Class IV laser dose concern. An update from Prof. Jan Bjordal. World Association for Laser Therapy (WALT)

The title of last months PMLS editorial was Low Level Laser Therapy (LLLT) and World Association for Laser Therapy (WALT) Dosage Recommendations. Written by the Scientific Secretary Prof. Jan Bjordal. He describes how far we have come and the importance of the WALT dosage recommendations. No abstract is available for editorials so I have prepared one for you below.

In this editorial Jan celebrates LLLT academic progress noting that the annual scientific output now exceeds 400 publications a year, that several treatment advisory boards recommend use of LLLT (American Physical Therapy Association, National Cancer Institute, Clinical Evidence at BMJ) for Achilles tendinopathy, cancer-therapy-induced oral mucositis, and tennis elbow and that dose is critical (along with treating a sufficient part of the target pathology).

Sadly two out of three Cochrane reviews failed to recognise this and published negative conclusions, but the remaining review cited the WALT guidelines and subgrouped trials by doses that are optimal and ones that are not. Progress at last.

Professor Bjordal raises concern about the Class IV laser devices which have entered the market and noting that several dose-finding studies show that more is not necessarily better, and that positive effects may, be lost by overdosing.

He notes that there are at least 125 randomized controlled trials investigating the pain-relieving effects of LLLT, and that 91% of tendinopathy trials conducted within WALT-recommended doses report positive effects and that there are credible biological mechanisms of action to explain these clinical effects.

He goes on to say that superpulsed 904 nm laser dose should be separated from the CW 780–860 nm lasers as there is a different effect between the wavelengths and / or output types.

At this time there are no WALT dose guidelines for nerve repair or peripheral nerve analgesia but he acknowledges that there is a higher dose range and possibly a higher power density than the musculoskeletal dosage recommendations.

I hope you all recognise Jans exceptional contribution to LLLT for musculoskeletal pain by joining WALT and reading his papers. You might even join me by getting on a plane to Australia in September to attend the WALT conference!

Do join WALT and look at the back issues – they are really worth a read if you are interested in LLLT.

To read the full article click here. Its free if you are a WALT member, US$51 if not, but for just US$220 you can become a WALT member which includes online access to all past papers published in that journal.

Click here to join WALT.

Click here for dosage recommendations

About Prof. Jan Bjordal

The first time I recall hearing of Jan Bjordal was 2001. Prof. David Baxter told me about a systematic review entitled “Low level laser therapy for tendinopathy, evidence of a dose – response pattern”. For a second published paper it was exceptional. Jan has gone on to author, co-author or supervise many of the most important LLLT papers in musculoskeletal pain. See my top ten Bjordal related papers below.

I first recall meeting Jan in Japan at the 2002 WALT conference; How naive was I then, I had no appreciation for dose. I, like many others, believed that more was better and that failed studies were caused by inadequate power or energy delivered. Well look at me now, ranting every month that less density (and longer time) is more effective for tissue repair and anti inflammatory effects. Jan can take the blame for triggering that!

Jan has risen through the ranks of his university and gone on to become not only professor but also as vice-rector for research, visiting professor of Leeds Metropolitan University ( just renewed), and president of International Society for ElectroPhysical Agents in Physiotherapy (which is a specialist subgroup of World Confederation of Physical Therapy) and is probably the most influential author in musculoskeletal LLLT.

According to Google Scholar, Jan has been sited 1632 times. If you wish to see Jan’s entire list of published work (laser and other) click here

Low level laser therapy for tendinopathy: evidence of a dose-response pattern

Bjordal J M, Couppe C, Ljunggren A E

This review assessed the effects of low-level laser therapy (LLLT) on pain from tendinopathy. The authors concluded that LLLT can reduce pain in subacute and chronic tendinopathy if a valid treatment procedure and location-specific dose is used. Differences among the studies were not examined and only the short-term outcomes were assessed. The authors’ conclusions may not be reliable.

Physical Therapy Reviews 2001; 6: 91-99

A systematic review of low level laser therapy with location-specific doses for pain from chronic joint disorders.

