Lecture 8 Device

Ultrasound Therapy
The Nature of Acoustic Energy
Ultrasound is a form of acoustic, or sound, energy. Sound waves are mechanical pressure waves. Unlike
transmission of electromagnetic energy—such as that delivered by diathermy, in which individual particles such
as photons or electrons may travel unhindered through a vacuum— transmission of acoustic energy requires a
medium such as a coupling gel when treating human tissues.

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 therefore also be called ultrasonic.

Frequency of Ultrasound:
Ultrasonic energy or ultrasound describes any vibration at a frequency above the audible sound range, i.e. 20–
20000 Hz but it is frequencies of a few megahertz that are typically used in physiotherapy: Several different
therapies are employed in range from 0.5 to 5 MHz. Majority of ultrasound generators are set at a frequency of
1 MHz, although there are ultrasound units that are set at a frequency of 3 MHz. A generator that can be set
between 1 and 3 MHz affords the therapist the treatment flexibility.

Ultrasound Treatment Heads

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Depth of Penetration of Ultrasound
Ultrasonic energy generated at 1 MHz is transmitted through the more superficial tissue and absorbed primarily
in the deeper tissues at depths of 3 to 5 cm. A 1 MHz frequency is most useful whenever the desired effects are
in the deeper structures. At 3 MHz, the energy is absorbed in the more superficial tissues with a depth of
penetration between 1 and 2 cm.

Properties of Waves
Sonic waves are a series of mechanical compression 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.

Velocity of Ultrasound
The velocity of a wave is the speed at which the wave moves through the medium, and it varies depending upon
the physical nature of the medium. Sound waves will pass more rapidly through material in which the molecules
are closed together, thus their velocity is higher in solids and liquids than in gases. The velocities of sound in
some media are:
• Air 344 m/s
• Water 1410 m/s
• Muscle 1540 m/s
• Bone 3500 m/s

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Production of Ultrasound: Ultrasound can be produced by following ways:
For 1 MHz machine a vibrating source with a frequency of one million cycles per second is needed. This is
achieved by using either a quartz or a barium titanate or a lead zirconate or nickel-cobalt ferrite crystal. These
crystals deform when subjected to a varying potential difference, this is called piezoelectric effect.

There is a source of high frequency current, which is conveyed by a coaxial cable to a transducer circuit or
treatment head or applicator or sound head. Inside the transducer circuit high frequency current is applied to the
crystal being fused to the metal front plate of the treatment head. Any change in the shape of the crystal cause a
movement of the metal front plate which in turn produces ultrasonic waves.

Production of Ultrasound

Transmission of Ultrasound
If ultrasonic beam encounters an interface between two media and is transmitted, it may be refracted, i.e.
deflected from its original path as light. When traveling from a medium in which its velocity is low into one in
which its velocity is high, it is refracted away from the normal. The significance of refraction is that in Figure if
T were the target refraction would cause the ultrasonic beam to miss it. As refraction does not occur when the
incident waves travel along the normal, treatment should be given with the majority of waves traveling along
the normal (i.e. perpendicular to the interface between the media) whenever possible.

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Attenuation of Ultrasound
It is the term used to describe the gradual reduction in intensity of the ultrasonic beam once it has left the
treatment head. There are two main factors that contribute to attenuation.
Absorption
Ultrasound is absorbed by the tissues and converted to heat at that point. This contributes the thermal effect of
ultrasound.
Scatter (to spread)
This occurs when the normally cylindrical ultrasonic beam is deflected from its path by reflection at interfaces,
bubbles or particles in its path.

The overall effect of these two is such that the ultrasonic beam is reduced in intensity the deeper it passes. This
gives rise to the expression “half-value distance” which is depth of soft tissue that reduces the ultrasound beam
to half its surface intensity. The half value distance for soft tissue varies for 1 MHz and 3 MHz output and is 4
and2 cm respectively. In practical terms when treating deeper structures consideration needs to be given to the
frequency and intensity of ultrasound chosen.

Coupling Media
Ultrasonic waves are not transmitted by air, thus some couplant which does transmit them must be interposed
between the treatment head (transducer) and the patient’s skin. Unfortunately, no couplant affords perfect
transmission and only a percentage of the original intensity is transmitted to the patient. Even most efficient
couplant reduces the applied dose by a quarter.
• Some coupling medias and their efficiency of transmission are:
1. Aquasonic gel 72.6%
2. Glycerol 67%
3. Distilled water 59%
4. Liquid paraffin 19%
5. Petroleum jelly 0%
6. Air 0%

Treatment Parameters
Ultrasound may be used in a continuous mode or in pulsed mode. In continuous mode, treatment head
continuously produces ultrasonic energy. In pulsed mode, the periods of ultrasound are separated by periods of
silence.

