THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

Therapeutic Ultrasound (US)

Sagar Naik,

PT

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Nature of Sonic (Sound) Waves:
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Sound is defined as the periodic mechanical disturbance of an elastic medium such as air. Sound requires a medium for its transmission and cannot cross a vacuum.  Ultrasound refers to mechanical vibrations, which are essentially the same as sound waves but of a higher frequency. Such waves are beyond the range of human hearing and can therefore also be called ultrasonic.  Vibration merges with sound at frequencies around 20 Hz; vibration below this frequency is often called infrasound or infrasonic. y Audible sound 20 to 20000 Hz y Ultrasound Greater then 20000 Hz y Infrasound Less than 20 Hz y Therapeutic ultrasound 0.5 to 5 MHz 1 to 3 MHz  The wavelength is the distance between the closest points on the wave that are performing the same motion at any instant in time.  The frequency is the number of times a particle undergoes a complete cycle in one second.  The velocity of a wave is the speed at which the wave moves through the medium, and varies depending upon the physical nature of the medium.

 Sonic waves are series of mechanical compressions and rarefactions in the direction of travel of the wave, hence they are called longitudinal waves. They can occur in solids, liquids, and gases and are due to regular compression and separation of molecules.

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THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

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 The passage of these waves of compression through matter is invisible because it is the molecules that vibrate about their average position as a result of the sonic wave. It is energy that travels and not the matter.  As sound waves pass through any material their energy is dissipated or attenuated. Sometimes all the energy is absorbed at once; sometimes the sound wave passes with almost no loss.  The molecules of all matter are in constant random motion; the amount of molecular agitation is what is measured as heat the greater the molecular movement, the greater the heat.  As the molecules jostle one another energy will be transferred from one to another so that some will oscillate at higher frequencies and with greater amplitude because they have gained energy while others will be at lower frequencies and amplitudes because their energy has been transferred by collision.  When sonic vibration is applied to a material it is superimposed on the existing motions and will add to them. The ultimate result is that the regular sonic wave energy tends to become randomized as the energy it gives to particular molecular motions becomes spread out in collisions with other molecules. In this way the sonic energy is steadily converted to heat energy.  The rate at which this exchange occurs will depend on both the nature of the material and the frequency of the sonic wave. Thus the ratio of transmission to absorption of sonic waves differs in different materials and varies with frequency of the sonic energy.  Sound waves will pass more rapidly through material in which the molecules are close together, thus their velocity is higher in solids and liquids than in gases. y Air 344 m/s y Water 1410 m/s y Salt water 1500 m/s y Muscle 1540 m/s  At other frequencies ultrasound is used for various purposes. y In industry low-frequency ultrasound is used for many cleaning and mixing processes since efficient vibration of very small particles is achieved. y It can also be used for cutting and engraving as well as detecting cracks in metal such as welding defects. y The other major medical uses of ultrasound are in body imaging and dental drills / descalers. These latter usually operate at between 20 to 60 kHz.

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THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

Production of Therapeutic Ultrasound:

 Piezoelectrical transducers are used to achieve the high-frequency ultrasound energy needed for imaging and therapy. These are suitably cut crystals, which change shape under the influence of an electric charge.  Many types of crystal can be used but the most favored are quartz, which occurs naturally, and some synthetic ceramic materials such as barium titanate and lead zirconate titanate (PZT). These crystals deform when subjected to a varying potential difference a piezo-electric effect. [Piezo-electric effect: The production of a small e.m.f. across certain substances on being subjected to external pressure. Such substances are known as piezo-electric substances.]  The crystal must be cut to suitable dimensions the most important being the thickness so that it will resonate at the chosen frequency and so achieve maximum vibration.  In order to apply the electric charges, metal electrodes must be fixed to the crystal. If a suitable metal plate is fixed to one surface of the crystal while the opposite surface is in air, then almost all the vibrational energy is transmitted from the crystal to the plate and hence to any solid or liquid to which it is applied. This is the treatment head, which is used to transmit sonic energy to the tissues.  The other essential parts of a therapeutic ultrasound generator are a circuit to produce oscillating voltages to drive the transducer and s controlling circuit, which can turn the oscillator on and off to give a pulsed output.  A suitable circuit can maintain a constantly oscillating electric charge to cause the piezoelectric crystal to change shape at the same frequency and so drive the metal plate backwards and forwards also at the same high frequency, producing a train of sonic compression waves in any medium with which it is in contact.  A suitable resistance circuit is provided to control the amplitude of an electrical oscillations which in turn controls the magnitude of the mechanical vibration of the crystal and hence the amplitude of the sonic wave.  This amplitude is referred to as the intensity and is the energy crossing unit area in unit time perpendicular to the sonic beam. It is therefore measured in watts per square centimeter (i.e., joules/sec/cm2).  Current supplied to the oscillator circuit can be automatically switched on and off to produce a pulsed output, typically giving ratios 1:1 or 1:4.  A meter is often included which measures the electrical oscillations applied to the crystal but not the vibration of the crystal.

