ULTRASOUND

A Deep Thermal & Non-thermal NonMechanical Modality

What is Ultrasound?
Located in the Acoustical Spectrum May be used for diagnostic imaging, therapeutic tissue healing, or tissue destruction Thermal & Non-thermal effects NonWe use it for therapeutic effects Can deliver medicine to subcutaneous tissues (phonophoresis)

Ultrasound
Sinusoidal waveform
Therapeutic ultrasound waves range from 750,000 to 3,000,000 Hz (0.75 to 3 MHz)

Displays properties of
wavelength, frequency, Amplitude

Transducer
A device that converts one form of energy to another Piezoelectric crystal: a crystal that produces (+) and (-) electrical charges when it contracts or expands
Crystal of quartz, barium titanate, lead zirconate, or titanate housed within transducer

Reverse (indirect) piezoelectric effect: occurs when an alternating current is passed through a crystal resulting in contraction & expansion of the crystal
US is produced through the reverse piezoelectric effect Vibration of crystal results in high-frequency sound waves high-

Fresnal zone (near field) area of the ultrasound beam on the transducer used for therapeutic purposes

Types of Current
Direct Current: the uninterrupted unidirectional flow of electrons Alternating Current: the uninterrupted bidirectional flow of electrons
Ultrasound is produced by this type of current flowing through a piezoelectric crystal

Pulsed Current: the flow of electrons interrupted by discrete periods of noncurrent flow

Longitudinal vs. Transverse Waves

Longitudinal waves molecular displacement is along direction in which waves travel (bungee cord)
Compression (molecules in Rarefraction (molecules in regions of high molecular density high pressure areas compress) regions of low molecular density low pressure areas expand)

Transverse waves molecular displacement in direction perpendicular to wave (guitar string)

Longitudinal waves liquids

travel in solids &

Soft tissue more like liquids US primarily travels as longitudinal wave

Transverse waves cannot pass through fluids; found in the body only when ultrasound strikes bone

Frequency
Frequency: number of times an event occurs in 1 second; expressed in Hertz or pulses per second
Hertz: cycles per second Megahertz: 1,000,000 cycles per second
In the U.S., we mainly use ultrasound frequencies of 1, 2 and 3 MHz 1 = low frequency; 3 = high frequency

q frequency = o depth of penetration o frequency = sound waves are absorbed in more superficial tissues (3 MHz)

Velocity
The speed of sound wave is directly related to the density (o velocity = o density) (o Denser & more rigid materials have a higher velocity of transmission At 1 MHz, sound travels through soft tissue @ 1540 m/sec and 4000 m/sec through compact bone

Influences on the Transmission of Energy

Reflection occurs when the wave can t pass through the next density Refraction is the bending of waves as a result of a change in the speed of a wave as it enters a medium with a different density Absorption occurs by the tissue collecting the wave s energy

Attenuation
Decrease in a wave s intensity resulting from absorption, reflection, & refraction
o as the frequency of US is o because of molecular friction the waves must overcome in order to pass through tissues

US penetrates through tissue high in water content & is absorbed in dense tissues high in protein o Absorption = o Frequency (3 MHz) , and o Penetration = q Absorption (1 MHz) , so o Penetration = q Frequency + q Absorption (1 MHz) Tissues o water content = low absorption rate (fat) Tissues o protein content = high absorption rate (peripheral nerve, bone)
Muscle is in between both

Attenuation: Acoustic Impedance

Determines amount of US energy reflected at tissue interfaces
If acoustic impedance of the 2 materials forming the interface is the same, all sound will be transmitted The larger the difference, the more energy is reflected & the less energy that can enter the 2nd medium

US passing through air = almost all reflected (99%) US through fat = 1% reflected Both reflected/refracted @ m. interface SoftSoft-tissue: bone interfaced = much reflected As US energy is reflected @ tissue interfaces with different impedances, intensity is increased creating a Standing Wave (hot spot)