Intensity
1. Space averaged intensity: where the average intensity over a specified area is given, e.g. Watts per square cm
(Wcm–2).
2. Time averaged/space averaged intensity can be used when the ultrasound is being applied in a pulsed mode,
and gives the average intensity over the whole treatment time (per second) for a specified area (Wcm–2). For
example, if 0.5 Wcm2 is applied pulsed 1 : 4, then in one second the average intensity (as if the ultrasound were
continuous) would be 0.1 Wcm–2. The output meters on some ultrasound generators automatically make this
adjustment when using pulsed ultrasound.

Pulsed Mark: Space Ratio

When ultrasound is applied in its pulsed mode, the ratio of the time on to time off should be expressed. This is
the mark: space ratio, the mark being the time ultrasound on, space being the silence, both being measured in
milliseconds. Some units have a single fixed M : S ratio of 2 : 8, whereas others have a variable range, e.g. 1 : 1,
1 : 4, 1 : 7.

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Reflection of Ultrasound
Sound obeys the law of reflection and if an ultrasonic beam traveling through one medium encounters another
medium which will not transmit, reflection takes place. Air will not transmit ultrasonic waves, so in ultrasonic
treatment great care is taken to avoid leaving air between the treatment head and the patient to minimize
reflection. However, there will always be some reflection at each interface that the ultrasound beam encounters.
This gives rise to the term acoustic impedance (Z) which is the ratio between the reflected and transmitted
ultrasound at an interface. When the acoustic impedance is low, transmission is high and vice versa.

Application
• The treatment head is moved continuously over the surface while even pressure is maintained.
• The emitting surface must be kept parallel to the skin surface to reduce reflection and pressed sufficiently
firmly to exclude any air.
• The pattern of movement can be a series of overlapping parallel strokes, circles or figures of eight.

Methods of application

Techniques of Application
1. Direct contact Method: If the surface to be treated is fairly regular

2. Water Bath Method: When direct contact is not possible because of irregular shape

3. Water bag method: Another method of applying ultrasound therapy to irregular

surface which cannot conventionally be placed in a water bath is treated with a
plastic or rubber bag filled with water

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Dosage
Three factors which determine ultrasound dosage are as follows: 1. size of the treatment area
2. depth of the lesion from the surface
3. nature of lesion.

Parameters of Ultrasound
1. Mode
2. Frequency
3. Intensity
4. Duration of treatment.

Mode
Continuous mode produces more heat so it is used for musculoskeletal conditions such as muscular spasm, joint
stiffness, pain, etc. Pulsed mode produces less heat so it is used for soft tissue repair, e.g. tendinitis. For
example, 0.5 W/cm2 pulsed at 1 : 4 deliver the same energy as 0.1 W/cm2 on a continuous mode.

Frequency
Attenuation increases with increase in frequency effectively lower frequency penetrate further.
• 1. Ultrasonic 3 MHz—superficial tissue
• 2. Ultrasonic 0.75 to 1 MHz—penetrate deeply.

Intensity
Power is the total energy/sec supplied by the machine and is measured in watts. Intensity applied is according to
the nature of the lesion.
• For acute and immediate post-traumatic: 0.1 to 0.25 W/cm2
• For chronic and scar tissue: 0.25 to 1 W/cm2.

Duration of Treatment
Amount of energy depends on intensity and duration of treatment. Size of area determine the treatment time,
1–2 minutes for every cm2. Many transducer heads have an area of 5 cm2
• Minimum — 1–2 minutes
• Maximum — 8 minutes
• Average — 5 minutes
• For chronic — Longer treatment time
• For acute — Lesser treatment time

Physiological Effects of Ultrasound

Thermal Effect
As the ultrasound waves are absorbed by the tissues they are converted into heat. The amount of heat developed
depends upon:
• Absorption of the tissues, e.g. protein absorbs ultrasound more effectively and therefore produces much heat.
• The number of times the treatment head passes over the part.
• When using continuous ultrasound, the amount of heat developed is
directly proportional to the intensity and duration of application.
• When using pulsed ultrasound there is less thermal effect than with continuous and a mark : space ratio 1 : 4
produces less heat than 1 : 1.
• Reflection of ultrasound at a tissue interface produces a concentration of heating effect at a specific point.

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Uses of Thermal Effects
The local rise in temperature could be used to accelerate healing. The extensibility of collagen is increased by
rise in temperature and so stretching of scars or adhesions is easier following ultrasound. The thermal effect
may also help reducing pain.

Non-Thermal Effects
Cavitation
This is the oscillatory activity of highly compressible bodies within the tissues such as gas or vapor filled voids.

Mechanical Effect or Micromassage

This occurs where the longitudinal compression waves of the ultrasound beam produces compression and
rarefaction of cells, and affect the movement of tissue fluid in interstitial spaces. This can help in reducing
edema. Combined with the thermal effect the extensibility of scars. It is also possible that the mechanical effect
could help reduce pain.

Biological Effect
Ultrasound can have some useful effects in stages of repair.

Therapeutic uses of ultrasound

• Scar tissue
• Bone injuries
• Chronic indurated edema
• Varicose ulcers
• Blood flows
• Plantar warts
• Placebo effect
• Soft tissues injuries

Dangers of ultrasound
• Burns
• Cavitation
• Overdose
• Danger to equipment