ULTRASOUND

College of Physical Therapy

Pamantasan ng Lungsod ng Maynila
Topic Outline
Therapeutic Uses Thermal Effects
Advantages from Diathermy Non-thermal Effects
Production of US Different Coupling Media

Difference of Piezoelectric
and its Transmissivity
Effect from Reverse
Types of US Therapy
Piezoelectric Effect Parameters
Frequencies Used Precautions, Indications,

Near Field vs Far Field and its

Contraindications
Effects Phonophoresis
Parts Related Dangers
Important Terms Application Procedures
Physical Phenomena Documentation
Physiological Effects

ULTRASOUND
Ultrasound
A form of acoustic or sound energy which

travels through vibration.

Ultrasound waves: >20, 000 Hz
Therapeutic: 0.7- 3.3 MHz
A deep heating modality
Therapeutic Uses
Soft tissue inflammation and pain
For increasing tissue extensibility, scar tissue

remodeling, and healing acute soft tissue

injuries
Vs. Diathermy
Tissues high in collagen may be selectively

heated to a therapeutic range without causing

a significant tissue temperature increase in

skin or fat.
Parts of US
Generator
Key component: electrical oscillator that

generates the high-frequency alternating current

Transformer - raises voltage from the power

source
Oscillator circuit - modifies frequency

Coaxial cable
Transfers electrical energy from console to the

transducer
Parts of US
Applicator - housing for the crystal and sound head
Two key elements:
Piezoelectric crystal - composed of a thin sheet (2-3

mm thick) of lead zirconate or titanate ceramic

TRANSDUCER
Electrical energy --> Sound/acoustic energy
Soundhead - aluminum, stainless steel, or ceramic; it

covers the irradiating surface and is connected to the

piezoelectric crystal
Stainless steel > aluminum or ceramic
TRANSMITTER
Applicator's faceplate
Production of US Generated by applying a high-frequency alternating

electrical current to the crystal.

Compressions and rarefactions
Piezoelectric effect - Compression/expansion -->

electrical energy
Reverse piezoelectric effect - Electrical energy -->

Compression/expansion
Basis of ultrasound
Produces a well-collimated beam because of its high

frequency.
Frequency: 1 -3 MHz
ERA (Effective Radiating Area) is smaller than the

crystal & soundhead.

Terms Related to Application

of US
Frequency
"Hot Spot" or Spatial Peak Intensity
Spatial Average Intensity
Spatial Average Temporal Peak Intensity
Spatial Average Temporal Average Intensity
Beam Non-Uniformity Ratio
Effective Radiating Area
Duty Cycle On:Off Ratio (Continuous vs. Pulsed US)
Frequency
The number of waves per second delivered to the patient
Frequency: 0.75 - 3.3 Mhz
1 MHz - penetrates superficial tissues and absorbed at

deeper tissues
3 MHz - absorbed at superficial tissues
Depth of US is inversely proportional to frequency
Intensity
2
Measured in watts/cm
Uneven intensity produces a high level of energy in the

center of the US beam --> "hot spot" or peak spatial

intensity
Spatial Peak Intensity - acoustic power of the ultrasound

beam at its highest point

Spatial Average Intensity - measure of the average

acoustic power across the ERA

2
Formula: Power (watts) /ERA (cm )
Mode
Continuous US - delivered at a constant energy level

throughout the treatment; thermal

Pulsed US - there is a periodic cessation of the energy

flow; non-thermal
Temporal Average Intensity (TAI)
Duty Cycle
Formula: (pulse duration / pulse period) x 100
Where:
Pulse duration - on time
Pulse period - on-off time
 TAI = (pulse duration /

pulse period) x 100

TAI = (2 msec / 10 msec)

x 100
TAI = 20%
SATP vs SATA
Spatial Average Temporal Peak (SATP) Intensity
Spatial average intensity of the US during the on

time

Spatial Average Temporal Average (SATA) Intensity

Spatial average intensity averaged over the on &

off time
US Beam
Therapeutic US – Less divergent beam of sound waves
Larger diameter of soundhead --> Focused or

collimated beam

NEAR FIELD FAR FIELD

Fresnel zone Fraunhofer zone

Convergent region Divergent region

Irregular field More uniform

Many interference Little interference

BNR
Beam Non-uniformity Ration (BNR) - the ratio

between the spatial peak intensity (ISP)measured

anywhere within the ERA and the spatial average

intensity (ISA) averaged over the entire ERA.

Ratios that are less than or equal to 6:1 are

considered acceptable for clinical use.

