ULTRASOUND

Chapter 9
I. Introduction
A. Sound waves are mechanical pressure waves described in terms of their frequency: first used in WW II for
SONAR in submarines.
1. Audible sound – 16-20,000 cycles/sec or Hz
2. Ultrasound - > 20,000 Hz
3. Therapeutic ultrasound – generally 0.7-3.3 megahertz (MHz – million Hz)
a. The frequency determines how quickly the energy is absorbed as the beam travels through
the tissue
b. 1MHz (for deep tissues)
● Heats tissues up to 5 cm deep
● Original US frequency – if a unit has only one frequency, it is 1 MHz
c. 3MHz (for superficial tissues)
● Heats tissues 1 - 2 cm deep
● Produces higher absorption coefficients so more energy is absorbed as the US beam passes
through tissue
⮚ higher temperatures are produced (almost 4X greater temperature increase than 1 MHz)
⮚ therefore lower intensities should be utilized (1/3 to 1/4 of the intensity used with 1MHz)
d. Continues to be one of the most frequently used physical agents in rehab practice
e. US is a high-frequency sound wave that can be described by its:
● Intensity
● Frequency
● Duty cycle
● Effective radiating area (ERA)
● Beam nonuniformity ratio (BNR) (lower BNR decreases hotspots/ more uniform)
f. Either frequency of US may be produced continuously, or pulsed
● Continuous Ultrasound: Used for Thermal effects
● Pulsed Ultrasound: Used for nonthermal effects: tissue repair and where evidence
S
supports benefits in inflammatory, proliferative, and remodeling phases, and to promote
transdermal drug delivery (phonophoresis)
B. Production of US beam
1. US is generated by applying a high-frequency, alternating electrical current to the crystal in the
transducer of an US unit.
2. The transducer contains a crystal with piezoelectric ("pee-ay-zo-electric”) properties
a. Piezoelectric is the crystal’s ability to expand and contract at the same frequency that the current
changes polarity
● When the crystal expands, it compresses the material in front of it
 ● When the crystal compresses/contracts, it rarifies (thins out) the material in front of it
b. Ultrasound uses these properties above by the following:
● A high frequency current is applied to a thin crystal in the transducer causing the crystal to
expand and compress (vibrate) at the same frequency as the current
S ● These deformations or oscillations produce pressure waves known as ultrasound waves; they
alternately compress & rarefy the material in the direction of the wave propagation
c. Optimum efficiency is achieved when the thickness of the crystal matches the frequency (each
frequency has an optimal crystal thickness; multi-frequency crystals are of a thickness for only one
of the frequencies and are less efficient at the other frequency)
d. Smaller (thinner) crystals resonate at higher frequencies
● To produce ultrasound, crystals need to be very thin and are relatively fragile – be careful with
ultrasound transducers
C.