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THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

Transmission of Sonic Waves:

 Due to the fact that the wavelength of these waves is much smaller than the transducer face; the sonic beam is roughly cylindrical and of the same diameter as the transducer.  This beam of ultrasound emitted from the transducer is by no means uniform even in a homogenous medium. The beam non-uniformity ratio (BNR) is the ratio between peak intensity and average intensity in the beam. The lower the BNR the more uniform the beam.  Waves emitted from the different places on the face of the transducer will travel to the same point in space in front of the transducer face by different paths and hence arrive out of phase.  Some waves cancel out, others reinforce so that the net result is a very irregular pattern of the sonic waves in the region close to the transducer face, called the near field or Fresnel zone. In the region beyond this, the far filed or Fraunhofer zone, the sonic field spreads out somewhat and becomes much more regular because the differing paths lengths from points on the transducer become insignificant at greater distances.  The length of the near field depends directly on the square of the radius of the transducer face and inversely proportional to the wavelength of the sonic waves. Length of Fresnel zone = r2 /

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 For practical purposes therapeutic ultrasound utilizes the near field and hence is irregular. There relatively more energy on average, carried in the central part of the cross-section of the beam.  The intensity of such fields cannot be expressed in a simple way because it varies from place to place in the ultrasonic beam. Thus the spatial peak intensity or the spatial average intensity may be specified.  If the output is pulsed the intensity over time varies so it can either be expressed as temporal average intensity or temporal peak intensity.  Thus intensity can be described in four ways: y Spatial average temporal average (SATA) y Spatial peak temporal average (SPTA) y Spatial peak temporal peak (SPTP) y Spatial average temporal peak (SATP)  This irregularity can be ironed out to some extent by continuous movement of the treatment head during the therapy.

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THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

Boundaries between Media:

 Sonic waves involve vibratory motion of molecules so that there is a characteristic velocity of wave progression for each particular medium.  It depends on the density and elasticity of the medium and together these specify what is known as the acoustic impedance of the medium.  The acoustic impedance can be found by multiplying the density of the medium by the velocity of sonic waves through it. Acoustic impedance = density of medium velocity of wave

 The energy carried by a wave also depends on its frequency (the higher the frequency, the greater the energy) and its amplitude (the larger the amplitude, the greater the energy).

Medium (High velocity) incident radiation

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Medium (Low velocity)
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 When sonic waves come to a boundary, various changes occur: 1) They must travel in the new medium at a velocity characteristic for that medium and related to its acoustic impedance. 2) The frequency remains the same, so the wavelength must change.

