative and chronic pathologies
Osteoarthrosis
Degenerative chondropathies
Fibromyalgia syndrome

26. CONTRAINDICATIONS
Therapy using the system is contraindicated for those patients who:
• have known sensitivity to the device
• take anticoagulants
• take medication that is known to increase sensitivity to sunlight
• have seizure disorders triggered by light
• are pregnant
• suspected of carrying serious infectious disease and/or disease where
it is advisable to suppress heat or fever
• with hemorrhagic diatheses
• have HIV positive history
E’ bene, comunque, trattare pazienti portatori di pacemaker, donne in stato di gravidanza, pazienti epilettici o applicare la luce Laser su ghiandole endocrine sotto stretto monitoraggio medico.
Inoltre, il Laser non deve essere a contatto con aree infette (piaghe, ulcere) ma l’applicazione va effettuata a distanza.
Da evitare assolutamente il puntamento della radiazione sull’occhio, organo principalmente esposto a danni.

27. CONTRAINDICATIONS The device should not be used:
• over areas of suspicious, potentially or known cancerous tissue
• over areas of active hemorrhage
• over areas injected with steroids in the past 2-3 weeks
• over the thoracic area if the patient is using a pacemaker
• over the sympathetic ganglia
• over the vagus nerve
• over the neck (thyroid or carotid sinus region)
• over or near bone growth centers until bone growth is complete
• over area where analgesia may mask progressive pathology
E’ bene, comunque, trattare pazienti portatori di pacemaker, donne in stato di gravidanza, pazienti epilettici o applicare la luce Laser su ghiandole endocrine sotto stretto monitoraggio medico.
Inoltre, il Laser non deve essere a contatto con aree infette (piaghe, ulcere) ma l’applicazione va effettuata a distanza.
Da evitare assolutamente il puntamento della radiazione sull’occhio, organo principalmente esposto a danni.

28. CONTRAINDICATIONS The device should not be used:
• over anesthetic areas
• over an area of the spinal cord following a laminectomy, i.e., when major covering tissue have been removed
• on ischemic tissue where the blood supply would be unable to follow the increase in metabolic demand and tissue necrosis might result
• for symptomatic local pain relief unless a pain syndrome has been diagnosed or unless etiology is established
Trattamenti sopra i gangli simpatici, sul nervo vago, sulla regione cardiaca, in pazienti con malattie cardiache (possibile alterazione della funzione neurale) sono possibili solo se eseguiti da personale medico e a basse potenze.
Neoplasie: non usare Laser su lesione primaria o secondaria non diagnosticata. Tuttavia, il Laser viene impiegato come terapia del dolore nello stadio terminale della malattia o per il trattamento di danni iatrogeni.

29. WARNINGS No direct aim into the eyes of humans or animals
Patients with an implanted neurostimulation device must not be treated with or be in close proximity to any shortwave diathermy, microwave diathermy, therapeutic laser diathermy or laser diathermy anywhere on their body.
Energy from diathermy can cause tissue damage and can result in severe injury or death, even if neurostimulation system is turned off.
Trattamenti sopra i gangli simpatici, sul nervo vago, sulla regione cardiaca, in pazienti con malattie cardiache (possibile alterazione della funzione neurale) sono possibili solo se eseguiti da personale medico e a basse potenze.
Neoplasie: non usare Laser su lesione primaria o secondaria non diagnosticata. Tuttavia, il Laser viene impiegato come terapia del dolore nello stadio terminale della malattia o per il trattamento di danni iatrogeni.

30. WARNINGS
The application on wounds has to be performed at a certain distance to avoid the spread of bacteria.
Higher output levels have a greater potential for patient discomfort. Choose a lower dosage to reduce output or select a frequenced output to decrease patient discomfort.
Trattamenti sopra i gangli simpatici, sul nervo vago, sulla regione cardiaca, in pazienti con malattie cardiache (possibile alterazione della funzione neurale) sono possibili solo se eseguiti da personale medico e a basse potenze.
Neoplasie: non usare Laser su lesione primaria o secondaria non diagnosticata. Tuttavia, il Laser viene impiegato come terapia del dolore nello stadio terminale della malattia o per il trattamento di danni iatrogeni.

31. DIATHERMY AND HYPERTHERMIA TRADITIONAL LASER THERAPY
ELECTROTHERAPY
1-Chemical effect
2-Thermal effect
SHOCK WAVES
1-Mechanical effect
MAGNETOTHERAPY
2-Magneto-mechanical effect
ULTRASOUND
1-Thermal effect
2-Mechanical effect
DIATHERMY AND HYPERTHERMIA
1-Thermal effect
TRADITIONAL
LASER THERAPY
1-Photochemical effect
2-Photothermal effect
1- PHOTOCHEMICAL EFFECT
2- PHOTOTHERMAL EFFECT
3- PHOTOMECHANICAL EFFECT

32. CLINICAL EVIDENCES

33. Conservative treatment of low back pain caused by intervertebral disk displacement: Comparison among HILT ®, TENS e NSAID
(Zati et al. Medicina dello Sport, 2004, 57: 77-82)

34. Clinical protocol 60 low back pain patients, divided in 3 groups.
Treatment lasted 15 days.
HILT, n=20 pts: 10 Tx, 5 Tx/week
TENS, n=20 pts: 10 Tx, 5 Tx/week
NSAID, n=20 pts: Ketoprofene 200 mg/d. (15 days)
Clinical tests: Backill and VAS at:
T/0 : before treatment
T/1 : 15 days after T/0 (end of treatment)
T/2 : 45 days after T/0
T/3 : 180 days after T/0

35. Total Backill test scores
Results
TENS
NSAID
TENS
NSAID
HILT
HILT
Backill test – t scores
Total Backill test scores

36. Results Total VAS test scores VAS test – t scores HILT TENS NSAID HILT

37. VAS score and Backill score
Results
score
score
HILT
TENS
NSAID
HILT
TENS
NSAID
VAS score and Backill score

38. Hilterapia® effects are more long-lasting
Conclusion
In low back pain Hilterapia® is safe and well-tolerated.
In short terms we obtained similar results using HILT ®, TENS and NSAIDs.
While, in mid and long terms HILT ® allows better and longer results than TENS and NSAIDs.
Hilterapia® effects are more long-lasting

39. Hilterapia® for the treatment of calcifying tendonitis of the rotator cuff
(Valent A., Benedetti E., Istituti Ortopedici Rizzoli, 2003)