The biological effect of low-intensity laser radiation (helium-neon and infrared light) provides a wide range of photochemical and photophysical changes that cause the intensification of structural and metabolic processes that are not associated with a violation of the integrity of the irradiation zones3.

The impact of coherent radiation with a wavelength of 0.63 μm on a biological tissue causes various reactions of the body, namely:

1) an increase in the concentration of alkaline phosphatase in the blood serum;

2) an increase in the content of immunoglobulins O, T-lymphocytes, as well as the phagocytic activity of leu-

3) decrease in the factor that inhibits the migration of macrophages;

4) strengthening of microcirculation and fibrinolytic activity of blood;

5) increase in the mitotic index and nerve action potential;

6) normalization of increased vascular resistance.

The main points in the complex mechanism of the action of laser radiation on biological structures are the perception of light rays by photoreceptors, the transformation of their molecular composition and the change in their physicochemical state. Subsequently, biochemical reactions are activated with the initiation of active and allosteric centers in enzymes and an increase in their number. This is confirmed by a large number of publications on the increase in enzymatic activity after laser therapy4.

The action of coherent light on biological tissue is carried out through specific enzymes - photoreceptors. Schematically, the primary response of biological systems to laser exposure is as follows: the chromophore group of photoreceptors excited by light transfers the energy of electronic excitation to the protein associated with it, and if the latter is attached to the membrane, then to the membrane as a whole. As a result of these processes, the heat that occurs during nonradiative transitions can cause local heating of photoreceptors, which contributes to its reorientation. In this case, the photoreceptor passes through a number of intermediate relaxation states that provide both dynamic and static conformational transformations of the protein and, accordingly, the membrane, with which

a swarm of the photoreceptor is bound, which, in turn, leads to a change in the membrane potential and the sensitivity of the membrane to the action of biologically active substances.

A wide range of biochemical and physiological reactions observed in the body in response to the impact of a low-intensity laser (Fig. 9.1) indicates the promise of its use in various fields of medicine. Analysis of the results of our own observations showed that the use of infrared coherent light in the early postoperative period in patients with genital endometriosis (endometriosis of the ovaries and uterine body [myometrectomy], retrocervical endometriosis) helps to reduce pain, improves blood circulation in the arteries that feed the uterus and ovaries (according to data of transvaginal ultrasound Doppler) and, most importantly, prevents the formation of adhesions in the small pelvis.

During repeated laparoscopy, performed in order to clarify the clinical situation in some patients with ovarian endometriosis, who underwent salpingo-ovariolysis during the previous operation, and in the postoperative period intravaginal low-intensity laser exposure as a rehabilitation treatment, in all cases, no signs of adhesions.

We adhere to the point of view that low-intensity laser is the method of choice for rehabilitation measures at the second (main) stage of physical treatment of patients with genital endometriosis. At the same time, one should not belittle the merits of other highly effective techniques - a low-frequency pulsed electrostatic field, currents of overtonal frequency (ultratonic therapy), alternating and constant magnetic fields.

Research V.M. Strugatsky et al.10 found that the use of a low-frequency pulsed electrostatic field in gynecological patients leads to a decrease in local pain in the small pelvis along the vessels and nerve trunks, as well as correction of hormone-dependent disorders. Despite the fact that the main clinical effects of a pulsed electrostatic field - defibrosing and analgesic - are somewhat less pronounced than in the treatment with traditional physical factors with a similar effect, this method has a significant advantage, namely, the ability to regulate the estrogen-progesterone ratio. Due to this ability, a low-frequency pulsed electrostatic field can be used to treat patients with hyperestrogenia and/or concomitant hormone-dependent formations of the internal genital organs, i.e., when the use of heat-forming or heat-transfer factors is excluded or limited.

Ultratonotherapy is a method of electrotherapy, in which the patient's body is exposed to an alternating current of supratonal frequency (22 kHz) of high voltage (3-5 kV). Currents of ultratonal frequency have a mild effect on the biological tissue, without causing any discomfort. Under the influence of ultratonotherapy, there is an improvement in local blood and lymph circulation, activation of metabolic processes, relief of pain. This method is one of

highly effective means of preventing reocclusion of the fallopian tubes.

The mechanism of action of a magnetic field on a biological tissue is associated with the stimulation of physicochemical processes in biological fluids, biocolloids, and blood elements. It is assumed that anisotropic macromolecules change their orientation under the influence of a magnetic field and, thereby, acquire the ability to penetrate through membranes, thus affecting biological processes. Such biological processes as free radical reactions of lipid oxidation, reactions with electron transfer in the cytochrome system, oxidation of non-heme iron, as well as reactions involving metal ions of the transition group are sensitive to the action of a magnetic field. The magnetic field causes an acceleration of blood flow, reduces the need for tissues and cells in oxygen, has a vasodilating and hypotensive effect, and affects the function of the blood coagulation system. Along with the influence of magnetic fields on physical and chemical processes, the mechanism of their therapeutic action is based on the induction of eddy currents in the tissues, which emit very little heat; the latter, in turn, activates blood circulation, metabolic processes and enhances regeneration, and also provides sedative and analgesic effects5,11.

It should be noted that in the complex of rehabilitation therapy for patients with endometriosis, it is recommended to use radon waters in the form of general baths, vaginal irrigations, microclysters. Radon therapy has a beneficial effect on the body of patients with various allergic reactions, chronic

colitis and neuralgia of the pelvic nerves.

BIBLIOGRAPHY

1. Arslanyan KN., Strugatsky V.M., Adamyan L.V., Volobuev A.I. Early restorative physiotherapy after microsurgical operations on the fallopian tubes. Obstetrics and Gynecology, 1993, 2, 45-48

2. Zheleznoe B.I., Strizhakov A.N. Genital endometriosis. "Medicine", Moscow, 1985

3. Illarionov V.E. Fundamentals of laser therapy. "Respect", Moscow, 1992

4. Kozlov V.I., Builin V.A., Samoilov N.1., Markov I.I. Fundamentals of laser physio- and reflexotherapy. "Healthy" I, Kyiv-Samara, 1993

5. Orzheshkovsky V.V., Volkov E.S., Tavrikov N.A. etc. Clinical physiotherapy. “I am healthy”, Kyiv, 1984

6. Savelyeva G.M., Babinskaya L.N., Breusenko V.1. Prevention of adhesions after surgery in gynecological patients in the reproductive period. Obstetrics and Gynecology, 1995, 2, 36-39

Moskvin Sergey Vladimirovich - doctor biological sciences, Candidate of Technical Sciences, Leading Researcher, State Scientific Center for Laser Medicine named after N.N. OK. Skobelkin FMBA of Russia”, Moscow, author of more than 550 scientific publications, including more than 50 monographs, and 35 copyright certificates and patents; email mail:[email protected] website: www.lazmik.ru

A more detailed description of the primary mechanism of the biological, or, as it is now customary to say, biomodulating action (BD) of LILI, as well as the proof of the model we proposed, can be found in the first two volumes of the series of books "Effective Laser Therapy" [Moskvin S.V., 2014, 2016], which are best downloaded for free on the website http://lazmik.ru.

In this chapter, as well as in some other sections of the book, material is also presented on the secondary processes that occur during the absorption of laser light by living cells and biological tissues, the knowledge of which is extremely important for the clinical application and understanding of the LT methodology as applied to the problem of pain and trophic disorders.

To study the mechanisms of DB LILI, we have chosen a systematic approach to data analysis, for which some part is conventionally distinguished from the whole organism, united by the type of anatomical structure or type of functioning, but each part is considered exclusively in terms of interaction as a single system. The key point of this approach is the determination of the backbone factor [Anokhin PK, 1973]. The scientific literature was analyzed, primarily related to the study of the mechanisms of the BD, the practice of using LILI in clinical medicine, as well as contemporary ideas about the biochemistry and physiology of both a living cell and at the level of organization of regulation of human homeostasis in general. Based on the data obtained, some fundamentally important conclusions were made, which were confirmed in the course of numerous experimental and clinical studies [Moskvin S.V., 2008, 2008(1), 2014].

It is shown that as a result of the absorption of LILI energy, it is transformed into biological reactions at all levels of the organization of a living organism, the regulation of which, in turn, is realized in many ways - this is the reason for the extraordinary versatility of the effects that appear as a result of such an impact. In this case, we are dealing only with the external triggering of the processes of self-regulation and self-recovery of disturbed homeostasis. Therefore, there is nothing surprising in the universality of laser therapy: it is only the result of the elimination of pathological fixation of the body outside the boundaries of normal physiological regulation. Photobiological processes can be schematically represented as the following sequence: after the absorption of photons by acceptors, the absorption spectrum of which coincides with the wavelength of the incident light, biochemical or physiological reactions are triggered that are characteristic (specific) for these absorbing elements. But for laser-induced bioeffects, everything looks as if there are no specific acceptors and responses of biological systems (cells, organs, organisms), the interaction is absolutely non-specific. This is confirmed by the relative non-specificity of the "wavelength - effect" dependence, the response of a living organism to one degree or another takes place in the entire studied spectral range, from the ultraviolet (325 nm) to the far infrared region (10,600 nm) [Moskvin S. IN 2014; Moskvin S.V., 2017].

The absence of a specific spectrum of action can only be explained by the thermodynamic nature of the interaction of LILI with a living cell, when the temperature gradient that occurs at the absorbing centers triggers the launch of various physiological regulation systems. As the primary link, as we assume, are intracellular calcium depots, capable of releasing Ca2+ under the influence of many external factors. There are enough arguments to confirm this theory, however, due to the limitation of the size of the book, we will give only one: all known effects of laser-induced biomodulation are secondary and Ca2+-dependent [Moskvin S.V., 2003, 2008, 2008(1)]!

Turning to energy regularities, even more surprising than spectral ones, let us repeat some basic concepts and foundations, the axioms of laser therapy. The most famous of them is the presence of an optimum dependence "energy density (ED) - effect", which is sometimes called "biphasic", i.e. the desired result is achieved only with the optimal ED of exposure. A decrease or increase in this value in a very narrow range leads to a decrease in the effect, its complete disappearance, or even an inverse response.

This is the fundamental difference between DB LILI and photobiological phenomena, where the dependence on EF has a linearly increasing character over a wide range. For example, the more sunlight, the more intense photosynthesis and increase in plant mass. Does the biphasic nature of the biological action of LILI contradict the laws of photobiology? Not at all! This is only a special case of the manifestation of the physiological law of the dependence of the response on the strength of the current stimulus. In the “optimum” phase, after reaching the threshold level, as the stimulus strength increases, an increase in the response of cells and tissues and a gradual achievement of the reaction maximum are observed. A further increase in the strength of the stimulus leads to inhibition of the reactions of cells and the body, inhibition of reactions or a state of parabiosis develops in the tissues [Nasonov D.N., 1962].