Bjordal JM, Couppe C, Chow RT, Tuner J, Ljunggren EA

Section of Physiotherapy Science, University of Bergen, Bergen, 5020, Norway

We investigated if low level laser therapy (LLLT) of the joint capsule can reduce pain in chronic joint disorders. A literature search identified 88 randomised controlled trials, of which 20 trials included patients with chronic joint disorders. Six trials were excluded for not irradiating the joint capsule. Three trials used doses lower than a dose range nominated a priori for reducing inflammation in the joint capsule. These trials found no significant difference between active and placebo treatments. The remaining 11 trials including 565 patients were of acceptable methodological quality with an average PEDro score of 6.9 (range 5-9). In these trials, LLLT within the suggested dose range was administered to the knee, temporomandibular or zygapophyseal joints. The results showed a mean weighted difference in change of pain on VAS of 29.8 mm (95% CI, 18.9 to 40.7) in favour of the active LLLT groups. Global health status improved for more patients in the active LLLT groups ( relative risk of 0.52; 95% CI 0.36 to 0.76). Low level laser therapy with the suggested dose range significantly reduces pain and improves health status in chronic joint disorders, but the heterogeneity in patient samples, treatment procedures and trial design calls for cautious interpretation of the results.

Aust J Physiother 2003 49(2) 107-16

A randomised, placebo controlled trial of low level laser therapy for activated Achilles tendinitis with microdialysis measurement of peritendinous prostaglandin E2 concentrations.

Bjordal JM, Lopes-Martins RA, Iversen VV

Physiotherapy Science, University of Bergen, Bergen, Norway

BACKGROUND: Low level laser therapy (LLLT) has gained increasing popularity in the management of tendinopathy and arthritis. Results from in vitro and in vivo studies have suggested that inflammatory modulation is one of several possible biological mechanisms of LLLT action. OBJECTIVE: To investigate in situ if LLLT has an anti-inflammatory effect on activated tendinitis of the human Achilles tendon. SUBJECTS: Seven patients with bilateral Achilles tendinitis (14 tendons) who had aggravated symptoms produced by pain inducing activity immediately before the study. METHOD: Infrared (904 nm wavelength) LLLT (5.4 J per point, power density 20 mW/cm2) and placebo LLLT (0 J) were administered to both Achilles tendons in random blinded order. RESULTS: Ultrasonography Doppler measurements at baseline showed minor inflammation through increased intratendinous blood flow in all 14 tendons and measurable resistive index in eight tendons of 0.91 (95% confidence interval 0.87 to 0.95). Prostaglandin E2 concentrations were significantly reduced 75, 90, and 105 minutes after active LLLT compared with concentrations before treatment (p = 0.026) and after placebo LLLT (p = 0.009). Pressure pain threshold had increased significantly (p = 0.012) after active LLLT compared with placebo LLLT: the mean difference in the change between the groups was 0.40 kg/cm2 (95% confidence interval 0.10 to 0.70). CONCLUSION: LLLT at a dose of 5.4 J per point can reduce inflammation and pain in activated Achilles tendinitis. LLLT may therefore have potential in the management of diseases with an inflammatory component.

Br J Sports Med 2006 Jan 40(1) 76-80; discussion 76-80

Effects of Low-Level Laser Therapy and Eccentric Exercises in the Treatment of Recreational Athletes With Chronic Achilles Tendinopathy.

Stergioulas A, Stergioula M, Aarskog R, Lopes-Martins RA, Bjordal JM

Peloponnese University, Sparta, Laconia, Greece.

BACKGROUND: Eccentric exercises (EEs) are recommended for the treatment of Achilles tendinopathy, but the clinical effect from EE has a slow onset. HYPOTHESIS: The addition of low-level laser therapy (LLLT) to EE may cause more rapid clinical improvement. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 52 recreational athletes with chronic Achilles tendinopathy symptoms were randomized to groups receiving either EE + LLLT or EE + placebo LLLT over 8 weeks in a blinded manner. Low-level laser therapy (lambda = 820 nm) was administered in 12 sessions by irradiating 6 points along the Achilles tendon with a power density of 60 mW/cm(2) and a total dose of 5.4 J per session. RESULTS: The results of the intention-to-treat analysis for the primary outcome, pain intensity during physical activity on the 100-mm visual analog scale, were significantly lower in the LLLT group than in the placebo LLLT group, with 53.6 mm versus 71.5 mm (P = .0003) at 4 weeks, 37.3 mm versus 62.8 mm (P = .0002) at 8 weeks, and 33.0 mm versus 53.0 mm (P = .007) at 12 weeks after randomization. Secondary outcomes of morning stiffness, active dorsiflexion, palpation tenderness, and crepitation showed the same pattern in favor of the LLLT group. CONCLUSION: Low-level laser therapy, with the parameters used in this study, accelerates clinical recovery from chronic Achilles tendinopathy when added to an EE regimen. For the LLLT group, the results at 4 weeks were similar to the placebo LLLT group results after 12 weeks.