S Sound wave characteristics
1. Sound waves are compression waves (longitudinal waves)
2. As a molecule is set into vibration it will cause its neighbor to vibrate, and so on until the vibration has
propagated throughout entire material (the molecule doesn’t move along with the wave)
3. Sound waves travel best through solids and liquids
4. Travels poorly through air (therefore coupling medium is required to replace the air on the skin and in
the pores)
5. Ultrasound waves can be absorbed, transmitted, reflected or refracted depending on the medium
through which they are traveling
S a. Definitions
● Reflection – redirection of a beam away from a reflecting surface at an angle equal to and
opposite the angle of incidence
⮚ at air-skin interface 100% is reflected
⮚ no reflection at medium-sound head interface
⮚ at transmission medium-skin interface 0.1% is reflected
⮚ soft tissue-bone interface ~35% is reflected
● Refraction – redirection of a wave at an interface, wave enters tissue at one angle and
continues through tissue at another angle
⮚ Refraction is minimized when the wave enters perpendicular to the tissue interface
b. Reflection and refraction occur when US is transmitted from a material of one density to a material
of another density – tissue interfaces (fat-muscle, muscle-fascia, tendon-periosteum, ligament-
periosteum)
c. Attenuation is the measure of the decrease in energy as it travels through tissue, caused by
combination of scattering (reflection and refraction) and absorption of energy as the sound
wave travels through a medium – end result is that the energy contained within a sound beam
is decreased as it travels through tissue –
● it is tissue and frequency specific
● higher for tissues with higher collagen content and increases in proportion to the frequency
 ● Scattering is the deflection of sound out of the beam when the sound strikes a reflecting surface
(tiny blood vessels, cell nuclei etc. can cause this) and more scattering at higher frequencies
therefore less energy available for penetration to deeper tissues
● Absorption is the conversion of the mechanical energy of ultrasound into heat, occurs in
part because of the friction that needs to be overcome in the passage of sound,
⮚ higher frequencies result in more friction and consequently more absorption (so
higher frequencies don’t penetrate as deeply)
● About 50% of attenuation is due to absorption
D. Thermal Response
1. Thermal effects
a. Increase metabolic rate
b. Decrease pain
c. Decrease muscle spasm
d. Alter nerve conduction velocity
e. Increase circulation
f. Increase soft tissue extensibility
2. Generally, heats smaller, deeper areas than superficial heating agents
3. Tissues of high collagen content are heated more, tissues of high water content (low collagen) are
heated less; following list highest to lowest, based on absorption coefficient (measure of rate of
temperature rise): See page 192 under “absorption coefficient” for exact numbers
a. bone
b. cartilage
c. tendon
d. skin
e. blood vessels
f. muscle
g. nerve
h. fat
i. blood
4. Ultrasound is considered to be most effective for treating
a. Tendons
b. Ligaments
c. Joint capsules
d. Fascia
e. Scar tissue
5. And not as effective for
a. Muscles
b. Large areas
 c. Adipose tissue
6. Additional factors (in addition to absorption) affecting TTR (tissue temperature rise)
a. Thermal conductivity (density) of the tissue – high conductivity tissue can dissipate heat quickly
b. Vascularity of the tissue – blood flow dissipates heat
c. Rate at which the energy is applied – controlled by intensity knob, the mode of application
(continuous or pulsed) and the size of the treatment area
● If applied too quickly heat is produced faster than it is dissipated and tissue can heat
enough to stimulate pain receptors
● TTR is NOT directly affected by the speed of transducer movement
7. 1 MHz US delivered at 1 W/cm2 produces an average TTR of 0.2˚ C per minute
8. However, when applying US to heat tissues, set treatment parameters according to theory and research,
but the use the patient’s report of warmth to determine final ultrasound intensity
a. If intensity is too high: patient will feel a deep ache from overheating
b. If intensity is too low: patient will not feel any increase in temperature
E. Nonthermal Responses
1. Increased skin and cell membrane permeability
2. Improve function of cell types:
a. Increased intracellular calcium
b. Increased mast cell degranulation
c. Increased chemotactic factor
d. Increased histamine release
e. Increased macrophage responsiveness
f. Increased rate of protein synthesis by fibroblasts and tendon cells