For effective exposure to LILR, it is necessary to provide both optimal power and power density (PM), i.e., it is important to distribute light energy over the area of ​​cells in vitro and the area and/or volume of biological tissues in animal experiments and in the clinic.

The exposure (exposure time) to one zone is extremely important, which should not exceed 300 s (5 min), except for some variants of the method of intravenous laser illumination of blood (up to 20 min).

By multiplying the exposure by the PM, you get the power density per unit time, or EF. This is a derivative value that does not play any role, but is often and erroneously used in the special literature under the name "dose", which is absolutely unacceptable.

For pulsed lasers (pulse power is most often in the range of 10-100 W, the duration of the light pulse is 100-150 ns), with an increase in the pulse repetition rate, the average power increases proportionally, i.e., the EF of exposure.

Interestingly, the EF for pulsed lasers (0.1 J/cm2) is ten times less than for continuous LILI (1-20 J/cm2) for similar experimental models [Zharov V.P. et al., 1987; Nussbaum E.L. et al., 2002; Karu T. et al., 1994], which indicates a greater efficiency of the pulse mode. There is no analogue of such regularity in photobiology.

I would like to mention one more interesting fact- non-linear dependence of DL LILI on exposure time, which is easily explained by the periodicity of waves of increased Ca2+ concentration propagating in the cytosol after activation of intracellular calcium depots by laser light. Moreover, for completely different types of cells, these periods are completely identical and are strictly 100 and 300 s (Table 1). Clinical Research, confirming the effectiveness of LT techniques when using such an exposure, hundreds of times more. We also draw attention to the fact that the effect is observed in a very wide range of wavelengths, therefore, intracellular calcium depots localized in different parts of the cell have a different structure.

Table 1

Optimal exposure 100 or 300 s for maximum in vitro effect

cell type	Result	LILI wavelength, nm	Link
E. coli, S. aureus	Proliferation	467	Podshibyakin D.V., 2010
hippocampus	epileptiform activity	488	Walker J.B. et al., 2005
fibroblasts	Proliferation	633	Rigau J. et al., 1996
fibroblasts	Increasing the concentration of Ca2+	633	Lubart R. et al., 1997(1); 2005
Keratinocytes	Increase in IL-1α and IL-8 mRNA production and expression	633	Yu H.S. et al., 1996
macrophages	Proliferation	633	Hemvani N. et al., 1998
Fibroblasts, E. coli	Proliferation	660	Ribeiro M.S. et al., 2010
Human neutrophils	Increased Ca2+ concentration in the cytosol	812	Løvschall H. et al., 1994
Human buccal epithelial cells	Proliferation	812	Løvschall H., Arenholt-Bindslev D., 1994
E. coli	Proliferation	890	Zharov V.P. et al., 1987
Myoblasts C2C12	Proliferation, viability	660, 780	Ferreira M.P.P. et al., 2009
HeLa	Mitotic activity	633, 658, 785	Yang H.Q. et al., 2012
E. coli	Proliferation	633, 1064, 1286	Karu T. et al., 1994

To illustrate and demonstrate that the activation of mitochondria is a secondary process, only a consequence of an increase in the concentration of Ca2+ in the cytosol, we present the corresponding graphs from only one study (Fig. 1) .

Rice. 1. Change in Ca2+ concentration (1) in the cytosol and redox potential of mitochondria ΔΨm (2) under the action of laser radiation (wavelength 647 nm, 0.1 mW/cm2, exposure 15 s) on human foreskin fibroblasts (Alexandratou E. et al., 2002)

The most important fact is the increase in Ca2+ concentration solely due to intracellular depots (where calcium ions are re-injected after the end of the physiological cycle after 5-6 minutes), and not as a result of the intake of ions from the outside, as many believe. Firstly, there is no correlation between the level of ATP in cells and the transport of Ca2+ into the cell from the outside, the activation of mitochondria is carried out only by increasing the concentration of Ca2+ from intracellular depots. Secondly, the removal of calcium ions from the serum does not delay the increase in the Ca2+ concentration in the anaphase of the cell cycle, i.e., the activation of cell proliferation under the action of LILI is in no way associated with extracellular calcium, membranes, specifically dependent pumps, etc. These processes are only important when exposed to cells that are in the whole body, and are secondary.

The regularities demonstrated above can be easily explained if the mechanisms of the LILR database are arranged in the following sequence: as a result of illumination of the LILR, a thermodynamic disturbance occurs inside the cell (“temperature gradient”), as a result of which the intracellular depot is activated, and they release calcium ions (Ca2+) with a short-term (up to 300 c) an increase in their concentration with the subsequent development of a cascade of responses at all levels, from cells to the body as a whole: activation of mitochondria, metabolic processes and proliferation, normalization of immune and vascular systems, inclusion in the process of ANS and CNS, analgesic effect, etc. (Fig. 2) [Moskvin S.V., 2003, 2008, 2014, 2016].

Rice. 2. The sequence of development of biological effects after exposure to LILI (mechanisms of biological and therapeutic action)

This approach makes it possible to explain the non-linear nature of the dependences "EP-effect" and "exposure-effect" by the peculiarities of the work of intracellular calcium depots, and the absence of an action spectrum - by the nonspecificity of their inclusion. We repeat that what was said above refers to “laser-” and not “photo-” (biomodulation), i.e. only for monochromatic light and in the absence of a specific effect (for example, bactericidal action).

The most important thing in knowing and correctly understanding the mechanisms of DL LILI is the ability to develop and optimize laser therapy techniques, understand the principles and conditions for the effective application of the method.

The dependence of the effect on the modulation frequency, monochromaticity, polarization, etc. forces us to consider these patterns also not entirely from the standpoint of classical photobiology. Here, in our opinion, to characterize the supporters of the “acceptor”, static approach to the study of the mechanisms of the DB LILI, it is appropriate to quote the words of the American writer G. Garrison: “They sorted out the facts. Whereas they analyzed the most complex closed system with such elements as positive and negative feedback, or variable switching. Yes, and the whole system is in a dynamic state due to continuous homeostatic correction. No wonder they didn't get anything." So photobiologists with a similar approach to research did not understand anything about the mechanisms of the LILI database.

So how do biological processes induced by laser light develop? Is it possible to trace the entire chain, from the absorption of photons to the patient's recovery, to fully and reliably explain the existing scientific facts and on their basis to develop the most effective methods of treatment? In our opinion, there is every reason for an affirmative answer to these questions, of course, within the limited general knowledge in biology and physiology.

The mechanisms of the biological (therapeutic) action of low-intensity laser light on any living organism must be considered only from the standpoint of the general nature of both the acting light energy and the organization of living matter. On fig. Figure 2 shows the main sequence of reactions, starting from the primary act of absorbing a photon and ending with the reaction of various body systems. This scheme can only be supplemented with details of the pathogenesis of a particular disease.

Where does it all begin? Based on the fact that low-intensity laser light causes the corresponding effects in vitro in a single cell, it can be assumed that the initial starting point when exposed to biological tissues is the absorption of LILI by intracellular components. Let's try to figure out which ones.

The facts presented above and obtained by T. Karu et al. (1994), the data convincingly prove that such regularities can only be the result of thermodynamic processes that occur when laser light is absorbed by any, i.e., any, intracellular components. Theoretical estimates show that under the action of LILR, local "heating" of acceptors by tens of degrees is possible. Although the process lasts a very short period of time - less than 10-12 s, this is quite enough for very significant thermodynamic changes both in the group of chromophores directly and in the surrounding areas, which leads to significant changes in the properties of molecules and is the starting point of the reaction induced by laser radiation. We emphasize once again that any intracellular component that absorbs at a given wavelength, including water, which has a continuous absorption spectrum, can act as an acceptor, i.e. local temperature gradient, and we are dealing with a thermodynamic rather than a photobiological effect (in the classical sense of the term), as previously thought. This is a fundamentally important point.

At the same time, it must be understood that the “temperature gradient” does not mean a change in temperature in the generally accepted, “everyday” sense, we are talking about a thermodynamic process and terminology from the corresponding section of physics - thermodynamics, which characterizes the change in the state of the vibrational levels of macromolecules and describes exclusively energy processes [Moskvin S.V., 2014, 2016]. This "temperature" cannot be measured with a thermometer.

However, it is precisely the “lack of direct experimental evidence of a local intracellular temperature rise” that is the main argument in criticizing our theory [Ulashchik V.S., 2016]. The remark of V.S. Ulaschik (2016) regarding the fact that the result of this process cannot be only the release of calcium ions, should be recognized as fair. Indeed, there is, albeit a very limited, list of identified patterns that are difficult to explain only by Ca2+-dependent processes, this remains to be studied.

Nevertheless, the conclusions from our theory have already made it possible to qualitatively improve the efficiency of laser therapy methods, their stability and reproducibility, which is already quite enough for its recognition (although it does not reject the need for further development). And it is absolutely impossible to agree with the opinion of a highly respected specialist [Ulashchik V.S., 2016], that “theories” have the right to exist only if there are some “experimental data”, which are often very doubtful and misinterpreted, the conclusions from which are detrimental to clinical practice. For example, the consequence of all such hypotheses is the impossibility of using LILI with a wavelength in the range of 890-904 nm for laser therapy. And what would you order tens of thousands of specialists to do when they have been successfully using just such laser light for more than 30 years, consider it the most effective and get excellent treatment results? Abandon reality in favor of the ambitions of units?

There are no reasonable arguments against the thermodynamic nature of the LILI interaction at the cellular level, otherwise it is simply impossible to explain the incredibly wide and almost continuous spectrum of action (from 235 to 10 600 nm), so we will continue to adhere to our concept regarding the primary process.

With minor local thermodynamic perturbations that are insufficient to transfer the molecule to a new conformational state, however, the geometry and configuration of the molecules can change relatively strongly. The structure of the molecule is, as it were, "leaded", which is facilitated by the possibility of rotations around the single bonds of the main chain, not very strict requirements for the linearity of hydrogen bonds, etc. This property of macromolecules decisively affects their functioning. For efficient energy conversion, it is sufficient to excite such degrees of freedom of the system that slowly exchange energy with thermal degrees of freedom [Goodwin B., 1966].

Presumably, the ability to direct conformational changes, i.e. to their movement under the influence of local gradients, is a distinctive feature of protein macromolecules, and the required relaxation changes may well be caused by laser light of “low” or “therapeutic” intensity (power, energy) [Moskvin S.V., 2003(2)].