Am J Sports Med 2008 Feb 13

A systematic review with procedural assessments and meta-analysis of low level laser therapy in lateral elbow tendinopathy (tennis elbow).

Bjordal JM, Lopes-Martins RA, Joensen J, Couppe C, Ljunggren AE, Stergioulas A, Johnson MI

Institute of Physiotherapy, Faculty of Health and Social Sciences, Bergen University College, Moellendalsvn, 6, 5009 Bergen, Norway.

BACKGROUND: Recent reviews have indicated that low level level laser therapy (LLLT) is ineffective in lateral elbow tendinopathy (LET) without assessing validity of treatment procedures and doses or the influence of prior steroid injections. METHODS: Systematic review with meta-analysis, with primary outcome measures of pain relief and/or global improvement and subgroup analyses of methodological quality, wavelengths and treatment procedures. RESULTS: 18 randomised placebo-controlled trials (RCTs) were identified with 13 RCTs (730 patients) meeting the criteria for meta-analysis. 12 RCTs satisfied half or more of the methodological criteria. Publication bias was detected by Egger’s graphical test, which showed a negative direction of bias. Ten of the trials included patients with poor prognosis caused by failed steroid injections or other treatment failures, or long symptom duration or severe baseline pain. The weighted mean difference (WMD) for pain relief was 10.2 mm [95% CI: 3.0 to 17.5] and the RR for global improvement was 1.36 [1.16 to 1.60]. Trials which targeted acupuncture points reported negative results, as did trials with wavelengths 820, 830 and 1064 nm. In a subgroup of five trials with 904 nm lasers and one trial with 632 nm wavelength where the lateral elbow tendon insertions were directly irradiated, WMD for pain relief was 17.2 mm [95% CI: 8.5 to 25.9] and 14.0 mm [95% CI: 7.4 to 20.6] respectively, while RR for global pain improvement was only reported for 904 nm at 1.53 [95% CI: 1.28 to 1.83]. LLLT doses in this subgroup ranged between 0.5 and 7.2 Joules. Secondary outcome measures of painfree grip strength, pain pressure threshold, sick leave and follow-up data from 3 to 8 weeks after the end of treatment, showed consistently significant results in favour of the same LLLT subgroup (p < 0.02). No serious side-effects were reported. CONCLUSION: LLLT administered with optimal doses of 904 nm and possibly 632 nm wavelengths directly to the lateral elbow tendon insertions, seem to offer short-term pain relief and less disability in LET, both alone and in conjunction with an exercise regimen. This finding contradicts the conclusions of previous reviews which failed to assess treatment procedures, wavelengths and optimal doses.

BMC Musculoskelet Disord 2008 9 75

Effect of 655-nm low-level laser therapy on exercise-induced skeletal muscle fatigue in humans.

Leal Junior EC, Lopes-Martins RA, Dalan F, Ferrari M, Sbabo FM, Generosi RA, Baroni BM, Penna SC, Iversen VV, Bjordal JM

Laboratory of Human Movement, University of Caxias do Sul, Caxias do Sul, RS, Brazil.