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refracted radiation emergent radiation

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reflected radiation

THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

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Absorption of Sonic Waves:
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3) Some of the energy is reflected back. The amount of the energy reflected is proportional to the difference in acoustic impedance between the two media. Water / Glass 63% of energy is reflected Water / Soft tissue 0.2% of energy is reflected 4) If the wave front strikes the boundary at some other angle the reflected wave will travel away from the boundary at the same angle; that is, the angle of incidence of a beam equals the angle of reflection and is in the same plane. 5) If some energy is reflected back, but the frequency remains the same, there must be decrease in amplitude of the wave. 6) Refraction also occurs with sonic waves due to the difference in acoustic impedance. The beam of sonic energy that passes through the second medium does not continue in a straight line but changes direction at the boundary because of the different velocities in the two media. If the acoustic impedances are closely matched little refraction will occur. 7) The tuning back of a wave in the same medium has a further consequence. Two waves, the original and the reflected, are traveling in opposite directions so that at some points they will be combined, producing a much greater amplitude and hence wave energy, and at other points they will cancel one another out. This tends to produce a stationary wave pattern, logically called a standing wave.

 Kinetic energy is converted to heat energy as it passes through the material.  The energy will decrease exponentially with distance from the source because a fixed proportion of it is absorbed at each unit distance so that the remaining amount will become a smaller and smaller percentage of the initial energy.  There is an inverse relationship between the amount of energy that penetrates a material and the amount that is absorbed. Thus if a beam of ultrasound is passed through the tissues it will be steadily reduced in intensity. This can be expressed as the absorption coefficient. D Half-Value Depth:  The depth or distance at which half the initial energy has been absorbed is known as half-value depth.

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THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

 The conversion of sonic energy to heat is due to increased molecular motion it follows that the amount converted will depend on the nature of those molecules and on the frequency / wavelength of the ultrasound.  Thus the half-value depth will be different in different tissues for any given ultrasound frequency. Half-value depth of penetration in mm for 1 MHz and for 3 MHz is as follows: Tissue Skin Fat Muscle Bone 1 MHz 40 50 10 20 15 3 MHz 25 16 30 60 5

 Absorption of sonic energy is greatest in tissues with largest amounts of structural protein and lowest water content. Protein content & absorption of ultrasound in various tissues Blood Least protein content Least absorption of US Fat Nerve Muscle Skin Tendon Cartilage Bone Greatest protein content Greatest absorption of US

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Attenuation of Ultrasound in the Tissues:

 The loss of energy from the ultrasound beam in the tissues is called attenuation and depends on both absorption (the energy of the ultrasonic beam is converted to heat by the tissues) and scattering (the normally parallel beam becomes more dispersed the further it passes into the medium).  Absorption accounts for some 60 80% of the energy lost from the beam. The scattered energy may also be absorbed other than in the region to which the ultrasound beam is applied.

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THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

 Scattering is caused by reflections and refractions, which occur at interfaces throughout the tissues. This is particularly apparent where there is a large difference in acoustic impedance. At 1 MHz Fat 100 80 60 40 20 0 0 Muscle Bone Fat 100 80 At 3 MHz Muscle Bone

10 20 30 40 50 60 depth in tissues (mm)

Proportional heating of 1 and 3 MHz ultrasound through tissues

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 Shear waves can also be formed which transmit energy along the periosteal surface at right angles to the ultrasound beam. Due to the fact that this reflection is quite large (almost 25%) and that sonic energy is absorbed almost immediately in bone, there is marked heating at the bone surface. This mechanism is considered to account for the periosteal pain that can arise with excessive doses of therapeutic ultrasound. Differences of acoustic impedance between other soft tissues are much smaller. D Heating in the Tissues due to Ultrasound:  The important factor for heating in the tissue due to ultrasound is the rate of tissue heating, which is, influenced both by the blood flow, which constantly carries heat away, and by heat conduction.  In highly vascular tissues such as muscle it is likely that heat would be rapidly dissipated preventing any large temperature rise; on the other hand, less vascular tissue, such as dense connective tissue in the form of tendon or ligament, may experience a relatively greater temperature rise.  Moving the transducer head during the treatment is important because of following effects:

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THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

Pulsed Ultrasound:

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 A circuit in the ultrasonic generator is arranged to turn the ultrasound on in short bursts or pulses.  This reduces the time averaged intensity and hence the amount of energy available to heat the tissues while ensuring that the energy available in each pulse (pulsed averaged intensity) is high enough for mechanical rather than thermal effects to predominate.  Many therapeutic ultrasound generators produce 2 ms pulses and vary the intervals between pulses. This can be expressed either as: y The mark : space ratio, which is the ratio of the pulse length to the interval y The duty cycle, which is the ratio of the pulse length to the total length of the pulse plus interval, expressed as percentage. Ratio of pulse Mark:space Duty to total period Pulse Interval ratio cycle 2 ms 2 ms 1:1 1 in 2 50% 2 ms 8 ms 1:4 1 in 5 20%

D Effects of Pulsing:  If pulsed ultrasound is applied at a mark:space ratio of 1:4 the amount of introduced energy is one-fifth of that which would be introduced by continuous ultrasound applied for the same length of time and at the same intensity.  The same amount of energy could be introduced into the tissues either by extending the treatment for 5 times the length or giving 5 times the intensity of the continuous treatment. The effect is not the same because with pulsed treatment there is time for heat to be dissipated by conduction

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y To smooth out the irregularities of the near field y It also reduces some of the irregularities of absorption that might occur due to reflection at interfaces, standing waves, refraction, and differences in tissue thermal conduction or blood flow y It also reduces shear wave formation and thereby reduces chances of periosteal pain  Thus resulting heating pattern is likely to be much more evenly distributed. It has been estimated that for an output of 1 W/cm2 there is a temperature rise of 0.8C/min if vascular cooling effects are ignored.

THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

Physical & Physiological Effects of Ultrasound:

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1) Cavitation:

D Thermal Effects:  The advantage of using ultrasound to achieve heating is due to the preferential heating of collagen tissue and to the effective penetration of this energy to deeply placed structures.  Heating fibrous tissue structures such as joint capsules, ligaments, tendons, and scar tissue may cause a temporary increase in their extensibility, and hence a decrease in joint stiffness.  Mild heating can also have the effect of reducing pain and muscle spasm and promoting healing processes. D Non-Thermal Effects:  Cavitation is the formation of tiny gas bubbles in the tissues as a result of ultrasound vibration. These bubbles, generally of a micron (10-6 m) or so in diameter.  These can be of two types, namely stable cavitation or transient cavitation.  Stable cavitation occurs when the bubbles oscillate to and fro within the ultrasound pressure waves but remain intact.
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As oscillation or sonic energy is passed through the body tissue, it causes transfer of heat energy in the body tissues. If this energy is not dissipated by normal physiological response, then there is local rise in temperature, which accounts for thermal effects. If heat dissipation equals heat generation there is no net rise in temperature and any effects are said to be non-thermal. Using low intensities or pulsing the output achieves non-thermal effects.

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in the tissues and in the circulating blood. Therefore, higher intensities can be safely used in a pulsed treatment because the average heating is reduced.  Ultrasound application can increase rates of ion diffusion across cell membranes; this could be due to increased particle movement on either side of the membrane and possibly, increased motion of the phospholipids and proteins that form the membrane.  Mild mechanical agitation of the tissues has certain effects, which remain the same no matter how long the agitation, is continued but that short bursts of more vigorous agitation have different, more significant effects.

THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

2) Acoustic Streaming:

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3) Standing Waves:
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Acoustic streaming is a steady circulatory flow due to radiation torque.  Additionally, as a result of either type of cavitation there is a localized, unidirectional fluid movement around the vibrating bubble. These very small fluid movements also occur around cells, tissue fibres, and other boundaries, which is known as microstreaming.  Microstreaming exerts viscous stress on the cell membrane and thus may increase membrane permeability.  This may alter the rate of ion diffusion causing therapeutically useful changes, which includes increased secretion from mast cells, increased calcium uptake, and greater growth factor production by macrophages.  All these effects could account for the acceleration of repair following ultrasound therapy.  Standing waves are due to reflected waves being superimposed on the incident waves.  The result is a set of standing or stationary waves with peaks of high pressure (antinodes), half a wavelength apart, between which are zones of no pressure (nodes).  Gas bubbles collect at the antinodes, and cells collect at the nodes.  This pressure pattern causes stasis of cells in blood vessels at the pressure nodes.  The endothelium of the blood vessels exposed to standing waves can also be damaged leading to thrombus formation.