The functioning of most intracellular components is closely related not only to the nature of their conformations, but most importantly, to their conformational mobility, which depends on the presence of water. Due to hydrophobic interactions, water exists not only in the form of a bulk phase of a free solvent (cytosol), but also in the form of bound water (cytogel), the state of which depends on the nature and localization of the protein groups with which it interacts. The lifetime of weakly bound water molecules in such a hydration shell is short (t ~ 10-12 ÷ 10-11 s), but near the center it is much longer (t ~ 10-6 s). In general, several layers of water can be held stably near the surface of the protein. Small changes in the quantity and state of a relatively small fraction of water molecules that form the hydration layer of a macromolecule lead to sharp changes in the thermodynamic and relaxation parameters of the entire solution as a whole [Rubin A.B., 1987].

Explanation of the mechanisms of DB LILI from the thermodynamic point of view makes it possible to understand why the effect is achieved when exposed to laser light, and its most important property is its monochromaticity. If the width of the spectral line is significant (20–30 nm or more), i.e., commensurate with the absorption band of the macromolecule, then such light initiates the oscillation of all energy levels and there will be only a weak, hundredths of a degree, "heating" of the entire molecule. Whereas light with a minimum spectral line width characteristic of LILR (less than 3 nm) will cause a temperature gradient of tens of degrees, so necessary for a full-fledged effect. In this case, all the light energy of the laser will be released (relatively speaking) in a small local area of ​​the macromolecule, causing thermodynamic changes, an increase in the number of vibrational levels with a higher energy, sufficient to trigger a further physiological response. Drawing a conditional analogy, the process can be represented as follows: when a magnifying glass concentrates sunlight on a point, paper can be set on fire, while when scattered light illuminates its entire area, only a slight heating of the surface occurs.

The consequence of the photoinduced “behavior” of macromolecules is the release of calcium ions from the calcium depot into the cytosol and the propagation of waves of increased Ca2+ concentration through and between cells. And this is the main, key point of the primary stage in the development of the laser-induced process. Together with the act of photon absorption, the appearance and propagation of waves of increased concentration of calcium ions can be defined precisely as the primary mechanism of DL LILI.

The possible participation of calcium ions in laser-induced effects was first suggested by N.F. Gamaleya (1972). Later it was confirmed that the intracellular concentration of calcium ions in the cytosol under the influence of LILI increases many times [Smolyaninova N.K. et al., 1990; Tolstykh P.I. et al., 2002; Alexandratou E. et al., 2002]. However, in all studies, these changes were noted only in combination with other processes, they were not distinguished in any special way, and only we for the first time suggested that an increase in the Ca2+ concentration in the cytosol is precisely the main mechanism that subsequently triggers secondary laser-induced processes, and it has also been observed that all the physiological changes that occur as a result of this at the most diverse levels, calcium dependent [Moskvin S.V., 2003].

Why do we pay attention to calcium ions? There are several reasons for this.

1. Calcium is in the greatest degree in a specifically and non-specifically bound state both in cells (99.9%) and in the blood (70%) [Murry R. et al., 2009], i.e., in principle, there is the possibility of a significant increase in concentration free calcium ions, and this process is provided by more than a dozen mechanisms. Moreover, in all living cells there are specialized intracellular depots (sarco- or endoplasmic reticulum) for storing only calcium in a bound state. The intracellular concentration of other ions and ionic complexes is regulated exclusively by transmembrane ion currents.
2. The extraordinary versatility of the Ca2 + regulation mechanisms of many physiological processes, in particular: neuromuscular excitation, blood coagulation, secretion processes, maintaining the integrity and deformability of membranes, transmembrane transport, numerous enzymatic reactions, the release of hormones and neurotransmitters, the intracellular action of a number of hormones, etc. [Grenner D. , 1993(1)].
3. The intracellular concentration of Ca2+ is extremely low - 0.1-10 μm/l, therefore, the release of even a small absolute amount of these ions from the bound state leads to a significant relative increase in the concentration of Ca2+ in the cytosol [Smolyaninova N.K. et al., 1990; Alexandratou E. et al., 2002].
4. More and more is known about the role of calcium in maintaining homeostasis every day. For example, a Ca2+-induced change in the mitochondrial membrane potential and an increase in intracellular pH lead to an increase in ATP production and ultimately stimulate proliferation [Karu T.Y., 2000; Schaffer M. et al., 1997]. Stimulation with visible light leads to an increase in the level of intracellular cAMP almost simultaneously with a change in the concentration of intracellular Ca2+ in the first minutes after exposure, thus contributing to the regulation carried out by calcium pumps.
5. It is important to note that the organization of the cell itself ensures its homeostasis, in most cases, precisely through the influence of calcium ions on energy processes. In this case, the general cellular oscillatory circuit acts as a specific coordinating mechanism: Ca2+ of the cytosol - calmodulin (CaM) - a system of cyclic nucleotides [Meerson FZ, 1984]. Another mechanism is also involved through Ca2+-binding proteins: calbindin, calretinin, parvalbumin and effectors such as troponin C, CaM, synaptotagmin, S100 proteins and annexins, which are responsible for the activation of Ca2+-sensitive processes in cells.
6. The presence of various oscillatory contours of changes in the concentrations of active intracellular substances is closely related to the dynamics of the release and regulation of the content of calcium ions. The fact is that a local increase in Ca2+ concentration does not end with a uniform diffuse distribution of ions in the cytosol or the activation of mechanisms for pumping excess into intracellular depots, but is accompanied by the propagation of waves of increased Ca2+ concentration inside the cell, causing numerous calcium-dependent processes. Calcium ions released by one cluster of specialized tubules diffuse to neighboring ones and activate them. This hopping mechanism allows the initial local signal to trigger global waves and fluctuations in Ca2+ concentrations.
7. Sometimes the Ca2+ waves are very limited in space, for example, in amacrine cells of the retina, in which local signals from the dendrites are used to calculate the direction of movement. In addition to such intracellular waves, information can be propagated from cell to cell via intercellular waves, as has been described for endocrine cells, vertebrate gastrula, and intact perfused liver. In some cases, intercellular waves can move from one cell type to another, as happens in endothelial cells and smooth muscle cells. The fact of such propagation of Ca2+ waves is very important, for example, for explaining the mechanism of generalization of laser action during the healing of a significant wound (for example, a burn) under local action of LILI.

So, what happens after the waves of increased Ca2+ concentration began to propagate under the influence of LILI in the cytosol of the cell and between groups of cells at the tissue level? To answer this question, it is necessary to consider what changes LILI causes at the level of the organism. Laser therapy has become widespread in almost all areas of medicine due to the fact that LILI initiates a wide variety of biochemical and physiological responses, which are a set of adaptive and compensatory reactions resulting from the implementation of primary effects in tissues, organs and the whole living organism and aimed at its recovery:

• activation of cell metabolism and increase in their functional activity;
• stimulation of reparative processes;
• anti-inflammatory action;
• activation of blood microcirculation and an increase in the level of trophic provision of tissues;
• anesthesia;
• immunomodulatory action;
• reflexogenic effect on the functional activity of various organs and systems.

Two important points should be noted here. Firstly, in almost each of the listed points, the unidirectional influence of LILI (stimulation, activation, etc.) is a priori set. As will be shown below, this is not entirely true, and laser light can cause exactly the opposite effects, which is well known from clinical practice. Secondly, all these processes are Ca2+-dependent! This is something that no one really paid attention to before. Let us now consider exactly how the presented physiological changes occur, giving as an example only a small part of the known ways of their regulation.

Activation of cell metabolism and an increase in their functional activity occur primarily due to a calcium-dependent increase in the redox potential of mitochondria, their functional activity and ATP synthesis [Karu T.Y., 2000; Philippine L. et al., 2003; Schaffer M. et al., 1997].

Stimulation of reparative processes depends on Ca2+ at various levels. In addition to activating the work of mitochondria, with an increase in the concentration of calcium ions, protein kinases are activated, which take part in the formation of mRNA. Calcium ions are also allosteric inhibitors of membrane-bound thioredoxin reductase, an enzyme that controls the complex process of synthesis of purine deoxyribonucleotides during active DNA synthesis and cell division [Rodwell V., 1993]. In addition, the main fibroblast growth factor (bFGF) is actively involved in the physiology of the wound process, the synthesis of which and activity depend on the Ca2+ concentration.

The anti-inflammatory effect of LILI and its effect on microcirculation are due, in particular, to Ca2+-dependent release of inflammatory mediators, such as cytokines, as well as Ca2+-dependent release of vasodilator nitric oxide (NO), a precursor of endothelial vascular wall relaxation factor (EDRF), by endothelial cells.

Since exocytosis is calcium-dependent, in particular, the release of neurotransmitters from synaptic vesicles, the process of neurohumoral regulation is completely controlled by Ca2+ concentration, therefore, it is also subject to the influence of LILI. In addition, it is known that Ca2+ is an intracellular mediator of the action of a number of hormones, primarily mediators of the CNS and ANS [Grenner D., 1993], which also suggests the involvement of laser-induced effects in neurohumoral regulation.

The interaction of the neuroendocrine and immune systems has not been studied enough, but it has been established that cytokines, in particular IL-1 and IL-6, act in both directions, playing the role of modulators of the interaction of these two systems [Royt A. et al., 2000]. LILI can affect immunity both indirectly through neuroendocrine regulation and directly through immunocompetent cells (which has been proven in in vitro experiments). Among the early triggers of lymphocyte blast transformation is a short-term increase in the intracellular concentration of calcium ions, which activates protein kinase, which is involved in the formation of mRNA in T-lymphocytes, which, in turn, is a key moment laser stimulation T-lymphocytes [Manteifel V.M., Karu T.Y., 1999]. The impact of LILI on fibroblast cells in vitro also leads to increased generation of intracellular endogenous γ-interferon.

In addition to the physiological reactions described above, to understand the picture as a whole, it is also necessary to know how laser light can affect the mechanisms of neurohumoral regulation. LILI is considered as a non-specific factor, the action of which is not directed against the pathogen or symptoms of the disease, but to increase the body's resistance (vitality). It is a bioregulator of both cellular biochemical activity and the physiological functions of the body as a whole - neuroendocrine, endocrine, vascular and immune systems.

Data scientific research allow us to say with full confidence that laser light is not the main therapeutic agent at the level of the organism as a whole, but, as it were, eliminates obstacles, an imbalance in the central nervous system (CNS), which interferes with the sanogenetic function of the brain. This is carried out by a possible change under the action of laser light in the physiology of tissues both in the direction of strengthening and in the direction of suppressing their metabolism, depending mainly on the initial state of the body and the energy density of LILI, which leads to the attenuation of pathological processes, the normalization of physiological reactions and restoration of the regulatory functions of the nervous system. Laser therapy, when used correctly, allows you to restore the disturbed systemic balance [Moskvin S.V., 2003(2); Skupchenko V.V., 1991].

