Principles of Ultrasound

Types of Ultrasound
Diagnostic (20,000 Hz 750,000 Hz) Therapeutic (.75 MHz 3 MHz) Surgical (3 MHz 10 GHz)
Human ear can hear (16-20,000 Hz)

Definition
Ultrasound is a deep penetrating modality capable of producing thermal and nonthermal effects Produced by an alternating current (AC) flowing through a piezoelectric crystal
Reverse piezoelectric effect
Contraction / expansion of the crystal produces high-frequency sound waves

Thermal Effects
Increased collagen tissue extensibility Increased blood flow Increased nerve conduction velocity Increased pain threshold Increased enzymatic activity Decreased muscle spasm

Non-thermal Effects
Increased cell membrane permeability Increased vascular permeability Increased blood flow Reduction of edema Cavitation Acoustical streaming

Cavitation
Sound waves cause cells and molecules to oscillate formation of gas-filled bubbles
Stable cavitation (Good)
Contraction and expansion of bubbles with sound wave pressure changes
Allows fluid movement and membrane transport

Unstable cavitation (Bad)

Violent collapse of bubbles resulting in tissue destruction

Acoustical Streaming (Microstreaming)

Movement of fluids along cell membranes due to mechanical pressure exerted by sound waves Facilitates fluid movement Increases cell membrane permeability

Parameters / Terminology
Frequency Intensity Beam Non-uniformity Treatment Area Duty Cycle Effective Radiating Area Attenuation

Attenuation
Energy within a sound beam decreases as it travels through tissue
Scattering
Deflection of sound waves when striking a reflecting surface (Bone)

Absorption
Transfer of energy to surrounding tissues (Muscle)

Increase frequency Increase attenuation

Effective Radiating Area (ERA)

Portion of the sound head that produces ultrasound waves ERA is always of lesser area than the sound head

Beam Non-uniformity Ratio (BNR)

Degree to which the intensity within the ultrasound beam varies BNR = spatial peak intensity spatial average intensity Must be indicated on US unit 1:1 ratio is ideal 8:1 is unacceptable

Frequency
Number of waves in 1 second
Measured in megahertz (MHz)

1 MHz
Deeper penetration, less attenuation Used on tissues > 1 2 cm deep

3 MHz
Greater attenuation Used on tissues < 1 2 cm

Intensity (Power)
Amount of energy being produced
Measured in Watts (W) or W/cm2

Half-layer value
Depth at which 50% of energy has been absorbed
1 MHz = 5 cm 3 MHz = 1.5 cm

Intensity
Spatial Average Intensity
Amount of energy passing through the sound head (Output meter reading)

Temporal Average Intensity

Measures the energy delivered over a given period (only applies to pulsed US)

Duty Cycle
Continuous wave
US intensity remains constant

Pulsed wave
US intensity is intermittently interrupted
Duty Cycle = Time on Time on + Time off Typically range from 5% - 50%

Treatment Area / Time

Area
No more than 3-4x size of sound head

Time
Minimum of 1 minute / cm2
15 minute maximum

Frequency of Treatments
Acute injuries
1 2 times daily

Subacute
Daily

Chronic
5 3 per week

Continually evaluate the effectiveness of treatments

Application Techniques
Overlapping Circles / Parallel Stroking Avoid the Stationary Technique Speed of Movement (BNR based)
1 cm / second BNR 2 5 4 cm / second BNR 6 9

Application Methods
Direct
Conductive Medium
Oils, Aqueous gels/lotions, water cushions

Indirect
Underwater
Degassed water is ideal

Combination
W / electrical stimulation

Documentation
Frequency Intensity Duty Cycle Duration

3MHz / .8 w/cm2 / 50% / 4 minutes

Contraindications
Thrombophlebitis Pregnancy Genitalia Carotid arteries Heart Cancer Caution Areas:
Growth plates Decreased sensation Bony prominences Spinal cord Metal implants

Effects on Injury Cycle

Blood Flow
Increased local blood flow up to 45 minutes

Research is varied
Study 1: Hot pack + US diminished the blood flow increase Study 2: Ice massage + US same as US alone Study 3: Cold pack + US decreased intramuscular temperature (1.8o vs. 4.0o)

 Tissue Healing
Acute / Sub-acute phases
Low duty cycle / low intensity Encourage fluid movement

Later phases
Continuous US Good results with tendon healing, superficial wounds

 Tissue Stretching
Must increase target tissue by 5o C Stretching Window (Draper)
3 MHz: 3.3 minutes 1 MHz: 5.5 minutes

Stretch during US and after US will produce better results

 Pain Control
Direct
Alters activity of nerve fiber increases pain threshold Thermal effects increase NCV (Gate Control)

Indirect
Increase blood flow, cell permeability increase oxygen reduce sensitivity of pain receptors Decrease muscle spasm, Increased muscle relaxation

Case Studies
20 year old basketball player with patellar tendinitis ~ 3 weeks 18 year old soccer player with Grade II lateral ankle sprain ~ 1 day ago 45 year old secretary with R cervical and interscapular pain ~ 6 months

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