OBJECTIVE: To investigate if development of skeletal muscle fatigue during repeated voluntary biceps contractions could be attenuated by low-level laser therapy (LLLT). BACKGROUND DATA: Previous animal studies have indicated that LLLT can reduce oxidative stress and delay the onset of skeletal muscle fatigue. MATERIALS AND METHODS: Twelve male professional volleyball players were entered into a randomized double-blind placebo-controlled trial, for two sessions (on day 1 and day 8) at a 1-wk interval, with both groups performing as many voluntary biceps contractions as possible, with a load of 75% of the maximal voluntary contraction force (MVC). At the second session on day 8, the groups were either given LLLT (655 nm) of 5 J at an energy density of 500 J/cm2 administered at each of four points along the middle of the biceps muscle belly, or placebo LLLT in the same manner immediately before the exercise session. The number of muscle contractions with 75% of MVC was counted by a blinded observer and blood lactate concentration was measured. RESULTS: Compared to the first session (on day 1), the mean number of repetitions increased significantly by 8.5 repetitions (+/- 1.9) in the active LLLT group at the second session (on day 8), while in the placebo LLLT group the increase was only 2.7 repetitions (+/- 2.9) (p = 0.0001). At the second session, blood lactate levels increased from a pre-exercise mean of 2.4 mmol/L (+/- 0.5 mmol/L), to 3.6 mmol/L (+/- 0.5 mmol/L) in the placebo group, and to 3.8 mmol/L (+/- 0.4 mmol/L) in the active LLLT group after exercise, but this difference between groups was not statistically significant. CONCLUSION: We conclude that LLLT appears to delay the onset of muscle fatigue and exhaustion by a local mechanism in spite of increased blood lactate levels.

Photomed Laser Surg 2008 Oct 26(5) 419-24

Comparison Between Single-Diode Low-Level Laser Therapy (LLLT) and LED Multi-Diode (Cluster) Therapy (LEDT) Applications Before High-Intensity Exercise.

Junior EC, Lopes-Martins RA, Baroni BM, De Marchi T, Rossi RP, Grosselli D, Generosi RA, de Godoi V, Basso M, Mancalossi JL, Bjordal JM

1 Laboratory of Human Movement, University of Caxias do Sul , Caxias do Sul, RS, Brazil

Abstract Background Data and Objective: There is anecdotal evidence that low-level laser therapy (LLLT) may affect the development of muscular fatigue, minor muscle damage, and recovery after heavy exercises. Although manufacturers claim that cluster probes (LEDT) maybe more effective than single-diode lasers in clinical settings, there is a lack of head-to-head comparisons in controlled trials. This study was designed to compare the effect of single-diode LLLT and cluster LEDT before heavy exercise. Materials and Methods: This was a randomized, placebo-controlled, double-blind cross-over study. Young male volleyball players (n = 8) were enrolled and asked to perform three Wingate cycle tests after 4 x 30 sec LLLT or LEDT pretreatment of the rectus femoris muscle with either (1) an active LEDT cluster-probe (660/850 nm, 10/30 mW), (2) a placebo cluster-probe with no output, and (3) a single-diode 810-nm 200-mW laser. Results: The active LEDT group had significantly decreased post-exercise creatine kinase (CK) levels (-18.88 +/- 41.48 U/L), compared to the placebo cluster group (26.88 +/- 15.18 U/L) (p < 0.05) and the active single-diode laser group (43.38 +/- 32.90 U/L) (p < 0.01). None of the pre-exercise LLLT or LEDT protocols enhanced performance on the Wingate tests or reduced post-exercise blood lactate levels. However, a non-significant tendency toward lower post-exercise blood lactate levels in the treated groups should be explored further. Conclusion: In this experimental set-up, only the active LEDT probe decreased post-exercise CK levels after the Wingate cycle test. Neither performance nor blood lactate levels were significantly affected by this protocol of pre-exercise LEDT or LLLT.

Photomed Laser Surg 2009 Mar 20

Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials.

Chow RT, Johnson MI, Lopes-Martins RA, Bjordal JM

Nerve Research Foundation, Brain and Mind Research Institute, University of Sydney, Sydney, NSW, Australia.

BACKGROUND: Neck pain is a common and costly condition for which pharmacological management has limited evidence of efficacy and side-effects. Low-level laser therapy (LLLT) is a relatively uncommon, non-invasive treatment for neck pain, in which non-thermal laser irradiation is applied to sites of pain. We did a systematic review and meta-analysis of randomised controlled trials to assess the efficacy of LLLT in neck pain. METHODS: We searched computerised databases comparing efficacy of LLLT using any wavelength with placebo or with active control in acute or chronic neck pain. Effect size for the primary outcome, pain intensity, was defined as a pooled estimate of mean difference in change in mm on 100 mm visual analogue scale. FINDINGS: We identified 16 randomised controlled trials including a total of 820 patients. In acute neck pain, results of two trials showed a relative risk (RR) of 1.69 (95% CI 1.22-2.33) for pain improvement of LLLT versus placebo. Five trials of chronic neck pain reporting categorical data showed an RR for pain improvement of 4.05 (2.74-5.98) of LLLT. Patients in 11 trials reporting changes in visual analogue scale had pain intensity reduced by 19.86 mm (10.04-29.68). Seven trials provided follow-up data for 1-22 weeks after completion of treatment, with short-term pain relief persisting in the medium term with a reduction of 22.07 mm (17.42-26.72). Side-effects from LLLT were mild and not different from those of placebo. INTERPRETATION: We show that LLLT reduces pain immediately after treatment in acute neck pain and up to 22 weeks after completion of treatment in patients with chronic neck pain. FUNDING: None.