Consideration of the CNS and the autonomic nervous system (ANS) as independent structures has ceased to suit many researchers in recent years. There are more and more facts confirming their closest interaction and mutual influence. Based on the analysis of numerous scientific research data, a model of a single system that regulates and maintains homeostasis, called the neurodynamic generator (NDG) [Moskvin S.V., 2003(2)], was proposed.

The main idea of ​​the NDG model is that the dopaminergic department of the CNS and the sympathetic department of the ANS, combined into a single structure, named by V.V. Skupchenko (1991) phasic motor-vegetative (FMV) system complex, are closely related to another, mirror-cooperative (P.K. Anokhin's term) structure - tonic motor-vegetative (TMV) system complex. The presented mechanism functions not so much as a reflex response system, but as a spontaneous neurodynamic generator that restructures its work according to the principle of self-organizing systems.

The appearance of facts indicating the simultaneous participation of the same brain structures in providing both somatic and autonomic regulation is difficult to perceive, since they do not fit into known theoretical constructions. However, we cannot ignore what is confirmed by everyday clinical practice. Such a mechanism, having a certain neurodynamic mobility, is not only able to provide a continuously changing adaptive adjustment of the regulation of the entire range of energy, plastic and metabolic processes, which was first suggested and brilliantly proved by V.V. Skupchenko (1991), but manages, in fact, the entire hierarchy of regulatory systems from the cellular level to the central nervous system, including endocrine and immunological changes [Moskvin S.V., 2003(2)]. In clinical practice, the first positive results of this approach to the mechanism of neurohumoral regulation were obtained in neurology [Skupchenko V.V., Makhovskaya T.G., 1993] and in the removal of keloid scars [Skupchenko V.V., Milyudin E.S., 1994 ].

The terms "tonic" and "phasic" were originally formulated by the names of the corresponding types of muscle fibers, since the mechanism of interaction between the two types of nervous systems presented for the first time was proposed to explain movement disorders (dyskinesias). Despite the fact that this terminology does not reflect the full significance of NDG, we decided to keep it in memory of the discoverer of such a mechanism for regulating physiological processes - prof. V.V. Skupchenko.

On fig. Figure 3 shows a general scheme demonstrating the concept of GND as a universal regulator of homeostasis, of course, in a “static” state, so to speak. The main idea of ​​such a systematization is to show the unity of all regulatory systems. This is a kind of fulcrum around which the methodology of therapy is built under the motto: “The impact of unidirectional therapeutic factors” [Moskvin S.V., 2003(2)].

The scheme is rather conditional, which is emphasized by the presentation of LILI as the only method for regulating the neurodynamic state. In this case, we only demonstrate the ability of the same therapeutic effect, depending on the EP for the selected wavelength of LILI, to cause multidirectional effects, which is a characteristic property of, if not all, then most non-specific methods of biologically significant influence. However, laser light seems to us to be the most universal therapeutic physical factor, far beyond the scope of just one of the physiotherapeutic methods. And there is every reason for such a conclusion.

The proposed neurodynamic model for maintaining homeostasis allows a new assessment of the systemic mechanisms of mediator and autonomic regulation. The whole set of neurodynamic, neurotransmitter, immunological, neuroendocrine, metabolic, etc. processes reacts as a whole. When the vegetative balance changes at the organismic level, this means that at the same time neurodynamic restructuring covers the entire complex of a hierarchically organized system of internal regulation. Even more impressive is that a local change in homeostasis at the cellular level also causes a reaction of the entire neurodynamic generator, to a greater or lesser extent involving its various levels [Moskvin S.V., 2003(2)]. The details of the functioning of such a mechanism are not yet fully understood, however, over the past few years, the number of publications devoted to the study of this issue has increased like an avalanche in foreign neurological journals. It is more important for us to analyze general patterns associated with the body's response to external influences, some of them are already known and are actively used to improve the efficiency of predicting the results of laser therapy.

First of all, we draw attention to the need to use the terms “regulation” and “modulation”, and not “activation” or “stimulation”, in relation to the LILI DB, since it is now completely clear that laser light is not a unidirectional influence factor, but, as shown us, depending on the EP impact, a shift of homeostasis in one direction or another is possible. This is extremely important when choosing the energy parameters of the therapeutic effect, while at the same time correctly assessing the initial state of the body and for the etiopathogenetic substantiation of LT methods based on the proposed concept of the neurodynamic model of disease pathogenesis.

Normally, there are constant transitions from the phasic state to the tonic state and vice versa. Stress causes the inclusion of phasic (adrenergic) mechanisms of regulation, which is described in detail in the works of G. Selye (1960) as a general adaptation syndrome. At the same time, in response to the prevalence of dopaminergic influence, tonic (GABAergic and cholinergic) regulatory mechanisms are launched. The last circumstance remained outside the scope of G. Selye's research, but is, in fact, the most important moment explaining the principle of the self-regulatory role of the GND. Normally, two systems, interacting, themselves restore the disturbed balance.

Many diseases appear to us to be associated with the prevalence of one of the states of a given regulatory system. With a long, uncompensated influence of a stress factor, a malfunction occurs in the work of the NDG and its pathological fixation in one of the states: in the phasic, which happens more often, or in the tonic phase, as if switching to the mode constant readiness to the response to irritation, affecting almost all regulatory physiological processes, in particular metabolic ones. Thus, stress or constant nervous tension can shift homeostasis and fix it pathologically either in a phasic or tonic state, which causes the development of corresponding diseases, the treatment of which should be primarily aimed at correcting neurodynamic homeostasis. The combination of several circumstances - a hereditary predisposition, a certain constitutional type, various exogenous and endogenous factors, etc. - causes the development of any particular pathology in a particular individual, but the true cause of the disease is common - the steady prevalence of one of the conditions of NDG.

Rice. 3. Schematic representation of the concept of neurodynamic regulation of homeostasis by low-intensity laser light

Once again, pay attention to the most important fact that not only the CNS and ANS regulate various processes at all levels, but, conversely, locally acting external factor, for example, laser light, can lead to systemic shifts, eliminating the true cause of the disease - an imbalance of NDH, and with local illumination, eliminate the generalized form of the disease. This must be taken into account when developing laser therapy techniques.

Now it becomes clear the possibility of multidirectional influence, depending on the energy and spectral parameters of the acting laser light - stimulation of physiological processes or their inhibition. The universality of bioeffects is due, among other things, to the fact that, depending on the EP, LILI both stimulates and suppresses proliferation and the wound process [Kryuk A.S. et al., 1986; Al-Watban F.A.N., Zhang X.Y., 1995; Friedmann H. et al., 1991; Friedmann H., Lubart R., 1992].

Most often, the methods use the minimum, generally accepted EF of laser exposure (1-3 J/cm2 for continuous operation of a laser with a wavelength of 635 nm), but sometimes in clinical practice, it is the conditionally NOT stimulating effect of LILI that is required. For example, in psoriasis, the proliferation of keratinocytes is greatly increased; this disease is typical of a tonic state in which plastic processes are activated. It is clear that minimal EP LILI that stimulates proliferation is inappropriate in this case. It is necessary to act with super-high power at small areas of the illumination zone in order to suppress excessive cell division. The conclusions made on the basis of this model were brilliantly confirmed in practice in the development of effective methods for the treatment of patients with psoriasis [US Pat. 2562316 RU], atopic dermatitis [Pat. 2562317 RU], vitiligo [Adasheva O.V., Moskvin S.V., 2003; Moskvin S.V., 2003], Peyronie's disease [Ivanchenko L.P. et al., 2003].

Now that we have a fairly complete picture of the mechanisms of action of LILI, it is easy to get an answer to some well-known questions. For example, how to explain the biphasic character of the LILI database? With an increase in absorbed energy, the temperature gradient also increases, which causes the release of a larger number of calcium ions, but as soon as their concentration in the cytosol begins to exceed the physiologically permissible maximum level, the mechanisms of Ca2+ pumping into calcium depots are activated, and the effect disappears.

Why is the effect higher in the pulse mode at an average power, 100-1000 times less than in the continuous mode of radiation? Because the time of thermodynamic relaxation of macromolecules (10-12 s) is much shorter than the duration of the light pulse (10-7 s) and a very short, in our understanding, watt pulse has a much greater effect on the state of local thermodynamic equilibrium than continuous radiation in units milliwatt.

Is it effective to use laser sources with two different wavelengths? Absolutely yes! Different wavelengths cause the release of Ca2+ from different intracellular stores, potentially providing a higher concentration of ions, hence a higher effect. It is only important to understand that it is NOT ALLOWED to simultaneously illuminate laser light with different length waves, it must be spaced apart in time or space.

Other ways to increase the effectiveness of laser therapy, known and developed by us on the basis of the proposed concept of the mechanisms of the DL LILI, can be found in the 2nd volume of the series of books "Effective Laser Therapy" [Moskvin S.V., 2014].

Thus, the application of system analysis made it possible to develop a universal, unified theory of the mechanisms of the biomodulating action of low-intensity laser light. As a primary operating factor local thermodynamic shifts appear, causing a chain of changes in Ca2 +-dependent physiological reactions, both at the cellular level and the organism as a whole. Moreover, the direction of these reactions can be different, which is determined by the energy density, the wavelength of laser light and the localization of the impact, as well as the initial state of the organism itself (biological system).

The concept developed by us allows not only to explain almost all the existing scientific facts, but also to draw conclusions both about predicting the results of the influence of LILI on physiological processes, and about possible ways to increase the effectiveness of laser therapy.

Source: Moskvin S.V., Fedorova T.A., Foteeva T.S. Plasmapheresis and laser illumination of blood. - M.-Tver: Triada Publishing House LLC, 2018. - P. 7-23.

1. Physical characteristics of the action of laser light

Laser therapy belongs to one of the fastest growing branches of medicine and veterinary medicine and is widely used in the treatment of dystrophic and traumatic injuries of the musculoskeletal system. For therapeutic purposes, low-intensity laser radiation (LILI) with a wavelength of 0.632 μm and 0.830-0.888 μm (red and infrared optical region of the electromagnetic wave spectrum) is mainly used, which is produced by helium-neon and carbon dioxide lasers.

Mechanisms of action of LILI.

Currently, there are a number of hypotheses regarding the mechanisms of action of LILR on biological objects, which, according to the proposed level of exposure to light, can be conditionally divided into three groups: biophysical, physical, and biochemical, as well as the level of molecular structural changes in cell membranes.

The hypothesis of the biophysical level of impact connects the biological effect of LILI with the interaction of electromagnetic waves with the electric fields of cells. According to the generally accepted theory, the photoelectric effect is due to the primary absorption of a light quantum by an acceptor molecule and its transition to an excited state. In this case, a potential difference arises between the areas of the irradiated object, and the resulting photoelectromotive force activates physiological processes.