3. Can cause vasodilation from increased nitric oxide and results in increased blood flow to help
with healing
4. Nonthermal effects are produced by mechanical factors
a. Micromassage – microscopic movement or oscillations of body fluids and tissues, may be the
mechanics for the other nonthermal effects
● Acoustic streaming – steady circular flow of cellular fluids induced by US, moves material
from one part of US field to another and thus alters cellular activity
● Micro-streaming – microscale eddying (moving in a circle) that takes place near any small,
vibrating object; occurs around the gas bubbles set into oscillation by cavitation (see below)
b. Cavitation – vibrational effect on gas bubbles occurs more easily in vitro than in vivo as it is
questionable whether it happens at therapeutic frequencies; some say yes and more easily
with E stim produced muscle contraction or exercise; therefore maybe more dangerous to do
US/E stim – more research needed to prove more beneficial in combination or not use
● Small gas bubbles may be present in blood or tissue fluids
● Ultrasound may cause them to form
● When exposed to US, they will expand and compress
 ● Stable cavitation can result in diffusional changes along cell membranes (induced
microstreaming)
● Unstable or transient cavitation is the violent collapse of bubbles within the sound field
resulting in tissue destruction as a result of spotty cell destruction as a result of large,
brief local pressure and temperature increases; however this is NOT thought to occur at
clinical US frequencies (BAD)
5. Nonthermal effects are produced with all types and intensities of US, but the term is typically used to
describe effects that continue to be produced even when the intensity is insufficient to create thermal
effects
II. Physiological Effects
A. Decreases inflammation and may prevent development of chronic conditions (i. e. scarring and
reinjury of scar – microtears)
1. Due to mechanical and thermal effects
2. It should not be used at an intensity that produces heat in the acute stage (very low intensity or
pulsed)
B. Affects nerve conduction velocity and decreases pain
1. Pain relief is associated with an increase in temperature
2. Research indicates that there is more than a thermal effect on nerves – an effect on NCV has been
found but not understood yet
C. Reduces edema – better than other forms of heat
D. Enhances tissue healing
1. Tissue repair in both subcutaneous injuries and open wounds is enhanced
2. Effective in enhancing tendon healing immediately after the injury, prolonged use appears of no
value and may be harmful
E. Increases local circulation
1. Directly as a result of TTR
2. Reflex vasodilation is also initiated by US
F. Increases collagen extensibility
1. Collagen effectively absorbs US
2. Ligaments, joint capsules and tendons all have high collagen content and many lie deeper than
can be heated by diathermy or superficial heat
3. US may be only modality that can heat these tissues
1.
III. Clinical Indications for Ultrasound
A. US with stretching exercises
1. Research shows that the greatest increase in tendon length occurs when heat and stretch is applied
simultaneously and stretch is maintained during the cool-down period
a. US can penetrate to the depth of joint capsule, tendon, and ligaments: these all have high US
absorption coefficients, therefore can be effective in heating these tissues
 ● Best treatment parameters: 1 MHz (1.5 to 2.5 W/cm2 intensity) or 3 MHz frequency (.5 to 1.0
W/cm2 intensity), depending on tissue depth for 5 to 10 minutes
● Stretching needs to be applied during US treatment and then 5 to 10 minutes after US is
removed
2. Small fibrous lesions (scar tissue) also respond to US by relaxation of collagen tissue bonds (stretch
can also be applied to further break up scar)
B. Pain control
1. Continuous (thermal) US has been shown to reduce pain in a variety of conditions including
inflammatory conditions such as RA or soft tissue injury
a. Mechanism may include a direct effect on transmission of pain signals or modification of the
underlying cause of the pain
2. Dosages used in various studies include – 1 or 3 MHz (depending on target tissue depth), continuous
duty cycle, 0.5-3.0 W/cm2 for 3-10 minutes
C. Wound healing
1. Research on effectiveness of traditional US to improve open wound healing has been mixed
a. US treatment may be directed at the tissue around the wound, through a coupling sheet or
underwater
2. Treatment of surgical wounds with US has been shown to speed healing and reduce pain
a. Dosages used in studies include – 1 or 3 MHz, pulsed, 20% duty cycle, 0.5-0.8 W/cm2 for 3-5
