ULTRASOUND

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SOUND & ULTRASOUND

Periodic mechanical disturbance of an elastic medium such as air. Ultrasound refers to mechanical vibrations of a higher frequency, beyond the range of human hearing Frequency Typically 1 or 3 MHz

Wavelength - @ 1MHz would be 1.5mm and @ 3 MHz would be 0.5 mm. velocity of ultrasound - Sound waves can travel more rapidly in a more dense medium. The velocity varies from 331 m/sec in air 1450 m/sec in fat, 1570 m/sec in blood Sreeraj S R
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 Transducer

(sound head): A crystal that converts electrical energy into sound Power: The amount of acoustic energy per unit time. This is usually expressed in Watts. Intensity: The power per unit area of the sound head. This is usually expressed in Watts/centimeter2.
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Spatial Peak Intensity: The peak intensity of the ultrasound output over the area of the transducer. The intensity is usually greatest in the centre of the beam and lowest at the edges of the beam. Spatial Average Intensity: The average intensity of the ultrasound output over the area of the transducer. Beam Nonuniformity Ratio (BNR) : The ratio of the spatial peak intensity to the spatial average intensity . For most units this is usually between 5:1 and 6:1,

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Continuous Ultrasound: Pulsed Ultrasound: Pulsing the ultrasound minimizes its thermal effect. Duty Cycle: The proportion of the total treatment time that the ultrasound is on. This can be expressed either as a percentage or a ratio.
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Spatial Average Temporal Peak (SATP) Intensity: The spatial average intensity of the ultrasound during the on time of the pulse. Spatial Average Temporal Average (SATA) Intensity: The spatial average intensity of the Ultrasound averaged over both the on time and the off time of the pulse. SATP x duty cycle = SATA
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Effective Radiating Area (ERA)

area of the sound head that produces ultrasonic waves; expressed in square centimeters (cm2) 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
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Near Field/Far Field:

The near field, also known as the Fresnel zone is the convergent region and the far field, also known as the Fraunhofer zone, is the divergent region Length of near field = Radius of transduce2 / Wavelength of ultrasound (r2 /)
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Acoustic Impedance

It is a measure of the resistance of particles of medium to mechanical vibrations This resistance increases in proportion to the density of medium and velocity of ultrasound in the medium

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Reflection
most reflection occurring where there is the greatest difference between the acoustic impedance of adjacent tissues. In the body, most reflection i.e. 1% in soft tissue / fat interface about 35%, occurs at soft tissue-bone interfaces there is 100% reflection of ultrasound at the air skin interface and only 0.1% reflection at the transmission medium-skin interface

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Standing Wave
When reflected ultrasound meets further waves being transmitted, a standing wave (hot spot) may be created, which has potential adverse effects upon tissue. Such effects can be minimized by ensuring that the apparatus delivers a uniform wave, using pulsed waves and moving the transducer during treatment

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Standing Wave

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Absorption

Absorption coefficients are tissue and frequency specific. They are highest for Tissues with highest collagen content and Increase in proportion to the ultrasound frequency
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Refraction

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Attenuation

Attenuation is the result of absorption, reflection, and refraction, with absorption accounting for about onehalf of attenuation. Attenuation coefficients are tissue and Frequency specific. They are higher for tissues with a higher collagen content and increase in proportion to the frequency of the ultrasound
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Half value depth

this is the tissue depth at which 50% of the ultrasound delivered at the surface has been absorbed. The average 1/2 value depth of 3MHz ultrasound is at 2.5 cm and 1MHz ultrasound as 4.0 cm

Muscle Fat Tendon 1MHz 9.0mm 50.0mm 6.2mm 3MHz 3.0mm 16.5mm 2.0mm

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1.0

Quantity of Ultrasound
(fraction of beam being further propagated)

The quantity of the ultrasound beam decreases as the depth of the medium (tissue) increases. .5

.25 .125

1st Half Value

2nd Half Value

3rd Half Value

4th Half Value

Tissue depth

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Generation of Ultrasound

Pizoelectric effect - generated by pizoelectric crystals

occurs when an electric current is passed through the crystal crystal expands & contracts at frequencies that produce ultrasound
Wavelength

pizoelectric crystal in transducer head

ultrasound transducer

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Production

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Ultrasound Machine & Coupling Agent

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Types of Ultrasound Beams

Continuous

Wave - no interruption of beam: best for maximum heat buildup

Pulsed
builds

Wave - intermittent on-off beam modulation

up less heat in tissues used for post acute injuries

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Pulsed Wave
Mark Space ratio

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Physiological Effects of Ultrasound

Thermal effects (minimum 10 min - 2.0 watts - 1 MHz)

blood flow
inflammation and hematoma (remains controversial?)

enzyme activity sensory and motor nerve conduction velocity extensibility of connective tissue & possibly scar tissue joint stiffness muscle spasm pain