The hypothesis of the physical and biochemical level of LILR impact implies that the mechanism of action is associated primarily with photoacceptance by enzymes or substances containing metal ions. In animal cells, such substances include catalase, cytochrome oxidase complex, ceruloplasmin, porphyrins, hemoglobin, etc. A possible mechanism of LILI action may be the reactivation of respiratory chain enzymes (cytochrome c oxidase, NADH dihydrogenase), leading to the restoration of the electron flow, the formation of a transmembrane potential, which ultimately affects cellular metabolism and causes an increase in the antioxidant activity of the body. The physico-biomechanical theory does not exclude conformational transformations of membrane macromolecules. As a result of their structural and functional rearrangements, a physicochemical basis is created for the formation of nonspecific adaptive reactions of cells, which stimulates bioenergetic and biosynthetic processes in the body. In this regard, the hypotheses of the third group, which are based on the assessment of molecular structural changes in cell membranes under the action of laser radiation, are closely related to the hypotheses belonging to the second group. At present, two mechanisms of the possibility of laser action on the plasma membrane are being discussed - the mechanism of acceptance or reception of light quanta. We believe that, in general, the effect of LILI on the cell membrane acts as a triggering factor for a cascade of molecular and morphological sags. In the cell, the biosynthesis of nucleic acids and proteins, redox reactions, enzyme systems are activated, the energy potential increases, the biogenesis of membrane organelles is stimulated, and the charge difference on cell membranes increases. The action of LILI can also be accompanied by hyperplasia of intracellular organelles that mimic the functions of these cells.

Complex intracellular transformations are impossible without the participation of the genetic apparatus of the cell. At present, it has been experimentally proven that LILI affects the genetic apparatus of the cell without gross structural violations of chromosomes (mutations) by modifying individual genes, i.e. The effect of LILR on the cellular genome is of a modifying nature, manifested by activation or inhibition of individual gene loci and does not lead to the appearance of disturbances in the DNA molecule.

Main physical processes, occurring in the skin, mucous membranes and other tissues when light energy is absorbed, are reduced to the manifestation of an internal photoelectric effect, electrical dissociation of molecules and various complexes.

2. Biological aspects of the action of laser radiation

A variety of biological effects, manifested under the action of LILI at the molecular, cellular, tissue, organ and organism levels, also determine a wide range of medical effects: anti-edematous, anti-inflammatory,

analgesic, densibilizing, hypocholesterolonemic, bactericidal, bacteriostatic, immunomodulating, etc. (Petrakov K.A., Timofeev SV. 1994).

As practice shows, the insufficient experimental and theoretical validity of laser therapy methods in some cases, along with a positive effect, has a repulsive side effect. To obtain a predictable clinical effect of laser therapy, it is necessary to take into account individual treatment results. Often you should opt for a safer and simpler method of laser therapy, the effect of which is well studied and confirmed. experimental studies^ Timofeev SV, 2000).

The anti-inflammatory effect is manifested in:

- activation of microcirculation;

- changes in the level of prostaglandins;

- equalization of osmotic pressure;

- reducing tissue swelling. The analgesic effect is manifested in:

- increased levels of endorphins;

- activation of the metabolism of neurons;

- increased pain threshold.

Currently, there are many ways and options for laser therapy, which creates certain difficulties in choosing and rational combination with other methods of treatment.

Methods for laser therapy are divided depending on:

From the radiation power: high-intensity and low-intensity (therapeutic);

From application points (direct impact on organs and tissues, photodynamic therapy, use of irradiated infusion fluids and medicines);

From the method of delivering laser radiation to the tissues and organs of patients (remote, contact, through a liquid medium);

In combination with other physiotherapeutic factors (magnetotherapy, ultrasound, etc.);

Other (laser patch, laser pills).

We have proved that the severity of bioeffects under the influence of LILI depends much more on the points of application than on the method

NILI delivery. For the treatment of pathology of the musculoskeletal system and traumatic injuries, red and infrared radiation is widely used.

3. Method of laser therapy in animals with osteoarthritis

Since osteoarthritis is a disease accompanied by dystrophic changes in the articular cartilage in the epiphyses of the articulating bones, the main task of laser therapy should be pain relief, increased trophism and oxygenation of the tissues of the affected joints by activating macrocirculation, as well as stimulation of recovery processes that allow normalizing joint function. When applying scanning infrared laser radiation to the area of ​​large joints in animals suffering from coxarthrosis, gonorthrosis, arthrosis of the joints of the extremities, a decrease in pain and an increase in the range of motion in the affected joint are noted.

Currently, there is no single, generally accepted method for the treatment of osteoarthritis with laser radiation. There is still no consensus on the choice of the optimal irradiation regimen (radiation power, radiation flux density, exposure, number and regularity of sessions). Differences in the methods of treating osteoarthritis with the help of laser therapy, described in the available literature, are explained by the use of different types of laser devices, the presence of concomitant diseases in sick animals, and, finally, their own clinical and theoretical considerations of the attending physicians. Basically, laser therapy is used as an independent treatment factor, but we have received positive experimental and clinical data on the combination of laser therapy with other physiotherapeutic factors, in particular with magnetotherapy and ultrasound in the treatment of animals with osteoarthritis.

When using laser therapy in the treatment of osteoarthritis, one must take into account the fact that laser light affects the articular cartilage and synovial membrane - the main material substrate on which destructive-dystrophic and inflammatory processes manifest in the joint.

— The action of the laser on the knee joint under conditions of traumatic injury stimulates the biosynthesis of matrix macromolecules by chondrocytes. Pain zones in the area of ​​the joints are irradiated by the method of slow scanning (radiation power 4 mW, session duration 5-8 minutes, number of procedures 8-12).

– Laser therapy of animals with osteoarthritis of the extremities can be carried out by the method of point acupuncture with a red spectrum laser. 6 or 10 points are irradiated in the projection of the joint space (for each point 2 minutes, the total time is no more than 20 minutes). It is possible to carry out combined laser irradiation with a blue and red region of the spectra, as well as alternately separate laser exposure of the blue region of the spectrum (D = 441.6 nm), and then red (D = 632.8 nm) for 10 minutes (6 points in the area of ​​the pathological focus , and 4 points — projection on immunocompetent organs).

— In case of pathology of the hip joint, along with laser therapy (wavelength 0.6328 μm, power 120 mW/cm"), when exposed to reflexogenic paraarticular zones (total exposure 25-30 minutes, course duration 20 days), it is possible to use pulsed magnetic therapy. Combination of data methods can be used in the treatment of patients with osteoarthritis with concomitant diseases: glaucoma, ischemic disease heart and pneumosclerosis.

It should be taken into account that the action of the helium-neon laser "GNL" (wavelength 0.63 μm, mode 0.5 mW/cm2 with an exposure of 10 min and 15 mW/cm2, with an exposure of 2 min) on the growing bone tissue in small domestic animals of different ages is ambiguous. Thus, in young animals, a decrease in the rate of appositional growth is possible, in mature and old animals, an increase in this process.

Calculation of dosages of laser radiation

Average power Emissions by indicator Power - P, 1 mW \u003d 0.001 W					Exposure (time Irradiation) - T, s	Total dose Energy SDE, R*T, mJ

Arthritis, arthrosis

Laser irradiation area	Power (mW)
shoulder joint
elbow joint
wrist joint
Hip
Knee
Small joints of the forelimbs (up to 10 per session)
Small joints of the hind limbs (up to 10 per session)

The irradiated area must be free from any bandages, the coat must be clean. During treatment, the irradiation head is placed or moved slowly over the surface of the animal's body. A gap of 0.3-1.5 cm is maintained between the head of the emitter and the surface to be treated. It is recommended to use a magnetic nozzle. Before each procedure and after it, it is necessary to wipe the working surface of the emitter (or nozzle) with a swab moistened with 70% alcohol or other antiseptic solution.

5. Safety measures when working with lasers

- allow untrained persons to work with laser devices;

- disassemble power supplies;

- leave the device switched on unattended;

- direct the emitter to the eye area or to a mirror surface;

- use a device with mechanical damage. Recommended:

- when working with the device, use safety glasses with blue-green lenses;

- turn on the radiation only after the emitter is installed on the affected area of ​​the animal's body.

Contraindications:

- blood diseases with a primary lesion of the coagulation system (hemophilia),

- decompensated conditions of the cardiovascular system,

- failure of the adaptive system (lack of an adequate response to energy impact), deep sclerosis, severe decompensation in the vascular system.

A wide range of radiation spectra and variability of the energy flow, both in quantitative and resonant terms, reduces the list of contraindications to a minimum.

Practical skills in working with the apparatus, dosing accuracy allow the use of laser therapy in the most critical conditions, as the only still possible method of treatment - energy support. The existence of contraindications is not always a confirmation of the ban on the use of the method due to its negative influence, often contraindications are created due to the lack of experience in using this factor in a similar group of patients. The energy support of life support in any group of patients cannot be essentially negative. It's all about the dose of energy supplied and the body's ability to use it. Only knowledge of the mechanism of action of various radiation spectra, constant experience with laser emitters will ensure the effectiveness of the application and safety for a sick animal.

LASER LOW-INTENSITY THERAPY

Today, the situation in laser medicine can be characterized as enriched by new trends. If you get into the INTERNET, then more than 27,000 references on laser medicine will pop up, and if you add here the work done earlier in the USSR and Russia-CIS for 30 years, then the number of publications will surely exceed 30,000. laser surgery. Today, more than half of all publications are related to the problems of laser therapy. What has changed? First of all, the level of understanding of the mechanisms of the impact of low-intensity optical radiation (LEO) on living organisms has increased.

Recall: we subdivide the therapeutic effect of laser radiation into surgical and therapeutic. Therapeutic, as opposed to surgical, is manager, but not destructive, impact. This means that after exposure, the biological object remains alive. Moreover, if the task of controlling objects in a living organism, set as the main one in laser therapy, is solved correctly, then the biological object becomes “better than it was” after exposure - pathological processes are suppressed in it and natural processes that maintain homeostasis are stimulated. Note that there is a natural "reference point" for NIE - the spectrum of sunlight (see Figure 21.1).

Rice. 21.1.

Dependences of the spectral density of sunlight on the wavelength:

1 - outside the atmosphere; 2 - radiation of a completely black body with a temperature of 5900 0 K; 3 - on the surface of the Earth at middle latitudes (height 30 0 above the horizon).

This "benchmark" has already been discussed above (L1). The intensity of solar radiation integrated over the spectrum in free space at a distance equal to the average distance between the Earth and the sun is 1353 W/m 2 . On the way to the Earth's surface, the radiation is actively filtered by the Earth's atmosphere. Absorption in the atmosphere is mainly due to molecules of water vapor (H 2 O), carbon dioxide (CO 2), ozone (O 3), nitric oxide (N 2 O), carbon monoxide (CO), methane (CH 4) and oxygen ( About 2).

