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ULTRASOUND
A Deep Thermal & Non-thermal
Mechanical Modality
Made by
SUNIL
MPT, (C.P.R.S )
J. M. I
Ultrasound
• May be used for diagnostic imaging,
therapeutic tissue healing, or tissue destruction
• Thermal & Non-thermal...
Ultrasound
• Sinusoidal waveform
– Therapeutic ultrasound waves range from 750,000
to 3,000,000 Hz (0.75 to 3 MHz)
• Displ...
Transducer
• A device that converts one form of energy to another
• Piezoelectric crystal: a crystal that produces (+) and...
Longitudinal vs. Transverse Waves
• Longitudinal waves – molecular displacement is
along direction in which waves travel (...
• Longitudinal waves – travel in solids & liquids
– Soft tissue – more like liquids
– US primarily travels as longitudinal...
Frequency
• Frequency: number of times an event occurs in
1 second; expressed in Hertz or pulses per
second
– Hertz: cycle...
Velocity
• The speed of sound wave is directly related to the
density (↑ velocity = ↑ density)
• Denser & more rigid mater...
Influences on the Transmission of Energy
• Reflection – occurs when the wave can’t pass
through the next density
• Refract...
Attenuation
• Decrease in a wave’s intensity resulting from absorption,
reflection, & refraction
– ↑ as the frequency of U...
Attenuation: Acoustic Impedance
• Determines amount of US energy reflected at tissue interfaces
– If acoustic impedance of...
• Effective Radiating Area (ERA): area of the sound
head that produces ultrasonic waves; expressed in
square centimeters (...
Intensity Output & Power
• Power: measured in watts (W);
– amount of energy being produced by the transducer
• Intensity: ...
Intensity Output & Power
• Spatial Average Temporal Peak Intensity (SATP):
average intensity during the “on” time of the p...
Beam Nonuniformity Ratio (BNR)
• Ratio between the spatial peak intensity (SPI)
to the average output as reported on the
u...
Duty Cycle
• Percentage of time that US is actually being emitted
from the head
• Ratio between the US’s pulse length & pu...
Movement of the Transducer
• 4 cm2
/sec
• Remaining stationary can cause problems
• Moving too rapidly decreases the total...
Coupling Agents
• Optimal agent – distilled H20 (.2% reflection)
• Modern units have a shut down mechanism if sound
head b...
Direct Coupling
• Effectiveness is ↓ if body part is hair, irregular
shaped, or unclean
• Must maintain firm, constant pre...
Water Immersion
• Used for odd shaped parts
• Place head approx. 1” away from part
• Operator’s hand should not be immerse...
Bladder
• H20 filled balloon or plastic bag coated with
coupling gel
• Use on irregular shape part
• Place gel on skin, th...
Indications
• Soft tissue healing & repair
• Joint contractures & scar tissue
• Muscle spasm
• Neuroma
• Trigger areas
• W...
Contraindications
• Acute conditions (continous output)
• Ischemic areas or impaired circulation areas
• Tendency to hemor...
Thermal Effects
• ↑ blood flow
• ↑ sensory & motor nerve conduction velocity
• ↑ extensibility of structures (collagen); ↓...
Nonthermal Effects
• ↑ cell membrane permeability
• ↑ vascular permeability
• ↑ blood flow
• ↑ fibroblastic activity
• Alt...
Pulsed Ultrasound
• Stimulates phagocytosis (assists w/ ↓ of chronic
inflammation) & increases # of free radicals (↑ ionic...
Pulsed Ultrasound
• Acoustical Streaming: stable cavitation leads this; one-
directional flow of tissue fluids, & is most ...
Clinical Applications – Soft Tissue
• Stimulates release of histamine from mast
cells
– May be due to cavitation & streami...
Clinical Applications – Soft Tissue & Plantar
Warts
• Pitting edema - ↑ temp. makes thick edema
liquefy thus promoting lym...
Clinical Applications – Scar Tissue, Joint
Contracture, & Pain Reduction
• ↑ mobility of mature scar
• ↑ tissue extensibil...
Clinical Applications
• Chronic Inflammation - Pulsed US has been
shown to be effective with ↓ pain & ↑ ROM
– 1.0 to 2.0 W...
Treatment Duration & Area
• Length of time depends on the
– Size of area
– Output intensity
– Goals of treatment
– Frequen...
Thermal
Applications
Treatment Goal & Duration
• Adjust the intensity & time according to
specific outcome
• Desired temp.  ÷ /min. = treatme...
Phonophoresis
• US is used to deliver a medication via a safe, painless,
noninvasive technique
• Opens pathways to drive m...
Phonophoresis
• Factors affecting rate of medication diffusion
– Hydration – higher water content = skin more penetrable
–...
Ultrasound by Sunil
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Therapeutic ultrasound and application, physiotherapy based application of ultrasound, for basic understanding of ultrasound and its uses for therapeutic purpose.