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Non-thermal effects

cavitations alternating expansion & compression of small gas bubbles may cause cell membrane & vascular wall permeability ( nutrient and oxygen delivery) unstable cavitations may cause tissue damage unstable cavitations large, violent changes in bubble volume Micro streaming bubble rotation of fluid movement along cell membrane boundaries ( nutrient and oxygen delivery) changes in cell permeability & ion flux reduces healing time

Non-thermal Effects of Ultrasound

Cavitation Microstreaming

gas buble expansion

gas buble compression

bubble rotation & associated fluid movement along cell membranes

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Non-thermal effects

Possible therapeutic benefits of nonthermal effects difficult to make distinction from thermal benefits

capillary density & cell permeability fibroblastic activity and associated collagen production cortisol production around nerve bundles reduce inflammation
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Output Frequency Duration Duty Cycle Output Intensity

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Output Frequency
Determines

the treatment depth 1 MHz Output

Deep (5 to 7 cm) tissues Rotator cuff, vastus intermedius, gastroc

MHz Output

Superficial (up to 3cm deep) tissues Patellar tendon, MCL, brachialis

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Treatment Duration

Depends on:
Size of the treatment area Output intensity Therapeutic goals

Vigorous heating
1 MHz output 8 to 10 minutes 3 MHz output 3 to 4 minutes

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Direct Coupling Immersion Method Pad/Bladder Method

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Coupling Methods

Ultrasonic energy cannot pass through the air A coupling medium is required Medium should be water-based Coupling method should confirm to the body area The body area should be clean and relatively hair-free

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Direct Coupling

Gel or Creams Only use approved coupling agents Apply liberally to area Remove air bubbles by passing sound head over area (before power is increased)

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Direct Coupling

Move the sound head s-l-o-w-l-y

4 cm/sec

Moving the head faster decreases heating If the patient describes discomfort, decrease the output intensity

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Coupling Ability of Various Media

Substance Transmission Saran Wrap Lidex ge, fluocinonide (.05%) Thera-Gesic Mineral oil US Transmission gel US Transmission lotion Chempad-L Hydrocortisone powder (1%) Hydrocortisone powder (10%) Eucerin cream Myoflex White petrolatum gel 98 97 97 97 96 90 68 29 7 0 0 0
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Immersion Technique

Used to treat irregularly shaped areas The limb is immersed in a tub of degassed water If tap water is used, increase the output intensity by 0.5 w/cm2 Transducer is held appx. 1 from the body part Avoid the formation of air bubbles

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Pad (Bladder) Method

A mass of conductive gel

Commercial pads Self-made bladders

Conforms to the treatment area Commercial pads help limit the size of the treatment area

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Contraindications

Acute injuries (100% duty cycle) Ischemic areas Areas of impaired circulation including arterial disease Over areas of deep vein thrombosis Anesthetic areas Over cancerous tumors Over sites of active infection or sepsis Over the spinal cord or large nerve plexus in high doses Exposed metal that penetrates the skin (e.g., external fixation devices)

Areas around the eyes, heart, skull, or genitals Over the thorax in the presence of an implanted pacemaker Pregnancy when used over the pelvic or lumbar areas Over a fracture site before healing is complete Stress fracture sites or sites of osteoporosis Over the pelvic or lumbar area in menstruating female patients

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Precautions
Symptoms may increase after the initial treatments. Use caution when applying ultrasound around the spinal cord, especially after laminectomy. The use of ultrasound over metal implants is not contraindicated

Keep the sound head moving

Use caution when applying ultrasound over epiphyseal plates of growing bone

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PHONOPHORESIS

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PHONOPHORESIS

It is the movement of drugs through skin into the subcutaneous tissues under the influence of ultrasound Also known as sonophoresis or ultrasonophoresis

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Pathways of drug penetration

1.Through stratum corneum 2.Transfollicular 3.Through sweat gland

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Advantages

Avoid risk and inconvenience of IV therapy Bypass liver in terms of elimination Less chance of overdose or underdose Allow easy termination Permit both local and systemic treatment effects

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Effectiveness

Depends upon Anatomical area treated Hydration of the skin Health or pathological condition of the skin State of cutaneous and systemic metabolism Patients age

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Methods of application

Adequate quantity of drug rubbed into the skin over the target area Same gel mixed with standard ultrasound gel placed over transducer head as coupling medium US is then applied as a direct contact method Standard intensity is 1 to 2 w/cm Standard duration is 5 to 10 minutes Lower ultrasonic frequencies and pulsing lead to deeper penetration
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Phonophoretic agents
Drug Hydrocortison Lidocaine/xyclocaine Methyle salicylate Zinc oxide/siloderm Iodine Indication Anti inflammatory Acute pain Chronic painfull MS disorders Open wounds Sensitivity to aspirin Allergy to metals Reactions/ contraindications Skin rashes

Adhesion,calcification Allergic to sea food ,adhessive capsulitis

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