Living organisms in the process of evolution have repeatedly adapted to the changing "electromagnetic environment". About one and a half million species of living organisms live on the surface of the Earth, and all of them exist due to sunlight.

In the 20th century, the situation with the "electromagnetic environment" on Earth turned out to be very different from that which organisms faced during many millions of years of evolution. A lot of anthropogenic radiation has appeared. In the optical (UFICOP) range, laser devices are located above all in terms of spectral radiation density. The dependence of the spectral density of radiation from medical lasers on the wavelength in comparison with a similar dependence for the radiation of the Sun and some other light sources is shown in Fig. 21.2.

Rice. 21.2.

Emission spectrum of various light sources:

1 - sunlight on the Earth's surface in middle latitudes; 2 - maximum estimated level of natural background; 3 – continuous mode neon-helium laser, power 15 mW, wavelength 633 nm, spot area 1 cm2; 4 – superluminescent LED, integrated power 5 mW, maximum intensity 660 nm; 5 – quasi-continuous-wave semiconductor laser, 5 mW, 780 nm; 6 - semiconductor laser of repetitively pulsed mode, pulse power 4 W, 890 nm; 7 - household incandescent lamp 60 W, distance 60 cm.

The solid line covering the entire spectral range from UV to IR shows the "smoothed" level of sunlight at mid-latitudes on a clear summer day. In relation to the natural level of sunlight, the spectral densities of laser and LED devices used in medicine differ greatly. For example, the spectral maximum of the LED irradiator (curve 4, see below) in the corresponding spectral interval is at the level of solar radiation, and a similar curve of the IR laser device based on a quasi-continuous-wave semiconductor laser (curve 5) reaches the maximum estimated level of natural background (curve 2) . At the same time, the maxima of the curves for a pulsed semiconductor laser (curve 6) and especially for a neon-helium laser (curve 3) overlap these values ​​by several orders of magnitude. In this case, the maxima of the spectral density of sources reflect not so much the energy characteristics of light as the degree of its monochromaticity. Thus, the output power of a neon-helium laser exceeds the power of a red LED by only 3 times, and in terms of the maximum spectral density, this excess is more than 10 5 (!).

The increased level of "artificial" EMP in comparison with the natural background corresponds to the appearance on the Earth's surface of additional electromagnetic energy, the value of which is continuously increasing. This energy, in principle, can (and, perhaps, should) “interest” biological systems either in terms of developing a general adaptation syndrome (such as a stress reaction), or adapting to the impact like photosynthesis. The past century, obviously, is too short a period for the implementation of such a large-scale program, but it is necessary to think about the problem now.

Low-intensity optical radiation, primarily laser, has found the widest application in medicine. “It is difficult to name a disease in the treatment of which laser exposure would not be tested. A simple enumeration of the forms and variants of pathology, in the treatment of which the effectiveness of a laser beam is shown, will take up a lot of space, and the list of diseases in which the therapeutic effect of NRI is beyond doubt will be quite representative.

There are many works on studying the mechanisms of action of NEI on biological objects of different levels of organization. - from molecular to organismal and supraorganismal. However, there is still no generally accepted concept of the mechanism of NEI action on living organisms. There are several alternative points of view explaining particular phenomena or experiments.

Why do we say not LILI (low-intensity laser radiation) and LEH (low-intensity optical radiation)? Because of the main characteristics of laser radiation, the wavelength and spectral density. The coherence and polarization of laser radiation do not affect the biostimulation effect to such a strong extent, although there are no sufficient grounds to assert that they do not matter at all.

Among the problems of phototherapy, which are in the center of attention of both physicians and biologists, and equipment developers, the main - elucidation of the mechanisms of action of NRI on biological objects. This problem has been central for almost 50 years of the development of LILT. So far, it is far from being resolved, although the very fact of a sharp increase in interest in LILT in the last 10 years speaks of positive shifts in its study. Among physicians and biologists, an idea has been formed about the specificity and nonspecificity of the interaction of NEI with living organisms. Exactly, specific is called the interaction of light and BO associated with intense molecular absorption of light, i.e. one for which "specific" photoacceptors are installed, which carry out the primary absorption of light and then trigger a number of "specific" photochemical reactions. A typical example of such an interaction - photosynthesis. Respectively, non-specific interaction is considered when the biological response is large, and the absorption of light is so small that it is not possible to unambiguously determine the primary acceptor. It is this aspect - establishment of primary acceptors in the absence of strong absorption - and causes the most fierce discussions, since the transformation of a non-specific interaction into a specific one opens the way to practical application LILT is not on an empirical, but on a strictly scientific basis.

The phenomenon of NIE action is being investigated at various levels. This refers to the hierarchical levels of building a living system: molecular, organoid, cellular, tissue, organismic, supraorganismal. Each of these levels has its own problems, but the greatest difficulties are associated with transitions from one level to another.

If, first of all, one should take into account the spectral density and wavelength, then this means that a similar biological effect can be provided by both laser and incoherent sources (primarily LEDs), provided that the indicated characteristics coincide.

The spectral range in which laser therapeutic devices operate corresponds to the "transparency window" of biological tissues (600-1200 nm) and is far from the characteristic electronic absorption bands of all known body chromophores (exception - eye pigments that absorb at 633 and 660 nm). Therefore, about any significant absorbed energy is out of the question.

Nevertheless, under the influence of NEI, a number of clinical effects are observed, which for a long time serve as the basis of LILT. If we try to generalize all these effects, we can formulate non-specific integral action at the cellular level: laser radiation affects the functional activity of cells. However, it does not change the function itself, but can enhance its intensity. That is, the erythrocyte as it crawled through the capillaries, giving oxygen through its shell and walls of the capillaries, and continues to do this, but it after irradiation can do it better. The phagocyte both caught and destroyed pathogenic guests, and continues to do so, but with different speed. In other words, under the influence of NOI the rate of cellular metabolism processes changes. In physico-chemical terms, this means that potential barriers to key biological reactions change their height and width. In particular, NEI can strongly influence the membrane potential. With an increase in the membrane field strength, the activation barriers for enzymatic reactions related to membrane transport decrease, thereby providing exponential increase in the rate of enzymatic reactions.

The key concept when considering the action of the NIE is spectrum of biological activity (SBD) . The definition of SBD has already been given in the CFAF course. Because of its importance, let us recall it once more.

If, as a result of the absorption of light, some New Product, then the time dependence of the concentration of this product c(t) obeys the equation:

(21.1)

Where η - quantum Efficiency, σ - light absorption cross section in terms of a single quantum, Ι(t) - incident light intensity, ħω - energy of the absorbed photon.

Obviously, means the number of absorbed photons. If we introduce into consideration the function , which has the meaning of the rate of production of biomolecules of a given type in terms of one photon with a wavelength λ, then it is a quantitative expression of SBD. Qualitatively, SBD is defined as dependence of the relative efficiency of the studied photobiological effect on the wavelength. SBD, therefore, is that part of the absorption spectrum that is responsible for a certain photobiological effect. On molecular level one can consider the SDU in terms of a single quantum. But SBD is interesting in that it can be considered at any system level. Indeed, all the radiation absorbed by a biological object forms its absorption spectrum (AS). But the spectrum of biological action is formed only those molecules that initiate this effect. Therefore, it is natural to call the molecules responsible for SBD differential molecules (as opposed to background molecules responsible for the entire SP). Often SBD is considered as an additive part of the SP. But such a consideration can be recognized as correct only if there is a recipe for separating the SDU from the PN (similar to how a signal is distinguished from noise due to the difference in correlation functions under strong noise). If the noise is of a modulating nature, i.e. is not present as added to the signal magnitude, but how factor, so that the amplitude of the noise increases with the growth of the signal, then the selection useful information becomes drastically difficult. The additivity of the SDB with respect to the SP can only be considered in the case linearity interaction of laser radiation with the biomedium, or with a deliberately negligible interaction of differential molecules with each other. In very many cases, this does not seem obvious, since, as a rule, any photobiological effect has a threshold character, i.e. exhibits non-linearity. Therefore, for the registration of SDB, a methodological compromise is required, including transition from one system level to another. Exactly,

1) selection of a standard and, if possible, well-studied biological object with stable and reproducible characteristics;

2) the choice of the parameter P, which characterizes the biological object at a higher (in this case, cellular) level, so that P is linearly is associated with the probability of a microevent (the primary act of excitation of a biomolecule), i.e. its measurement would not introduce perturbations into the cell and would make it possible to realize an acceptable accuracy;

3) the presence of a radiation source that is tunable in a given range of the spectrum with sufficient monochromaticity and a given intensity to achieve the desired effect.

Simultaneous provision of these conditions presents great practical difficulties. Therefore, the information given in the literature on the measurement of SBD is almost all untenable from a methodological point of view. The exception is the work carried out at FIAN (S.D. Zakharov et al.) in conjunction with the Oncological Center of the Russian Academy of Medical Sciences. N.N. Blokhin (A.V. Ivanov et al.).

Investigation of biological action spectra - it is the path from the non-specific action of light to the specific. The main "stumbling block" in the search for a primary photoacceptor ("the problem of the primary photoacceptor") - it is the absence of noticeable NEI absorption for all wavelengths used in phototherapy. Therefore, within the framework of traditional photobiology, laser biostimulation effects do not find a satisfactory explanation. As for “non-traditional” photobiology, here water (intracellular, interstitial, etc.) comes to the fore as a universal nonspecific photoacceptor, suggesting the presence of primary photophysical processes. This concept assumes that primary The photoacceptor (at the molecular level) is dissolved molecular oxygen, which, upon absorption of a light quantum, passes into the singlet state. Thus, specificity at the molecular level is combined with nonspecificity at subsequent levels of the systemic hierarchy. The transition 3 O 2 → 1 O 2 occurs at wavelengths of 1270, 1060, 760, 633, 570, 480 nm, and this transition is forbidden for an isolated O 2 molecule. However, in an aqueous medium, the formation of singlet oxygen is possible, and this is primarily manifested in the excitation spectrum of the cellular reaction of erythrocytes (as a change in membrane elasticity). The maximum of this effect corresponds to 1270-1260 nm (absorption band of molecular oxygen), and the shape of the spectrum coincides in detail with the line of transition from the ground state to the first excited state of molecular oxygen (3 Σ g → 1 Δ g).