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Ultrasound by Sunil

  1. 1. ULTRASOUND A Deep Thermal & Non-thermal Mechanical Modality Made by SUNIL MPT, (C.P.R.S ) J. M. I
  2. 2. Ultrasound • May be used for diagnostic imaging, therapeutic tissue healing, or tissue destruction • Thermal & Non-thermal effects • Can deliver medicine to subcutaneous tissues (phonophoresis)
  3. 3. 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
  4. 4. 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 • Fresnal zone (near field) – area of the ultrasound beam on the transducer used for therapeutic purposes
  5. 5. Longitudinal vs. Transverse Waves • Longitudinal waves – molecular displacement is along direction in which waves travel (bungee cord) – Compression – regions of high molecular density (molecules in high pressure areas compress) – Rarefraction – regions of low molecular density (molecules in low pressure areas expand) • Transverse waves – molecular displacement in direction perpendicular to wave (guitar string)
  6. 6. • Longitudinal waves – travel in solids & liquids – 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
  7. 7. 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 • ↓ frequency = ↑ depth of penetration • ↑ frequency = sound waves are absorbed in more superficial tissues (3 MHz)
  8. 8. Velocity • The speed of sound wave is directly related to the density (↑ velocity = ↑ density) • 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
  9. 9. 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
  10. 10. Attenuation • Decrease in a wave’s intensity resulting from absorption, reflection, & refraction – ↑ as the frequency of US is ↑ 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 • ↑ Absorption = ↑ Frequency (3 MHz) , and • ↑ Penetration = ↓ Absorption (1 MHz) , so • ↑ Penetration = ↓ Frequency + ↓ Absorption (1 MHz) • Tissues ↑ water content = low absorption rate (fat) • Tissues ↑ protein content = high absorption rate (peripheral nerve, bone) – Muscle is in between both
  11. 11. 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 • Soft-tissue: bone interfaced = much reflected • As US energy is reflected @ tissue interfaces with different impedances, intensity is increased creating a Standing Wave (hot spot)
  12. 12. • 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
  13. 13. 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
  14. 14. 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
  15. 15. 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 areas in the beam (hot spots), it is necessary to keep the US head moving
  16. 16. 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%)
  17. 17. 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
  18. 18. 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 ↑ temp. • Types of agents: – Direct – H20 immersion – Bladder • Reduce amount of air bubbles
  19. 19. Direct Coupling • Effectiveness is ↓ if body part is hair, irregular shaped, or unclean • Must maintain firm, constant pressure • Various gels utilized
  20. 20. 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 ↑ .5 w/cm2 because of air & minerals • Don’t touch skin except to briefly sweep skin when bubbles form
  21. 21. 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
  22. 22. 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)
  23. 23. 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
  24. 24. Thermal Effects • ↑ blood flow • ↑ sensory & motor nerve conduction velocity • ↑ extensibility of structures (collagen); ↓ joint stiffness • ↑ collagen deposition • ↑ macrophage activity • Mild inflammatory response which may enhance adhesion of leukocytes to damaged endothelial cells • ↓ muscle spasm • ↓ pain • + all Nonthermal effects
  25. 25. Nonthermal Effects • ↑ cell membrane permeability • ↑ vascular permeability • ↑ blood flow • ↑ fibroblastic activity • Altered rates of diffusion across cell membrane • Secretion of chemotactics • Stimulation of phagocytosis • Production of granulation tissue • Synthesis of protein • ↓ edema • Diffusion of ions • Tissue regeneration • Formation of stronger CT
  26. 26. Pulsed Ultrasound • Stimulates phagocytosis (assists w/ ↓ of chronic inflammation) & increases # of free radicals (↑ 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 ↑-press. peaks followed expansion of bubbles during ↓-press. troughs – Unstable (transient) – compression of bubbles during ↑-press. Peaks, but is followed by total collapse during trough (BAD!)
  27. 27. Pulsed Ultrasound • Acoustical Streaming: stable cavitation leads this; one- 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, ↑ update of calcium in fibroblasts, ↑ 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
  28. 28. Clinical Applications – Soft Tissue • Stimulates release of histamine from mast cells – May be due to cavitation & streaming – ↑ 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 collagen-rich, well- vascularized tissue
  29. 29. Clinical Applications – Soft Tissue & Plantar Warts • Pitting edema - ↑ temp. makes thick edema liquefy thus promoting lymphatic drainage • ↑ fibroblasts = stimulation of collagen production = gives CT more strength • Plantar Warts - 0.6 W/cm2 for 7-15 min.
  30. 30. Clinical Applications – Scar Tissue, Joint Contracture, & Pain Reduction • ↑ mobility of mature scar • ↑ tissue extensibility • Softens scar tissue • ↑ pain threshold • Stimulates large-diameter myelinated n. fibers • ↑ n. conduction velocity
  31. 31. Clinical Applications • Chronic Inflammation - Pulsed US has been shown to be effective with ↓ pain & ↑ 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
  32. 32. 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 area 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 • Generally a 10-14 day treatment period
  33. 33. Thermal Applications
  34. 34. Treatment Goal & Duration • Adjust the intensity & time according to specific outcome • Desired temp.  ÷ /min. = treatment min. – Ex. For 1.5 W/cm2 : 2°C ÷ .3°C = 6.67 min.
  35. 35. 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 • Preheating the area may enhance delivery of medication – Encourages vascular absorption & distribution of meds. • Some medications are poor conductors
  36. 36. 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
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Therapeutic ultrasound and application, physiotherapy based application of ultrasound, for basic understanding of ultrasound and its uses for therapeutic purpose.

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