Lower BNR = more uniformly shaped beam
Higher BNR = more likely to cause discomfort due

to hot spots
ERA
Effective Radiating Area (ERA) - area of the

transducer from which the ultrasound energy

radiates
Always smaller than the crystal and sound head
2x up to 4x the ERA
Physical Phenomena
Reflection
Refraction
Attenuation
Absorption
Reflection & Refraction
Acoustic mismatch happens because each medium

has a different acoustic impedance.

Acoustic Impedance - refers to the resistance to

passage of ultrasound
Low acoustic impedance = high transmission,

material absorbs little sound

High acoustic impedance = less transmission,

material absorbs more energy

Reflection & Refraction
Reflection - redirection of an incident beam away

from a surface at an angle equal & opposite to the

angle of incidence.

Refraction - the bending of waves as they pass from

one medium to another in proportion to the

difference in acoustic impedance

Hold transducer head perpendicular to the tissue
o
Critical angle - 15
 Absorption & Attenuation
Absorption
Conversion of mechanical energy of US into heat
Proteins are major absorbers of ultrasound (collagen)
Absorption in water is very small
Bone - highest absorption coefficient
Blood - least absorption coefficient

Attenuation
Progressive loss of acoustic power as ultrasound energy

travels through a medium

Physiological Effects THERMAL EFFECTS
Decreased pain perception
Increase soft tissue extensibility
Decrease in joint stiffness
Increase local blood flow
Reduce pain and muscle spasm
Decreased muscle guarding
Promote healing processes
Increase motor and sensory nerves conduction
velocity
Microcellular vibration, increase cell metabolism,

and promote soft tissue healing --> soft-tissue

injury/disease management
Physiological Effects
NON-THERMAL EFFECTS

Stimulation of tissue regeneration

Soft tissue repair
Blood flow in chronically ischemic tissues
Protein synthesis
Bone repair
Wound maagement
Cavitation
Cavitation - formation & accumulation of gas-filled

bubbles caused by US

Stable cavitation - bubbles may expand & contract

to a smaller extent without bursting

Unstable (transient) cavitation - violent collapse or

implosion of gas bubbles resulting in tissue

destruction
Acoustic Streaming
Acoustic streaming - unidirectional movement of a

fluid in an ultrasound field.

2 types:
Bulk streaming - movement of fluid that is visible

when testing the output of ultrasound equipment

and that can occur in any fluid being insonated.

Microstreaming - very small or minute fluid

movements around the cells

Micromassage

Alternate

compression &

relaxation of tissue by

the pressure of sound

waves and

mechanical reactions

of the tissue.
Standing Waves
Due to reflected waves

being superimposed on the

incident waves.
Antinodes - peaks of high

pressure (can cause

transient cavitation)
Nodes - no pressure (can

cause stasis of blood)

Coupling Media
Required for effective treatment using

ultrasound so that no air comes between the

transducer and skin.

Coupling media are selected for their high

sound transmissivity.
Thixotropic agent – solid medium which

liquefies under the insonation

Requirements
Acoustic impedance similar to the tissues
High transmissivity for ultrasound
Low susceptibility for bubbles formation
Chemically inactive nature
Hypoallergenic
Relative sterility
Parameters
Mode
Mark:Space Ratio
Duty Cycle
Frequency
Intensity
Duration
Progression
Methods of application
Direct contact
Water bag
Water bath
Mode
Continuous US
Pulsed US
Short bursts or pulses of 2 ms
Mark:space ratio/pulse ratio – ratio of the pulse

length to the pulse interval

On:off ratio
Duty cycle – ratio of the pulse length to the total

treatment time, expressed as percentage

Formula: (on time/on time + off time) x 100
 RATIO OF

MARK:SPACE

PULSE INTERVAL PULSE TO

DUTY CYCLE
RATIO
TOTAL PERIOD

10 ms 10 ms 1:1 1 in 2 50%

4 ms 16 ms 1:4 1 in 5 20%

2 ms 8 ms 1:4 1 in 5 20%

2 ms 18 ms 1:9 1 in 10 10%
Frequency
0.75-3 MHz ; 1-3 MHz
3 MHz — superficial tissue (1-2 cm deep)
0.75 to 1 MHz — penetrate deeply (5 cm
deep)

The higher the frequency, the shorter the

wavelength, the greater the absorption
Intensity
W/cm2 ULTRASOUND DOSAGE GUIDELINES DURING THE

PHASES OF HEALING
SATP
(5 MIN FOR 1.5 TO 2 TIMES ERA)
SATA
INFLAMMATION
Pulsed 20%
Up to 1 W/cm2
PROLIFERATION
Pulsed 20% to 50%
Up to 1 W/cm2
REMODELING
CW up to 1.5 W/cm2
 Intensity
CONSIDERATIONS
Sharp, stabbing pain
Dull, aching pain
Prickling, tingling, stinging, vibrating or slight burning

sensation
Duration
5 to 10 mins for 2x ERA
Average: 5 mins
For optimal heating, if you have an area 4 times the

size of the soundhead, treat half of the area first,

then treat the second half.