Lancet 2009 Nov 12

Effects of Low-Level Laser Therapy (LLLT) in the Development of Exercise-Induced Skeletal Muscle Fatigue and Changes in Biochemical Markers Related to Post-Exercise Recovery.

Leal Junior EC, Lopes-Martins RA, Frigo L, De Marchi T, Rossi RP, de Godoi V, Tomazoni SS, da Silva DP, Basso M, Filho PL, de Valls Corsetti F, Iversen VV, Bjordal JM

STUDY DESIGN: Randomized crossover double-blinded placebo-controlled trial. OBJECTIVE: To investigate if low level laser therapy (LLLT) can affect biceps muscle performance, fatigue development, and biochemical markers of post-exercise recovery. BACKGROUND: Cell and animal studies have suggested that LLLT can reduce oxidative stress and inflammatory responses in muscle tissue. But it remains uncertain whether these findings can translate into humans in sport and exercise situations. METHODS: Nine healthy male volleyball players participated in the study. They received either active LLLT (cluster probe with 5 laser diodes, l=810 nm, 200 mW power output, 30 seconds of irradiation, applied in 2 locations over the biceps of the non-dominant arm, 60 J of total energy) or placebo LLLT using an identical cluster probe. The intervention or placebo were applied 3 minutes before the performance of exercise. All subjects performed voluntary elbow flexion repetitions with a workload of 75% of their maximal voluntary contraction force (MVC) until exhaustion. RESULTS: Active LLLT increased the number of repetitions by 14.5% (mean of 39.56, SD +/- 4.33 versus 34.56 +/- 5.64, p=0.037) and the elapsed time before exhaustion by 8.0% (p=0.034), when compared to the placebo treatment. The biochemical markers also indicated that recovery may be positively affected by LLLT as indicated by post-exercise blood lactate levels (p
J Orthop Sports Phys Ther 2010 Apr 12

Comparison between cold water immersion therapy (CWIT) and light emitting diode therapy (LEDT) in short-term skeletal muscle recovery after high-intensity exercise in athletes-preliminary results.

Leal Junior EC, de Godoi V, Mancalossi JL, Rossi RP, De Marchi T, Parente M, Grosselli D, Generosi RA, Basso M, Frigo L, Tomazoni SS, Bjordal JM, Lopes-Martins RA

Center for Research and Innovation in Laser, Nove de Julho University (UNINOVE), Rua Vergueiro, 235, 01504-001, Sao Paulo, SP, Brazil.

In the last years, phototherapy has becoming a promising tool to improve skeletal muscle recovery after exercise, however, it was not compared with other modalities commonly used with this aim. In the present study we compared the short-term effects of cold water immersion therapy (CWIT) and light emitting diode therapy (LEDT) with placebo LEDT on biochemical markers related to skeletal muscle recovery after high-intensity exercise. A randomized double-blind placebo-controlled crossover trial was performed with six male young futsal athletes. They were treated with CWIT (5 degrees C of temperature [SD +/-1 degrees ]), active LEDT (69 LEDs with wavelengths 660/850 nm, 10/30 mW of output power, 30 s of irradiation time per point, and 41.7 J of total energy irradiated per point, total of ten points irradiated) or an identical placebo LEDT 5 min after each of three Wingate cycle tests. Pre-exercise, post-exercise, and post-treatment measurements were taken of blood lactate levels, creatine kinase (CK) activity, and C-reactive protein (CRP) levels. There were no significant differences in the work performed during the three Wingate tests (p > 0.05). All biochemical parameters increased from baseline values (p < 0.05) after the three exercise tests, but only active LEDT decreased blood lactate levels (p = 0.0065) and CK activity (p = 0.0044) significantly after treatment. There were no significant differences in CRP values after treatments. We concluded that treating the leg muscles with LEDT 5 min after the Wingate cycle test seemed to inhibit the expected post-exercise increase in blood lactate levels and CK activity. This suggests that LEDT has better potential than 5 min of CWIT for improving short-term post-exercise recovery.