minutes, 3-5 times a week
3. New devices have been developed - “non-contact” ultrasound or “kilohertz” devices – Also known as
“Mist Ultrasound” that deliver a lower frequency longitudinal wave (40 kHz or .04 MHz) using a
saline mist as a coupling agent
a. Applicator held at 5 to 15 mm from the wound, perpendicular to the wound, and multiple vertical
and horizontal passes are made over the wound during treatment, treatment time will be 3 to 4
minutes typically depending on size of wound
b. These devices may still be considered “investigational” by insurance carriers but early research is
promising
D. Tendon/ligament injuries
1. Tendinitis - Research on US to treat tendinitis has produced mixed results, perhaps due to variations in
research protocols
a. Recommend nonthermal US during acute phase and thermal US combined with stretching during
chronic phase if scarring is present (adhesions)
b. Resorption of calcium deposits in calcific tendonitis has been demonstrated
2. Post-op tendon repairs
a. Research has produced mostly positive results with post-op US resulting in faster healing and
stronger tendon repairs
b. Dosages used in studies include – 1 or 3 MHz, pulsed or continuous, 0.5-2.5 W/cm2 for 3-5 minutes
● Text recommends using the loser intensity range
E. Carpal tunnel syndrome
1. Nonthermal US has been shown to improve neurologic deficits
 F. Bone Fractures
1. US has been shown to reduce healing time stimulate nonunion fractures to heal
2. Traditional US devices can be used for this purpose but this is not common
a. Treatment parameters include very low intensities (.15 W/cm2, 20% duty cycle) at 1.5 MHz
frequency, and long durations (15-20 min daily) are necessary
3. Specific devices are available with pre-set treatment parameters and used exclusively for fracture
healing
G. Phonophoresis
1. US used to enhance drug delivery
a. Advantages:
● Provides higher initial drug concentration to delivery site
● Avoids gastric irritation and first-pass metabolism by the liver
● Avoids the pain, trauma, and infection risk of injections
● Allows a larger area of delivery compared to injection
b. Proposed mechanism is increased permeability of the stratum corneum
c. Once into the skin, drugs are picked up by the circulatory system and become systemic
2. Dexamethasone (most commonly used), hydrocortisone, and lidocaine (and others) can be
administered by phonophoresis
3. Medications can also be rubbed into the skin prior to application of the coupling agent and
administration of US (10% hydrocortisone concentration and 1-2 W/cm² has been proven most
effective)
4. Dosage – 3 MHz, pulsed, 20% duty cycle, 0.5-0.75 W/cm2 for 5-10 minutes
IV. Contraindications
A. Malignant tumor
1. Data is concerning with regards to producing larger or heavier tumors due to US
a. Do not use in those with current cancer
b. If patient has had cancer within the last 5 years, consult with physician prior
B. Pregnancy
1. Maternal hyperthermia associated with fetal abnormalities
2. Do not use where it may reach the fetus
C. CNS tissue
1. May damage CNS tissue
D. Joint cement or plastic components:
1. These materials heat up rapidly, therefore do not use when cement or plastic parts are used in joint
replacements
E. Pacemaker or implantable cardiac rhythm device
1. US can affect the pacing and can cause damage
2. Do not apply within 6 inches of device, other areas may be applied
 3. If patient feels dizzy, lightheaded, or short of breath then US should be stopped immediately
F. Thrombophlebitis
1. May dislodge a clot
2. Do not apply over or near the area of thrombophlebitis
G. Eyes
1. Cavitation of the ocular fluid may damage the eyes
H. Reproductive organs
1. May affect gamete development and should not be applied over male or female reproductive organs

V. Precautions:
A. Acute inflammation
1. Heat can exacerbate inflammation
B. Epiphyseal plates
1. High-dose US can damage epiphyseal plates
2. Radiographic evaluation should be determined prior
C. Fractures
1. High intensity US causes pain
2. Use only low dose US for healing
D. Breast implants
1. Heat may increase pressure inside a breast implant leading to rupture
2. High-dose ultrasound should not be used
2.
VI. Adverse Effects:
A. Rarely occur, but most common are:
1. Burns due to high-intensity, continuous ultrasound
2. Standing waves causing blood cell stasis and endothelial damage
3. Cross-contamination of infection due to ultrasound heads and gels being contaminated
a. Move head of transducer during US
b. Clean head of transducer and gel bottle heads to reduce contamination
3.