Progression
The interval between successive treatments depends

upon the nature of the injury.

Progression is based on the outcome of previous

treatment.
Methods of Application
SIZE OF SOUNDHEAD
Big head vs Small head

CONTACT FORCE
Constant contact force

(450 g or 1 lb) is

maintained between the

transducer and the skin

overlying the treatment

area.
Methods of Application
SPEED OF SOUNDHEAD MOVEMENT
4 cm per second
2-3 sec/revolution or cycle

METHODS OF APPLICATION
Direct contact
Water bag
Water bath
Methods of Application
CALIBRATION
The machine should be calibrated on a regular

basis (at least annually) and the output checked at

more frequent intervals (ideally once a week).

Methods of Application
DIRECT CONTACT
Most common, convenient, & effective
The sound head glides on the skin
Couplant should be applied to the skin surface
Treatment head is placed on the skin before the output

is turned on
Treatment head is moved continuously while maintaning

an even pressure
The emitting surface must be kept parallel to the skin

surface
Overlapping parallel, circular, of figures-of-four strokes
Methods of Application
WATER BATH
Immersion Technique, Underwater or Water

Immersion
Used to treat irregularly shaped areas or if there is

tenderness
Limb is immersed in a tub of degassed water
Transducer is held approximately 1 cm from the

body part
Avoid formation of bubbles
Methods of Application
WATER BAG
Fluid-filled bag, Fluid Cushion Technique
Commonly used for irregular surfaces, open areas,

very bony surfaces

Use of plastic of rubber bag filled with water

(degassed if possible)
 Adhesions, joint contracture, scar tissue
Pain and muscle spasm
Soft tissue inflammation (acute, subacute, chronic)
Injury or inflammation of peripheral nerve
Pain caused by sympathetic dysfunction
Post-herpetic neuralgia
Neuroma
Calcific tendonitis
Indications

Hematomas
Swelling
Acute effusion
Chronic synovitis
Bone fractures (specialized equipment -- transosseous US)
Healing of wounds
Plantar warts (verruca vulgaris)
Bacteria
 Brain and spinal cord
Contraindications
The eye
Reproductive/gonads and abdominal organs
Pregnant uterus (pelvic, abdominal and lumbar area)
Pelvis immediately after menstruation
Acute infections or sepsis
Tumors/malignant areas
Deep x-ray therapy or radiotherapy
Below the ribs, over the heart
Over the stellate or cervical ganglia; over vagus

nerve, exposed nerve tissue

 DVT or arterial disease and other vascular problems
Contraindications
Hemophilia, tissue at risk of hemorrhage, ischemic

areas
Tuberculosis of lungs or bone
Anaesthetic areas
Joint cement/total joint replacements
Plastic components/implants
Pacemaker/electronic implants
Over epiphyseal plates of growing bones
 Acute inflammation / Acute & Post-acute

conditions
Over growing epiphyseal plates (in young

children)
Metal implants
Precautions

Over a fracture
Over breast implants
Areas of decreased temperature sensation &

circulation
Unable to communicate
Phonophoresis
Also known as sonophoresis or ultrasonophoresis
Movement of drugs through the skin into the

subcutaneous tissues under the influence of ultrasound

Can drive molecules at least 50 mm/5 cm in depth
Commonly used drugs:
Steroidal anti-inflammatory medication (e.g.

Hydrocortisone or dexamethasone)
Commercially prepared lotion containing NSAID agents

(e.g. Methyl salicylate)

Analgesics (e.g. Lidocaine)
Parameters: Pulsed, 20% duty cycle, 0.5- 0.75 W/cm2, 5- 10

minutes (Cameron)
Related Dangers
Infections
Burns
Tissue destruction (transient cavitation)
Blood cell stasis & endothelial damage
Documentation
The following should be documented:
Area of the body treated
Ultrasound frequency
Ultrasound intensity
Ultrasound duty cycle
Treatment duration
Whether the ultrasound was delivered under

water
Patient’s response to the intervention
 See
you
next
lesson