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 Transient (or collapse) cavitation occurs when the volume of the bubble changes rapidly and then collapses (implodes) causing high pressure and temperature changes and resulting in gross damage to tissues.  Stable cavitation associated with acoustic streaming, is considered to have therapeutic value but the transient cavitation, which is only likely to occur at high intensities, can be damaging.  In practice the danger of tissue damage due to cavitation is minimized by the following measures: y Using space-averaged intensities below 4W/cm2 y Using a pulsed source of ultrasound y Moving the treatment head during insonation

THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

4) Micromassage:

 The micromassage effect of ultrasound occurs at a cellular level where the cells are alternately compressed and then pulled further apart.  The waves of compression and rarefaction may produce a form of micromassage, which could reduce oedema.  Ultrasound has been found to be effective at reducing recent traumatic oedema and chronic indurated oedema.

Effects of Ultrasound on Inflammation & Tissue Repair:

D Acute Stage:  Stable cavitation and acoustic streaming increases calcium ion diffusion across the cell membrane, which works as a cellular secondary messenger, and thereby increases the production and release of wound-healing factors.  These include the release of histamine from mast cells and growth factors released from macrophages.  In this way, ultrasound has the potential to accelerate normal resolution of inflammation providing that the inflammatory stimulus is removed.  This acceleration could also be due to the gentle agitation of the tissue fluid, which may increase the rate of phagocytosis and movement of particles and cells.  Thus, ultrasound has a pro-inflammatory, not an anti-inflammatory action. D Proliferative (Granulation) Stage:  This begins approximately 3 days after injury and is the stage at which the connective tissue framework is laid down by fibroblasts for the new blood vessels.  During repair, fibroblasts may be stimulated to produce more collagen; ultrasound can promote collagen synthesis by increasing cell membrane permeability, which allows the entry of calcium ions, which control cellular activity.  Not only is more collagen formed but it is also of greater tensile strength after ultrasound treatment.
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 Erythrocytes can be lysed if they are swept through the arrays of bubbles situated at the pressure antinodes.  There is also the possibility of marked local heating where the amplitude of the combined waves is high.  If transducer head is moved during the treatment, then standing waves are unlikely to form.

THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

Therapeutic Uses of Ultrasound:

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 Acute tissue injury:

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 Varicose Ulcers: Ultrasound promotes healing of varicose ulcers and pressure sores (decubital ulcer). [Varicose Ulcer: Ulcer (circumscribed depressed lesion on the skin or mucous membrane of any internal organ following sloughing of necrotic inflammation) in the leg associated with varicose veins is known as varicose ulcer. Pressure Sore: A bed sore; a decubital ulcer appearing on dependent sites usually on lumbosacral region, most commonly in bed-ridden elderly persons is known as pressure sore.]  Pain relief: Ultrasound is used in herpes zoster, low backache, prolapsed intervertebral disc (PIV) and many other conditions. [Herpes Zoster: Shingles (band-like involvement of neurocutaneous tissues) caused by varicellazoster virus. It involves posterior root ganglia and presents with severe continuous pain in the distribution of the affected nerve. Prolapsed Intervertebral Disc: Abnormal descent of intervertebral disc between the vertebra is known as prolapsed intervertebral disc.]

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D Remodelling Stage:  This stage last months or years until the new tissue is as near in structure as possible to the original tissue.  Ultrasound is considered to improve the extensibility of mature collagen such as is found in scar tissue, which occur by promoting the reorientation of the fibres (remodelling), which leads to greater elasticity without loss of strength.

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 Ultrasound encourages the growth of new capillaries in chronic ischaemic tissue and the same could happen during repair of soft tissues after injury.  The enhanced release of growth factors from macrophages following exposure to therapeutic ultrasound may cause proliferation of fibroblasts.  It has been suggested that ultrasound treatment given during the first 2 weeks after injury accelerates bony union, but, if given to an unstable fracture during the phase of cartilage formation, it may result in the proliferation of the cartilage and consequently delay of bony union.

THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

Ultrasound is used in soft tissue and sport injuries, in occupational injuries and post-natal injuries. It is used for perineal post-natal pain, for painful shoulders and for both neurogenic & chronic pain.  Scar tissue: Ultrasound improves quality of scar tissue and excessive fibrous tissue. It is used in conditions like Dupuytrens contracture and plantar fasciitis. [Dupuytrens contracture: Thickening and contracture of palmar fascia, typically affects the ring finger and may involve years later incompletely little finger is called Dupuytrens contracture. Plantar fasciitis: Tenderness under the heel from plantar fibromatosis or tear of plantar fascia is called plantar fasciitis.]

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Dangers of Ultrasound:
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 Chronic Indurated Oedema: The mechanical effect of ultrasound has an effect on chronic oedema and helps in its treatment. It also breaks down adhesions formed between adjacent structures.

There are very less evidences of dangers of ultrasound but it may occur in some conditions only.  Burns could occur if the heat generated exceeded the physiological ability to dissipate it.  Tissue destruction would result from transient cavitation.  Blood cell stasis and endothelial damage may occur if there is standing wave formation. These dangers would be more likely with high-intensity continuous output with a stationary head or over bony prominences.

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 Bony injury: Ultrasound therapy in the first 2 weeks after bony injury can increase bony union, but, given to an unstable fracture during the phase of cartilage proliferation, it may result in the proliferation of cartilage and therefore decrease bony union. Ultrasound has also been used in the early diagnosis of stress fractures.

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THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

Contraindications of Ultrasound:
 Rapid dividing tissues: Since ultrasound affect tissue repair it is possible that it could affect abnormal tissue activity so that it might encourage neoplastic growth and provoke metastases. Therefore, treatment over tumours or over tissue in precancerous states should be avoided.

 Pregnant Uterus: To the rapidly dividing and differentiating cells of the embryo and fetus should be avoided by not applying treatment over the pregnant uterus. Diagnostic ultrasound is entirely safe and it is probable that low doses of therapeutic ultrasound would have no ill effects.

 Spread of Infection: Bacterial or viral infection could be spread by ultrasound, presumably by facilitating microorganism movement across membranes and through the tissues. The low-grade infections of venous ulcers, or similar, would seem to be safe to treat.

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 Tuberculosis: Due to the possible risk of reactivating encapsulated lesions tuberculous regions should not be treated.  Vascular Problems: Circumstances in which hemorrhage might provoke should not be treated. For example, where bleeding is still occurring or has only recently been controlled, such as an enlarging haemarthrosis or haematoma or uncontrollable haemophilia. Severely ischaemic tissues should be avoided because of the poor heat transfer and possible greater risk of arterial thrombosis due to stasis and endothelial damage. Treatment over recent venous thrombosis might extend the thrombus or disrupt its attachment to the vein wall forming an embolus. Areas of atherosclerosis are best avoided for the same reason. [Haemarthrosis: Bleeding into the joint usually from an injury, which results in a swelling of the joint, is known as haemarthrosis.

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 Epiphyseal Plates: Avoid giving ultrasound on cartilaginous epiphyseal plates because growth of the bone is impeded.

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THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

 Radiotherapy: Areas that have received radiotherapy in the last few months should not be treated because of the risk of encouraging pre-cancerous changes.  Nervous System: Where nerve tissue is exposed, e.g. over a spina bifida or after a laminectomy, ultrasound should be avoided. Treatment over the cervical ganglia or vagus nerve might be dangerous in cardiac disease. [Spina bifida: Failure of closure of the spinal canal due to defective fusion of the vertebral arch in the lumbosacral region and is associated with depression, pigmentation or presence of hair is known as spina bifida. Laminectomy: Surgical removal of the entire lamina of a vertebra as a treatment of herniation of intervertebral disc is known as laminectomy.

