Therapeutic

Ultrasound
Clinical Application

FDA Labeling
Requirements
Output frequency
Effective Radiating Area
(ERA)
Beam Nonuniformity Ratio
(BNR)
Beam profile
Date of last service/
calibration should also be
posted on the unit
2005 FA Davis

Treatment Area
US heats a limited
area
About the size of a
catsup packet

Treatment area
should be 2 to 3 times
the size of the ERA
For larger areas,
divide the treatment
area into smaller
zones
2005 FA Davis

Coupling Methods
Direct Coupling
Immersion Method
Pad/Bladder Method

Coupling Methods
Ultrasonic energy cannot pass through
the air
A coupling medium is required
Medium should be water-based
Coupling method should confirm to the
body area
The body area should be clean and
relatively hair-free
2005 FA Davis

Direct Coupling
Gel or Creams
Only use approved
coupling agents
Apply liberally to area
Remove air bubbles by
passing sound head
over area (before
power is increased)

2005 FA Davis

Direct Coupling
Move the sound
head s-l-o-w-l-y
4 cm/sec

Moving the head

faster decreases
heating
If the patient
describes
discomfort,
decrease the output
intensity
2005 FA Davis

Coupling Ability of Various

Media
Substance
Saran Wrap
Lidex ge, fluocinonide (.05%)
Thera-Gesic
Mineral oil
US Transmission gel
US Transmission lotion
Chempad-L
Hydrocortisone powder (1%)
Hydrocortisone powder (10%)
Eucerin cream
Myoflex
White petrolatum gel
2005 FA Davis

Transmission
98
97
97
97
96
90
68
29
7
0
0
0

Immersion Technique
Used to treat irregularly
shaped areas
The limb is immersed in a
tub of degassed water
If tap water is used,
increase the output
intensity by 0.5 w/cm2
Transducer is held appx.
1 from the body part
Avoid the formation of air
bubbles
2005 FA Davis

Pad (Bladder) Method

A mass of
conductive gel
Commercial pads
Self-made bladders

Conforms to the
treatment area
Commercial pads
help limit the size of
the treatment area

2005 FA Davis

Output Parameters
Output Frequency
Duration
Duty Cycle
Output Intensity

Output Frequency
Determines the treatment depth
1 MHz Output
Deep (5 to 7 cm) tissues
Rotator cuff, vastus intermedius, gastroc

3 MHz Output
Superficial (up to 3cm deep) tissues
Patellar tendon, MCL, brachialis

Remember that adipose tissue is

transparent to ultrasound
2005 FA Davis

Treatment Duration
Depends on:
Size of the treatment area
Output intensity
Therapeutic goals

Vigorous heating
1 MHz output
10 to 12 minuts

3 MHz output
3 to 4 minutes

Also see Output Intensity

2005 FA Davis

Duty Cycle
Determine the proportion of thermal and
nonthermal effects
High duty cycle: Predominantly thermal effects
Low duty cycle: Predominantly nonthermal effects

Thermal effect used in subacute and chronic

conditions
Nonthermal effects may be beneficial in
acute stages

2005 FA Davis

Output Intensity 1 MHz

At a 100% duty
cycle
1.75 W/cm2 output
Approximately 4 min
treatment is
required to increase
tissue temp 4C

2005 FA Davis

Output Intensity 3 MHz

At a 100% duty
cycle
1.5 W/cm2 output
Approximately 10
min treatment is
required to increase
tissue temp 4C

2005 FA Davis

Ultrasound and
Electrical Stimulation
Combo Treatment

US/Electrical Stimulation
Theoretically
combines the
benefit of the two
treatments
Used to treat:
Trigger points
Muscle spasm

Output parameters:
Thermal ultrasound
Motor level electrical
stimulation
2005 FA Davis

Set-up and Application

Contraindications
Acute injuries (100% duty
cycle)
Ischemic areas
Areas of impaired circulation
including arterial disease
Over areas of deep vein
thrombosis
Anesthetic areas
Over cancerous tumors
Over sites of active infection
or sepsis
Over the spinal cord or large
nerve plexus in high doses
Exposed metal that
penetrates the skin (e.g.,
external fixation devices)