VII. Application Guidelines
A. Moving sound head
1. Moving the sound head is required
a. To avoid producing standing waves
b. Because the US beam is not of uniform intensity
2. Sound head moved in a smooth rhythmical manner at a speed of 4 cm/second and maintained constant
parallel to the skin
 3. The slower it is moved the less intensity the patient will be able to tolerate
4. Patterns
a. Small overlapping circles, about the size of the sound head overlapping by ½ the width of the
sound head
b. Small overlapping strokes, overlapping by ½ the width of the sound head
B. Coupling Agents
1. Enhance transmission
2. Types
a. Gels or lotions
b. Solid gel pad
c. Mineral oil – must be < 64°F (18°C)
d. Water
C.
S Direct-contact procedure
1. Sound head glides directly on surface of the skin
2. Three basic requirements
a. Contour of part must allow good contact
b. Must not be too sensitive to pressure, can be minimized by 5-7 minutes of ice massage prior
c. Skin must be intact
D. Immersion procedure
1. Body part is immersed in a fluid medium
2. Good for small irregular surfaces, areas too sensitive to be touched, over broken skin
3. Sound head is held ½ - 1 inch from skin and perpendicular to surface
4. Air bubbles must be brushed away (use gauze attached to tongue depressor)
5. US generator must be plugged into a GFCI
6. Increase of 0.5 W/cm² is usually recommended

E. Fluid-filled bag or cushion procedure

1. More practical than immersion
2. Can attach thin-membraned bag to sound head, a fluid cushion or a gel pad
3. Drawback is the addition of at least one extra interface
4. Increase of 0.5 W/cm² is usually recommended
4.
VIII. Determining Treatment Protocol
A. Frequency:
1. For tissue up to 5 cm deep: 1 MHs is used
2. For tissue 1 to 2 cm deep: 3 MHs is used
B.
S Duty Cycle
1. Continuous US – energy is transmitted without interruption
a. Used when the goal is increased tissue temperature
S 2. Pulsed US – brief cyclic breaks in transmission throughout application
a. Typically used to produce nonthermal effects without increasing tissue temperature
b. Overall amount of energy available is reduced for a given treatment time and intensity as compared
to continuous
c. Duty cycle – percentage or ratio of the pulse duration (on time) to the pulse period (on + off time)
d. If nonthermal effects are required deep – use low duty cycle, and high intensity - @ 20% duty
cycle, the heat generated during the on time is dispersed during the off time
e. When giving pulsed US, intensity and duty cycle should be documented

C. Intensity
1. With a goal of increasing tissue temperature, the patient should feel some warmth within 2-3 minutes
and should not feel any discomfort during the treatment
a. 1 MHz frequency – 1.5-2.0 W/cm2 will generally be effective (deep heat)
b. 3 MHz frequency – 0.5 W/cm2 will generally be effective (smaller, more superficial volume of
tissue heating)
2. Adjust up or down according to patient’s report
a. Up if no sensation of warmth after 2-3 minutes
b. Down if patient complains of any discomfort
c. Down if there is superficial bone in the area
3. With a goal of nonthermal effects
a. Most applications – 1.0 W/cm2
b. Bone healing – as low as 0.15 W/cm2`

D. Duration of treatment
1. Depends on the size of the area to be treated and the ERA of the transducer
2. General guideline – 5-10 minutes for each treatment area that is twice the ERA of the transducer
a. Treatment area of 20 cm2 treated with a transducer that has an ERA of 10 cm2, treatment duration
should be 5-10 minutes
b. Treatment area of 40 cm2 treated with a transducer that has an ERA of 10 cm2, treatment duration
should be 10-20 minutes
3. Increase duration
a. When lower intensities are used
b. When treating areas larger than twice the ERA
c. When higher tissue temperatures are desired
4. Decrease duration
 a. When higher intensities are used
b. When higher frequency is used
c. When treating areas smaller than twice the ERA
d. When lower tissue temperatures are desired
5. Bone healing – 15-20 minutes

E. Size of area to be treated

1. Depends on the ERA of the transducer and the duration of treatment
2. 5-10 minutes for an area twice the ERA