Effective Radiating Area (ERA): area of the sound head that produces ultrasonic waves; expressed in square centimeters (cm2)
Represents the portion of the head s surface area that produces US waves Measured 5 mm from face of sound head; represents all areas producing more than 5% of max. power output Always lesser area than actual size of sound head Large diameter heads column beam Small diameter heads more divergent beam Low frequency (1 MHz) diverge more than 3 MHz

Treatment Duration: time for total treatment

Intensity Output & Power

Power: measured in watts (W);
amount of energy being produced by the transducer Intensity: strength of sound waves @ a given location within the tissues being treated Spatial Average Intensity (SAI): amount of US energy passing through the US head s ERA;
expressed in watts per square centimeter (W/cm2) (power/ERA) Changing head size affects power density (larger head results in lower density) Limited to 3.0 W/cm2 of maximum output

Intensity Output & Power

Spatial Average Temporal Peak Intensity (SATP): average intensity during the on time of the pulse
Output meter displays the SATP intensity

Spatial Peak Intensity (SPI): max. output (power) produced within an ultrasound beam Spatial Average Temporal Average Intensity (SATA) or Temporal (time) Average Intensity:
Power of US energy delivered to tissues over a given period of time Only meaningful for Pulsed US

SAI x Duty Cycles

Beam Nonuniformity Ratio (BNR)

Ratio between the spatial peak intensity (SPI) to the average output as reported on the unit s meter
The lower the BNR, the more uniform the beam is A BNR greater than 8:1 is unsafe Because of the existence of high-intensity highareas in the beam (hot spots), it is necessary to keep the US head moving

BNR
SPI

Duty Cycle
Percentage of time that US is actually being emitted from the head Ratio between the US s pulse length & pulse interval when US is being delivered in the pulsed mode
Pulse length = amount of time from the initial nonzero charge to the return to a zero charge Pulse interval amount of time between ultrasonic pulses Duty cycle = pulse length/(pulse length + pulse interval) x 100 100% duty cycle indicates a constant US output Low output produces nonthermal effects (20%)

Movement of the Transducer

4 cm2/sec Remaining stationary can cause problems Moving too rapidly decreases the total amount of energy absorbed per unit area
May cause clinician to treat larger area and the desired temps. May not be attained

Slower strokes can be easier maintained If patient complains of pain or excessive heat, then decrease intensity but increase time Apply constant pressure not too much & not too little

Coupling Agents
Optimal agent distilled H20 (.2% reflection) Modern units have a shut down mechanism if sound head becomes too hot (Dynatron beeps; red lights on Chattanoogas)
Improperly coupled head causes o temp.

Types of agents:
Direct H20 immersion Bladder

Reduce amount of air bubbles

Direct Coupling
Effectiveness is q if body part is hair, irregular shaped, or unclean Must maintain firm, constant pressure Various gels utilized

Water Immersion
Used for odd shaped parts Place head approx. 1 away from part Operator s hand should not be immersed No metal on part or operator s hand Ceramic tub is recommended If nondistilled H20 is used, intensity can be o .5 w/cm2 because of air & minerals Don t touch skin except to briefly sweep skin when bubbles form

Bladder
H20 filled balloon or plastic bag coated with coupling gel Use on irregular shape part Place gel on skin, then place the bladder on the part, and then place gel on bladder Make sure all air pockets are removed from bladder

Indications
Soft tissue healing & repair Joint contractures & scar tissue Muscle spasm Neuroma Trigger areas Warts Sympathetic nervous system disorders Postacute reduction of myositis ossificans Acute inflammatory conditions (pulsed) Has been shown to be ok to use following the stopping of bleeding with an acute injury (pulsed)

Contraindications
Acute conditions (continous output) Ischemic areas or impaired circulation areas Tendency to hemorrhage Around eyes, heart, skull, or genitals Over pelvic or lumbar areas in pregnant or menstruating females Cancerous tumors Spinal cord or large nerve plexus in high doses Anesthetic areas Stress fracture sites or over fracture site before healing is complete (continuous); epiphysis Acute infection