2005 FA Davis

Areas around the eyes,

heart, skull, or genitals
Over the thorax in the
presence of an implanted
pacemaker
Pregnancy when used over
the pelvic or lumbar areas
Over a fracture site before
healing is complete
Stress fracture sites or sites
of osteoporosis
Over the pelvic or lumbar
area in menstruating female
patients

Precautions
Symptoms may increase after the initial
treatments.
Use caution when applying ultrasound
around the spinal cord, especially after
laminectomy.
The use of ultrasound over metal implants is
not contraindicated
Keep the sound head moving

Use caution when applying ultrasound over

epiphyseal plates of growing bone
2005 FA Davis

Instrumentation

Duty cycle: Adjusts between continuous and pulsed ultrasound

application
Frequency: Selects the depth of penetration
Gel warmer: Used to preheat the transmission gel, primarily for patient
comfort
Intensity: Adjusts the output intensity.
The WATT METER displays the output in either total watts or watts per
square centimeter.

Maximum head temperature: Prevents overheating in case the head

is not properly coupled.
Pause: Interrupts the treatment but retains the remaining amount of
treatment time
Power: Turns the unit ON or OFF
Start-Stop: Initiates or terminates the production of ultrasound from
the transducer.
Timer: Sets the duration of the treatment.
Watt meter: Displays the output of ultrasound in total watts or watts
per square centimeter.

2005 FA Davis

Patient Preparation
Establish that no contraindications are present
Determine the method and mode of ultrasound application to be
used
Clean the area to be treated
Determine the type of coupling method to be used
Identify a treatment area that is 2 to 3 times the ERA
For direct coupling: spread the gel over the area to be treated
Explain the sensations to be expected during the treatment:
Mild to moderate warmth (but not pain or burning) for thermal
treatments
No subcutaneous sensations during pulsed ultrasound

For thermal treatments pre-heating with a moist heat pack will

decrease the treatment time required to reach vigorous heating
levels
Advise the patient to report any adverse, unusual, or painful
sensations during the treatment.

2005 FA Davis

Initiation of the Treatment

Reduce the INTENSITY to zero before turning on the POWER.

Select the appropriate mode for the output (CONTINUOUS or PULSED)
Set the WATT METER to displays the appropriate output for the type of
treatment
Set the TIMER to the appropriate treatment duration
Begin slowly moving the sound head over the medium

Slowly increase the INTENSITY

Keep the sound head moving

Move the head at a moderate pace (4 cm per second or slower)

Use firm, yet not strong, overlapping strokes
If pain is experienced:

Press the START button to begin the treatment session

Units having low BNR may be moved at a slower rate than those with a higher BNR

Move the sound head at a faster rate

Use a lower duty cycle
Use a lower the intensity

If the gel begins to wear away or if the sound head begins sticking on the skin,
depress the PAUSE button and apply more gel

2005 FA Davis

Phonophoresis Application
Preheating the area to increase the absorption of the
medication
Use only approved ultrasound transmission media.
The direct coupling method is recommended
Efficacy of phonophoresis using the bladder method has not been
established

Ensure that the skin is well moistened; avoid areas of dry skin
Position the extremity to encourage circulation.
Use a continuous output to maximize the effect of
phonophoresis
Unless the thermal effects of ultrasound are contraindicated

Follow the procedures described in Initiation of the Treatment

After treatment, cover the remaining medication with an
occlusive dressing.

2005 FA Davis

Termination of the
Treatment
If the treatment is being terminated prematurely:
Reduce the intensity before removing the transducer

Clean the remaining gel from the patients skin

To ensure continuity of treatment sessions:
Record the treatment parameters

Output frequency
Intensity
Duration
Duty cycle
Running count of ultrasound treatments given for this condition

Immediately initiate any post-treatment stretching

2005 FA Davis

Maintenance
Daily Maintenance
Clean ultrasound head and transducer face
as recommended by the manufacturer
Monthly Maintenance
Check all electrical cords for frays or kinks
Check the sound head cable for frays or
kinks
Clean the transmitter face as recommended
by the manufacturer.
Federal regulations require that therapeutic ultrasound units be
recalibrated annually by an authorized service technician
2005 FA Davis