3. Smaller areas can be treated in proportionately shorter times; however, it is impractical to treat areas
less than 1 ½ times the ERA
4. Larger areas can be treated in proportionately longer times; however, ultrasound should not be used to
treat areas larger than four times the ERA
F. Number and frequency of treatments
1. Depends on the goals
2. If patient is making progress, treatment should be continued
3. If patient is not making progress, treatment should be modified or ultrasound should be discontinued
4. Effect should be detectable within 1 to 3 treatments
5. Nonthermal may be applied in early stages (acute) and is often done daily
6. Thermal is not usually applied until subacute or chronic stage and is often done 3 times a week
G. Sequence
1. Should not be applied following an intervention that impairs sensation, such as ice
2. If it is being used to increase soft tissue extensibility, it should be applied during or immediately prior
to stretching
H. Always rely on patient’s response and clinical signs
1. Rapid onset of deep aching pain – periosteal pain from overheating
a. This may occur only under certain circumstances
● In an area where the bone is closer to the skin
● In an area where the transducer is moved more slowly
● In an area where the transducer is moved more frequently
b. Correct technique and/or reduce intensity
2. Constant dull, ache – intensity too high causing too rapid a TTR for heat to be dissipated – treatment
should be terminated
3. Prickling, tingling, stinging or vibration – not enough gel or inadequate skin contact
a. Apply more gel
b. Reposition to allow better skin contact
c. Change to immersion or fluid-filled bag procedure
 I. Some patients experience a mild increase in symptoms several hours after the 1st or 2nd treatment –
“treatment soreness”
1. Lasts only a few hours
2. Original symptoms improve the following day
3. May be the result of increased activity in the tissue
4. Patient should be warned about possibility but not alarmed
J. If patient’s symptoms increase immediately after the treatment and persist for 24 – 48 hours after the
treatment, US should be discontinued; if US is attempted again, use lower intensity after symptoms have
subsided
IX. Equipment Considerations
A. Definitions
1. Power – the amount of energy per unit of time, expressed in Watts
2. ERA – effective radiating area or size of radiating surface of the crystal
a. It will be smaller than the sound head
3. Intensity – power per unit area of the sound head (ERA), expressed in W/cm²
S 4. Spatial Average Intensity (SAI) – the average intensity of US output over the area of the transducer
(strength at point of application)
5. Spatial Peak Intensity (SPI) – peak intensity of US output over the area of the transducer, usually
greatest in center and lowest at edges of beam
6. Beam Nonuniformity Ratio (BNR)
a. The intensity of the US produced by the transducer is not the same in all spots on the transducer –
the beam is much higher in certain areas and lower in others
b. The BNR is the ratio of the peak intensity (SPI) to the average intensity (SAI) produced by the
transducer
● The BNR can be found on every device – lower is better
c. This ratio represents how much higher the peak intensity can be compared to the average intensity
● A transducer with a maximum BNR of 5:1 produces a peak intensity that is 5 times the average
intensity from at least one point of the transducer
d. The beam will create a hot spot if the sound head remains stationary; - remember – one study
showed that 20% of US units emitted at least 20% more E than meter showed
B. US generators should be calibrated regularly, the meters frequently do not indicate the actual amount of
energy; moving unit most frequent cause of loss of calibration
C. The meter reading represents the energy in the unit before it reaches the transducer and does not represent
the net ultrasonic energy output of the transducer
D. If the unit is on the intensity turned up, the sound head should not be held in the air for longer than a few
seconds to avoid damaging the crystal, newer units may have protective mechanisms
X. Documentation Hints – in your book
XI. Procedures – in your book
General settings
3mhz .5-1.0 watts
1mhz 1-2w/cm