Thermal Effects
o blood flow o sensory & motor nerve conduction velocity o extensibility of structures (collagen); q joint stiffness o collagen deposition o macrophage activity Mild inflammatory response which may enhance adhesion of leukocytes to damaged endothelial cells q muscle spasm q pain + all Nonthermal effects

Nonthermal Effects
o cell membrane permeability o vascular permeability o blood flow o fibroblastic activity Altered rates of diffusion across cell membrane Secretion of chemotactics Stimulation of phagocytosis Production of granulation tissue Synthesis of protein q edema Diffusion of ions Tissue regeneration Formation of stronger CT

Pulsed Ultrasound
Stimulates phagocytosis (assists w/ q of chronic inflammation) & increases # of free radicals (o ionic conductance on cell membrane) Cavitation: formation of gas bubbles that expand & compress due to pressure changes in tissue fluids
Stable occurs when bubbles compress during the opress. peaks followed expansion of bubbles during qpress. troughs Unstable (transient) compression of bubbles during opress. Peaks, but is followed by total collapse during trough (BAD!)

Pulsed Ultrasound
Acoustical Streaming: stable cavitation leads this; oneone-directional flow of tissue fluids, & is most marked around cell membranes
Facilitates passage of calcium potassium & other ions, etc. in/out of cells Collagen synthesis, chemotactics secretion, o update of calcium in fibroblasts, o fibroblastic activity

Eddies (Eddy) circular current of fluid often moving against the main flow
Flows around the cell membranes & its organelles Flow of bubbles in stream cause change in cell membrane permeability

Clinical Applications

Soft Tissue

Stimulates release of histamine from mast cells

May be due to cavitation & streaming o transport of calcium ions across membrane that stimulates histamine release Histamine attracts leukocytes, that clean up debris, & monocytes that release chemotactic agens & growth factors that stimulate fibroblasts & endothelial cells to form a collagencollagen-rich, well-vascularized tissue well-

Clinical Applications Plantar Warts

Soft Tissue &

Pitting edema - o temp. makes thick edema liquefy thus promoting lymphatic drainage o fibroblasts = stimulation of collagen production = gives CT more strength Plantar Warts - 0.6 W/cm2 for 7-15 min. 7-

Clinical Applications Scar Tissue, Joint Contracture, & Pain Reduction

o mobility of mature scar o tissue extensibility Softens scar tissue o pain threshold Stimulates large-diameter myelinated n. fibers largeo n. conduction velocity

Clinical Applications
Chronic Inflammation - Pulsed US has been shown to be effective with q pain & o ROM
1.0 to 2.0 W/cm2 at 20% duty cycle

Bone Healing Pulsed US has been shown to accelerate fracture repair

0.5 W/cm2 at 20% duty cycle for 5 min., 4x/wk Caution over epiphysis may cause premature closure

Treatment Duration & Area

Length of time depends on the
Size of area Output intensity Goals of treatment Frequency

Area should be no larger than 2-3 times the surface 2area of the sound head ERA If the area is large, it can divided into smaller treatment zones When vigorous heating is desired, duration should be 10-12 min. for 1 MHz & 3-4 min. for 3 MHz 103Generally a 10-14 day treatment period 10-

Thermal Applications

Treatment Goal & Duration

Adjust the intensity & time according to specific outcome
Desired temp. U z U/min. = treatment min.
Ex. For 1.5 W/cm2: 2C z .3C = 6.67 min. 2 .3

Phonophoresis
US is used to deliver a medication via a safe, painless, noninvasive technique Opens pathways to drive molecules into the tissues Not likely to damage or burn skin as with iontophoresis Usually introduces an anti-inflammatory drug antiPreheating the area may enhance delivery of medication
Encourages vascular absorption & distribution of meds.

Some medications are poor conductors

Phonophoresis
Factors affecting rate of medication diffusion
Hydration higher water content = skin more penetrable Age better with younger ages Composition better near hair follicles, sebaceous glands & sweat ducts Vasularity higher vascular areas are better Thickness thinner skin is better

Types of medications
Corticosteroids hydrocortisone, dexamethasone Salicylates Anesthetics - lidocaine