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 Specialized Tissue: The fluid-filled eye offers exceptionally good ultrasound transmission and retinal damage could occur. Treatment over the gonads is not recommended.  Implants: Smaller and superficial implants, like metal bone-fixing pins subcutaneously placed; as a precaution, low doses should be used in these circumstances. Plastics used in replacement surgery, such as high-density polyethylene and acrylic should be avoided. Treatment over implanted cardiac pacemakers should not be given because the sonic vibration may interfere with the pacemakers stimulating frequency.

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Haematoma: A collection of blood inside the body, caused by bleeding from an injured vessel is called haematoma. Haemophilia: An inherited coagulation defect characterized by a permanent tendency to hemorrhages due to a defect in the coagulation of blood is known as haemophilia. Atherosclerosis: A condition caused by intramural deposition of Low Density Lipoprotein (LDL), secondary to exposure of smooth muscles to lipid, resulting in platelet induced smooth muscle proliferation, formation of fibrotic plaques and calcification is known as atherosclerosis.]

THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

 Anaesthetic areas: High doses should not be given over anaesthetic areas.

Precautions of Ultrasound:
1) Use ultrasound only if adequately trained to do so 2) Use ultrasound to treat only those patients with conditions known to respond favorably to this treatment 3) Use the lowest intensity that produces the required effect, because higher intensities may be damaging 4) Move the applicator constantly throughout the treatment, to avoid the damaging effects of standing waves 5) If the patient feels any additional pain during treatment, either reduce the intensity to a pain-free level or abandon the treatment 6) Use properly calibrated and maintained equipment 7) If there is any doubt, do not irradiate

Phonophoresis:

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 Phonophoresis is the movement of drugs through skin into the subcutaneous tissues under the influence of ultrasound.  Many drugs are absorbed through the skin only very slowly; high-frequency sonic vibration may accelerate this process. It is also known as sonophoresis or ultrasonophoresis.  Phonophoresis relies on perturbation of the tissues causing more rapid particle movement and thus encouraging absorption of the drug.  The effects of phonophoresis are those of the particular drug employed, combined with the effects of ultrasound.  Theoretically phonophoresis is possible utilizing the acoustic streaming forces, which exist in the ultrasound field.  Phonophoresis will be dependent not only on the frequency, intensity, duty cycle and treatment duration of the ultrasound, but also on the nature of the drug molecule itself.  In phonophoresis: y Ultrasound facilitates the passage of some drugs into and through the skin y The effects are due both to absorption of the drug and to the ultrasound y Lower ultrasonic frequencies appear to lead to deeper drug penetration y Pulsing ultrasound may lead to better drug penetration
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THERAPEUTIC ULTRASOUND (US)

Sagar Naik, PT

y The quality of drug entering the skin is proportional, in general, to the time and intensity of ultrasound application

Drugs used in Phonophoresis:

 Phonophoresis of hydrocortisone has been used in the treatment of many skin conditions including psoriasis, scleroderma, and pruritus.  A lotion containing zinc oxide, tannic acid, urea, and menthol has been applied by phonophoresis to treat herpes simplex virus type II in both oral and genital infections.  Antibiotics such as penicillin have been given by phonophoresis for treatment of skin infections. Product Active ingredients

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Local anaesthetics 1) Emla cream 2) Xylocaine ointment

[Psoriasis: A chronic disorder characterized by well defined, scaly, erthematous plaques on the extensor surfaces of the extremities like elbows and knees, trunk, back and scalp is called psoriasis. It may be localized or generalized and is considered as an autoimmune disease. Scleroderma: Widespread thickening and fibrosis of the skin due to accumulation of excess collagen and polyglycans, a manifestation of systemic sclerosis (an induration of tissue due to excess fibrosis) is known as scleroderma. Pruritus: Severe itching is known as pruritus.]

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Steroids 1) Cobadex cream 2) Locoid lipocream Anti-inflammatory drugs 1) Intralgin gel 2) Movelat cream

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Hydrocortisone, Dimethicone Hydrocortisone Butyrate Benzocaine Salicylamide Corticosteroids, heparinoid, salicylic acid Lignocaine, Prilocaine Lignocaine Hydrochloride