Lasers Med Sci 2010 Nov 19

Inhibitory Effects of Laser Irradiation on Peripheral Mammalian Nerves and Relevance to Analgesic Effects: A Systematic Review.

Chow R, Armati P, Laakso EL, Bjordal JM, Baxter GD

1 Nerve Research Foundation, Brain and Mind Research Institute, The University of Sydney , Camperdown, New South Wales, Australia .

Abstract Objective: The objective of this review was to systematically identify experimental studies of non-ablative laser irradiation (LI) on peripheral nerve morphology, physiology, and function. The findings were then evaluated with special reference to the neurophysiology of pain and implications for the analgesic effects of low-level laser therapy (LLLT). Background: LLLT is used in the treatment of pain, and laser-induced neural inhibition has been proposed as a mechanism. To date, no study has systematically evaluated the effects of LI on peripheral nerve, other than those related to nerve repair, despite the fact that experimental studies of LI on nerves have been conducted over the past 25 years. Methods: We searched computerized databases and reference lists for studies of LI effects on animal and human nerves using a priori inclusion and exclusion criteria. Results: We identified 44 studies suitable for inclusion. In 13 of 18 human studies, pulsed or continuous wave visible and continuous wave infrared (IR) LI slowed conduction velocity (CV) and/or reduced the amplitude of compound action potentials (CAPs). In 26 animal experiments, IR LI suppressed electrically and noxiously evoked action potentials including pro-inflammatory mediators. Disruption of microtubule arrays and fast axonal flow may underpin neural inhibition. Conclusions: This review has identified a range of laser-induced inhibitory effects in diverse peripheral nerve models, which may reduce acute pain by direct inhibition of peripheral nociceptors. In chronic pain, spinal cord changes induced by LI may result in long-term depression of pain. Incomplete reporting of parameters limited aggregation of data.

Photomed Laser Surg 2011 Apr 1

A systematic review with meta-analysis of the effect of low-level laser therapy (LLLT) in cancer therapy-induced oral mucositis.

Bjordal JM, Bensadoun RJ, Tuner J, Frigo L, Gjerde K, Lopes-Martins RA

Centre for Evidence-Based Practice, Bergen University College-HiB, Moellendalsvn. 6, 5009, Bergen, Norway.

PURPOSE: The purpose of this study is to review the effects of low-level laser therapy (LLLT) in the prevention and treatment of cancer therapy-induced oral mucositis (OM). METHODS: A systematic review and meta-analysis of randomised placebo-controlled trials of LLLT performed during chemotherapy or radiation therapy in head and neck cancer patients. RESULTS: We found 11 randomised placebo-controlled trials with a total of 415 patients; methodological quality was acceptable at 4.10 (SD +/- 0.74) on the 5-point Jadad scale. The relative risk (RR) for developing OM was significantly (p = 0.02) reduced after LLLT compared with placebo LLLT (RR = 2.03 (95% CI, 1.11 to 3.69)). This preventive effect of LLLT improved to RR = 2.72 (95% CI, 1.98 to 3.74) when only trials with adequate doses above 1 J were included. For treatment of OM ulcers, the number of days with OM grade 2 or worse was significantly reduced after LLLT to 4.38 (95% CI, 3.35 to 5.40) days less than placebo LLLT. Oral mucositis severity was also reduced after LLLT with a standardised mean difference of 1.33 (95% CI, 0.68 to 1.98) over placebo LLLT. All studies registered possible side-effects, but they were not significantly different from placebo LLLT. CONCLUSIONS: There is consistent evidence from small high-quality studies that red and infrared LLLT can partly prevent development of cancer therapy-induced OM. LLLT also significantly reduced pain, severity and duration of symptoms in patients with cancer therapy-induced OM.

Support Care Cancer 2011 Aug 19(8) 1069-77

About James Carroll

Founder and CEO at THOR Photomedicine Ltd. View biography (PDF)
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