Singlet oxygen plays a key role in almost all processes of cellular metabolism, and a very small change in the concentration of 1 O 2 (within an order of magnitude) is required to change the nature of enzymatic reactions. The experiments of recent years (in particular, G. Klima) have shown that the cell growth rate for the most important cell cultures (leukocytes, lymphocytes, fibroblasts, malignant cells, etc.) varies significantly depending on the energy density (ranging from 10 to 500 J / cm 2), mode and wavelength of the incident radiation. The transition from the molecular level to the cellular level is carried out through a change in the structure of the water matrix. Quenching of singlet oxygen can occur, as is well known, either chemically or physically. In the absence of sensitizers (see below, Chap. 24), we can assume that physical quenching predominates (protection against chemical quenching is well developed in cells). During the physical deactivation of 1 O 2 molecules, an energy of the order of 1 eV is transferred to the vibrational sublevels of the surrounding molecules. This energy is sufficient to break hydrogen bonds, create ionic or orientational effects. The average vibrational energy per degree of freedom at physiological temperature (~ 310 K) is ~ 0.01 eV, so the local release of 1 eV energy leads to a strong perturbation of the structure of the near environment of the dissolved 1 O 2 molecule. If we assume that the medium is within molecular scales of distances obeys the laws of heat conduction (which, generally speaking, is not true!), then as a result of solving the equation for the spherically symmetric case, we obtain:

Where Q- instantly released energy at the initial moment, D- coefficient of thermal conductivity, H- heat capacity, ρ - the density of matter. If we substitute here the data for water and take Q= 1 eV, then over a time of about 10 -11 s, the release of such energy will lead to heating up to 100 0 С of a region with a diameter of ~10Å (10 -7 cm). This estimate, obviously unjustified at small distances, can be considered as the lower limit of the space-time scale for a kind of microhydraulic shock. In a thermodynamically stable state, a single perturbation at distances of ~10 -7 cm cannot play a significant role and must be destroyed with a guarantee by thermal fluctuations. However, biofluids cannot, generally speaking, be considered as thermodynamically equilibrium structures. To model processes in biofluids, one should use the metastable state of solutions of biomolecules that occurs in initial phases dissolution process. The peculiarity of such metastable states - high sensitivity to local perturbations.

Let us estimate the volume of the perturbation sphere without resorting to the heat equation. Assuming that the average vibrational energy per molecule of the water matrix is ​​0.01 eV, we find that the deactivation energy of 1 O 2 in 1 eV is evenly distributed among 100 water molecules. Intracellular or interstitial water are structures close to a liquid crystal (one-dimensional long-range order), with a distance between molecules of ~ 2.7 Å. When such particles are "folded" into a spherical layer, 100 molecules are just placed inside a sphere with a radius of ~ 10 Å, which qualitatively coincides with the "antiestimation" in terms of thermal conductivity.

The change in the structure of the water matrix should be reflected in the change in the refractive index of the bioliquid solution, which was observed experimentally when irradiating bioliquid solutions with He-Ne laser radiation (λ = 632.8 nm).

Note that dynamic excitations of liquid-crystal water can, under certain conditions, lead to the emergence of collective dynamic states (similar to exceeding the generation threshold in a laser, where an avalanche-like increase in the predominance of stimulated emission is denoted). In other words, the dynamics of water becomes coherent, so that the structure of the liquid in the volume of a certain cluster becomes dominant in the entire volume of the solution. According to estimates, in 1 cm 3 of water there are on average 10 16 -10 17 clusters, of which only 10 10 -10 11 molecules of photoexcited singlet oxygen appear (~ 10 -6 of the total number). Upon relaxation of these clusters, nuclei of a new structural phase are formed. Synergetics during the growth of embryos gives a change ∆n0, which is 10 6 times larger than would correspond to the reorientation of an individual cluster. This was just observed experimentally (SD Zakharov et al., 1989): absorption of light from a laser within 10 -2 -10 -9 J caused such a change in the refractive index of blood plasma, which would correspond to the "cooling" of the entire volume of the medium by ~ 6 J (!). After Zakharov, dependences similar in nature were observed in solutions of proteins, lipids, glycoproteins, etc. The common ingredient for all these substances is water, and this indirectly confirms the conclusion that water is universal nonspecific acceptor for all types of electromagnetic radiation, the "specific" acceptor for which is the dissolved gas from the air (О 2 , N 2 , CO 2 , NO, etc.). Thus, primary processes involving air gases (“respiratory chain”) lead to secondary processes associated with the reorientation of the water matrix.

Secondary processes are otherwise called dark, meaning that many reactions at the cellular level caused by irradiation occur long enough after the cessation of irradiation. For example, the synthesis of DNA and RNA after a 10-second exposure is observed after 1.5 hours. The abundance of possible secondary mechanisms today does not allow building a more or less convincing "bridge" between the cellular and tissue levels, similar to the "coherence" of the orientation of the water matrix. Nevertheless, the accumulation of data speaks in favor of the predominance of redox processes.

When analyzing processes at the tissue level, the characteristics of the incident radiation come to the fore (not only the wavelength and dose, but coherence, polarization, and spatial distribution of power). The role of coherence causes particular controversy.

In favor of the need to take into account coherence is the fact that when laser radiation is scattered from a biological object, a speckle structure is always observed, which carries information about the object (for more details, see below, Chap. 27) and makes it possible to achieve a therapeutic effect under certain conditions. The speckle structure is observed only at a sufficiently high degree of coherence of the incident radiation. This means that coherence cannot be neglected, especially since for various types laser sources, the degree of coherence can vary quite strongly (see Fig. 21.2, where the spectral density for a neon-helium laser is many times greater than that for a semiconductor laser due to higher monochromaticity; but monochromaticity - a direct consequence of temporal coherence).

Opponents of accounting for coherence argue in their favor that coherence is destroyed almost immediately when laser radiation interacts with optically anisotropic biological tissues. Numerous experiments at the cellular and subcellular levels show that similar effects are observed both when using a laser and incoherent sources (an incandescent lamp equipped with a light filter).

Apparently, the truth, as it usually happens, is hidden somewhere between polar points of view. In the process of reemission inside the tissue, coherence is indeed destroyed. But at the same time, zones are formed with a high degree spatial inhomogeneity of radiation. The degree of emerging spatial inhomogeneity is directly related to the degree of coherence of the incident radiation. The high power density causes local non-linear effects at the level primary processes. At the cellular level, this non-linearity will inevitably cause a corresponding non-specific reaction. Thereby:

1) biological tissue affects radiation, destroying coherence;

2) radiation affects the biological tissue, changing its characteristics in accordance with the degree of coherence of the incident radiation.

So, coherence does not disappear in tissues without a trace, but gives rise to a cascade of processes on which the effect at the tissue level depends. Detailed study The spatial and temporal characteristics of these processes will make it possible to unequivocally establish the role of coherence in specific cases (see the literature on L. 27).

The dose dependence of the effect at the tissue level can also take on a specific character. There are three dose thresholds:

1) the minimum dose that causes changes at the cellular level;

2) the optimal dose causing a) enhancement of morphogenesis processes, b) acceleration of proliferation, c) cell differentiation;

3) the limiting dose at which stimulation is replaced by inhibition of proliferative activity.

The quantitative expression of dose thresholds depends on many parameters (laser characteristics, functional state tissues, general condition of the body). In general, it is easy to establish a systemic connection between the complexity of elucidating mechanisms and the level of organization at which we want to establish any patterns: the higher we climb the hierarchy, the more noticeable the role of empiricism. Isolation of the primary photoacceptor at the molecular level makes it possible to build, albeit with considerable difficulty, a picture of secondary effects at the subcellular and cellular levels. The transition from the cellular to the tissue level is already much more difficult, so recommendations for choosing a dose are no longer at the level of writing solutions to certain equations, but at the level of a verbal description of possible processes. The transition from the tissue level to the organismic level generally involves a significant amount of shamanism: do as I say, otherwise it will be bad. But, on the one hand, not to become like the primitive clergy, and on the other - not to build a thoughtful theoretician out of himself, who all his life calculates not what is needed for practice, but what he himself likes, let's try to generalize the problem to supraorganismal level.

All living systems are open non-equilibrium systems operating on the balance of matter and energy in exchange with environment. A living system is constantly self-organizing, i.e. reduces its entropy. The intensity of the decrease in entropy is directly related to the amount of information entering the system. From this point of view, low-intensity optical radiation acts as an external signal (information), which abruptly transfers the trigger (energy-information state of the pathological focus with entropy predominance) from one stationary state to another. The transfer of an organism as a system from one state to another is inextricably linked with biorhythms. The range of biorhythms extends from 10 - 15 s (the time of one period of a light wave, which has the same order as the time of molecular electronic transitions) up to ~ 7 10 10 s ( average duration life), thus amounting to about 10 25 Hz on the frequency scale. The task of optimizing the impact at the organismal level - bring the impact in line with biorhythms.

With regard to low-frequency biorhythms, measured in days, weeks, months, years, exposure optimization means conducting irradiation sessions at those moments when it contributes to streamlining natural processes and fail pathological, which is an increase in the entropy of the organism as a system. For example, the treatment of chronic diseases that worsen in accordance with the seasons (spring, autumn) prescribes NILT courses at the beginning of the corresponding season, even before the next exacerbation of the disease begins. Practice shows that the effectiveness of treatment increases, and this applies not only to phototherapy itself, but also to concomitant medication and other methods of treatment. Prevention of long-term effects of radical treatment also recommends periodic repetition of LILT courses in accordance with the temporal characteristics of pathological processes (for more details, see L.23). Sometimes this approach to LILT at the organismal and supraorganismal levels is called chronobiological.

With regard to high-frequency biorhythms (within one session irradiation), the following features of laser therapy can be noted.

The high natural frequency of the acting electromagnetic radiation, corresponding to periodic processes in biomolecules at the level of electronic transitions, provides the richest opportunities for modulation impact. In addition, it is possible to form information block effects with an extremely large capacity. Within the framework of such a block, it is possible to create multifrequency impacts with a given spectrum of modulation frequencies. Finally, which is especially important from a systemic point of view, it is possible to introduce biosynchronization in self impact due to feedback through a biological object.

The organism as a whole has lower frequencies of biorhythms (fractions of hertz), its systems and organs - higher (units and tens of hertz). The spectrum of biorhythms is individual in nature and can be considered as an oscillatory "portrait" of a particular personality. Multi-frequency biosynchronized laser action can extremely effectively control all reactions of the body, including protective reactions to external adverse effects of the most diverse nature.

Literature for lecture 21.

1. Effect of electromagnetic radiation on biological objects and laser medicine. Sat. under the editorship of acad. IN AND. Ilyichev. - Vladivostok: FEB AN USSR, 1989, 236 p.

2. V.M. Chudnovsky, G.N. Leonova, S.A. Skopinov et al. Biological models and physical mechanisms of laser therapy. - Vladivostok: Dalnauka, 2002, 157 p.

MECHANISMS OF BIOLOGICAL EFFECTS OF LOW-INTENSITY LASER RADIATION

The biological (therapeutic) effect of low-intensity laser radiation (coherent, monochromatic and polarized light) can be divided into three main categories:

1) primary effects(changes in the energy of the electronic levels of molecules of living matter, stereochemical rearrangement of molecules, local thermodynamic disturbances, the emergence of concentration gradients of intracellular ions in the cytosol);

2) secondary effects(photoreactivation, stimulation or inhibition of bioprocesses, changes in the functional state of both individual systems of a biological cell and the organism as a whole);

3) aftereffects(cytopathic effect, formation of toxic products of tissue metabolism, response effects of the neurohumoral regulation system, etc.).

All this variety of effects in tissues determines the widest range of adaptive and sanogenetic reactions of the body to laser exposure. Earlier it was shown that the initial starting moment of the biological action of LILI is not a photobiological reaction as such, but local heating (more correctly, a local thermodynamic violation), and in this case we are dealing with a thermodynamic rather than a photobiological effect. This explains many, if not all, of the well-known phenomena in this field of biology and medicine.

Violation of thermodynamic equilibrium causes the release of calcium ions from the intracellular depot, the propagation of a wave of increased Ca2+ concentration in the cytosol of the cell, which triggers calcium-dependent processes. After that, secondary effects develop, which are complex of adaptive and compensatory reactions arising in tissues, organs and a holistic living organism, among which the following are distinguished:

1) activation of cell metabolism and increase in their functional activity;

2) stimulation of reparative processes;

3) anti-inflammatory action;

4) activation of blood microcirculation and an increase in the level of trophic provision of tissues;

5) analgesic action;

6) immunostimulating effect;

7) reflexogenic effect on the functional activity of various organs and systems.

It is necessary to pay attention to two important points. First, in each of the listed items, the unidirectionality of the influence of LILI (stimulation, activation, etc.) is a priori set. As will be shown below, this is not entirely true, and laser radiation can cause exactly the opposite effects, which is well known from clinical practice. Secondly, all these processes are calcium-dependent. Let us now consider exactly how the presented physiological changes occur, giving as an example only a small part of the known ways of their regulation.

Activation of cell metabolism and an increase in their functional activity occur primarily due to a calcium-dependent increase in the redox potential of mitochondria, their functional activity, and ATP synthesis.

Stimulation of reparative processes depends on Ca2+ at various levels. In addition to activating the work of mitochondria, with an increase in the concentration of free intracellular calcium, protein kinases are activated, which take part in the formation of mRNA. Also, calcium ions are allosteric inhibitors of membrane-bound thioredoxin reductase, an enzyme that controls the complex process of synthesis of purine disoxyribonucleotides during active DNA synthesis and cell division. In addition, the basic fibroblast growth factor (bFGF) is actively involved in the physiology of the wound process, the synthesis of which and activity depend on the concentration of Ca2+.

Anti-inflammatory effect of LILI and his influence on microcirculation are caused, in particular, by calcium-dependent release of inflammatory mediators such as cytokines, as well as calcium-dependent release by endothelial cells of the vasodilator nitric oxide (NO), a precursor of endothelial vascular wall relaxation factor (EDRF).

Since exocytosis is calcium-dependent, in particular, the release of neurotransmitters from synaptic vesicles, the process of neurohumoral regulation is completely controlled by the Ca2+ concentration, and, therefore, is also subject to the influence of LILI. In addition, it is known that Ca2+ is an intracellular mediator of the action of a number of hormones, primarily CNS and ANS mediators, which also suggests the involvement of effects caused by laser radiation in neurohumoral regulation.

The interaction of the neuroendocrine and immune systems has been little studied, but it has been established that cytokines, in particular IL-1 and IL-2, act in both directions, playing the role of modulators of the interaction of these two systems. LILI can affect immunity both indirectly through neuroendocrine regulation and directly through immunocompetent cells (which has been proven in in vitro experiments). Among the early triggers of lymphocyte blast transformation is a short-term increase in the concentration of free intracellular calcium, which activates protein kinase involved in the formation of mRNA in T-lymphocytes, which, in turn, is the key moment of laser stimulation of T-lymphocytes. The impact of LILI on fibroblast cells in vitro also leads to increased generation of intracellular endogenous g-interferon.

In addition to the physiological reactions described above, to understand the whole picture, it is also necessary to know how laser radiation can affect the mechanisms neurohumoral regulation. LILI is considered as a non-specific factor, the action of which is not directed against the pathogen or symptoms of the disease, but to increase the body's resistance (vitality). It is a bioregulator of both cellular biochemical activity and the physiological functions of the body as a whole - neuroendocrine, endocrine, vascular and immune systems.

Scientific research data allow us to say with full confidence that laser radiation is not the main therapeutic agent at the level of the organism as a whole, but, as it were, eliminates obstacles, imbalances in the central nervous system that interfere with the sanogenetic function of the brain. This is carried out by a possible change under the influence of LILI in the physiology of tissues both in the direction of strengthening and in the direction of suppressing their metabolism, depending on the initial state of the body and the dose of exposure, which leads to the attenuation of pathological processes, the normalization of physiological reactions and the restoration of the regulatory functions of the nervous system. Laser therapy, when used correctly, allows the body to restore disturbed systemic balance.

Considering the CNS and ANS as independent systems regulation in recent years has ceased to suit many researchers. There are more and more facts confirming their closest interaction. Based on the analysis of numerous scientific research data, a model of a single system that regulates and maintains homeostasis, called the neurodynamic generator (NDG), was proposed.

The main idea of ​​the NDG model is that the dopaminergic department of the CNS and the sympathetic department of the ANS, combined into a single structure, named by V.V. Skupchenko (1991) phasic motor-vegetative (FMV) system complex closely interacts with another, mirror-cooperative structure - tonic motor-vegetative (TMV) system complex. The presented mechanism functions not so much as a reflex response system, but as a spontaneous neurodynamic generator that restructures its work according to the principle of self-organizing systems.

The appearance of facts indicating the simultaneous participation of the same brain structures in providing both somatic and autonomic regulation is difficult to perceive, since they do not fit into known theoretical constructions. However, we cannot ignore what is confirmed by everyday clinical practice. Such a mechanism, having a certain neurodynamic mobility, is not only capable of providing a continuously changing adaptive adjustment of the regulation of the entire range of energy, plastic and metabolic processes, but controls, in fact, the entire hierarchy of regulatory systems from the cellular level to the central nervous system, including endocrine and immunological changes. In clinical practice, the first positive results of this approach to the mechanism of neurohumoral regulation were obtained in neurology and in the treatment of keloid scars.

Normally, there are constant transitions from the phasic state to the tonic state and vice versa. Stress causes the inclusion of phasic (adrenergic) mechanisms of regulation, as a general adaptation syndrome. At the same time, as a response to the prevalence of dopaminergic influence, tonic (GABAergic and cholinergic) regulatory mechanisms are launched. The last circumstance remained outside the scope of G. Selye's research, but is, in fact, the most important point explaining the principle of the self-regulatory role of the GND. Normally, two systems, interacting, restore the disturbed balance.

Many diseases appear to us to be associated with the prevalence of one of the states of a given regulatory system. With a long-term, uncompensated influence of a stress factor, a malfunction occurs in the work of the NDG and its pathological fixation in one of the states, in the phasic, which happens more often, or in the tonic phase, as if moving into a mode of constant readiness to respond to irritation. Thus, stress or constant nervous tension can shift homeostasis and fix it pathologically either in a phasic or tonic state, which causes the development of corresponding diseases, the treatment of which should be primarily aimed at correcting neurodynamic homeostasis.

A combination of various causes (hereditary predisposition, a certain constitutional type, various exogenous and endogenous factors, etc.) leads to the onset of the development of any particular pathology in a particular individual, but the cause of the disease is common - the steady prevalence of one of the conditions of NDH.

Once again, we draw attention to the most important fact that not only the CNS and ANS regulate various processes at all levels, but, conversely, a locally acting external factor, such as LILI, can lead to systemic shifts, eliminating the true cause of the disease - an imbalance of NDG, and when local action of LILI to eliminate the generalized form of the disease. This must be taken into account when developing laser therapy techniques.

Now it becomes clear that LILI can have a multidirectional effect depending on the exposure dose – stimulation of physiological processes or their inhibition. The versatility of the action of LILI is due, among other things, to the fact that, depending on the dose, laser exposure both stimulates and suppresses proliferation and the wound process.

Most often, the methods use the minimum, generally accepted doses of laser exposure (1–3 J/cm2 for continuous radiation), but sometimes in clinical practice, it is the conditionally NON-stimulating effect of LILI that is required. The conclusions drawn from the previously proposed model were brilliantly confirmed in practice in substantiating effective methods for the treatment of vitiligo and Peyronie's disease.

So, in the biological effects of LILI, local thermodynamic disturbances act as the primary acting factor, causing a chain of changes in calcium-dependent physiological reactions of the body. Moreover, the direction of these reactions can be different, which is determined by the dose and localization of exposure, as well as the initial state of the organism itself.

The developed concept allows not only to explain almost all the facts already available, but also to draw conclusions on the basis of these ideas both about predicting the results of the influence of LILI on physiological processes and about the possibility of increasing the effectiveness of laser therapy.

Indications and contraindications for the use of LILI

The main indication is the feasibility of using, in particular:

Pain syndromes of a neurogenic and organic nature;

Violation of microcirculation;

Violation of the immune status;

Sensitization of the body to drugs, allergic manifestations;

Inflammatory diseases;

The need to stimulate reparative and regenerative processes in tissues;

The need to stimulate homeostasis regulation systems (reflexology).

Contraindications:

Cardiovascular diseases in the phase of decompensation;

Violation of cerebral circulation II degree;

Pulmonary and pulmonary heart failure in the phase of decompensation;

Malignant neoplasms;

Benign formations with a tendency to progression;

Diseases of the nervous system with a sharply increased excitability;

Fever of unknown etiology;

Diseases of the hematopoietic system;

Liver and kidney failure in the stage of decompensation;

Diabetes mellitus in the stage of decompensation;

Hyperthyroidism;

Pregnancy in all terms;

Mental illness in the acute stage;

Hypersensitivity to phototherapy (photodermatitis and photodermatosis, porphyrin disease, discoid and systemic lupus erythematosus).

It should be noted that There are no absolute specific contraindications for laser therapy.. However, depending on the patient's condition, the phase of the course of the disease, etc., restrictions on the use of LILI are possible. In some areas of medicine - oncology, psychiatry, endocrinology, phthisiology and pediatrics - it is strictly necessary that laser therapy be prescribed and carried out by a specialist or with his direct participation.