ULTRASOUND Dr.

Muhammad Shahid Shabbir

DPT,MS.NMPT
HISTORY
Methods to generate and detect ultrasound first became available in the United States
in the 19th century.
The first large-scale application of ultrasound was for SONAR (Sound Navigation
and Ranging) during World War II.
Ultrasound was found to heat tissue with a high collagen content, such as tendons,
ligaments, or fascia and, for the past 50 years or more, has been widely used in the
clinical setting for this purpose
More recently, ultrasound has also been found to have non thermal effects and, over
the past 20 years, therapeutic applications of these effects have been developed.
DEFINITION
Ultrasound is defined as sound with a frequency of greater than 20,000 cycles per second (Hertz. Hz).

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 can therefore also be called
ultrasonic.

Audible sound – 20 to 20000 Hz

Ultrasound – Greater then 20000 Hz
Infrasound – Less than 20 Hz
Therapeutic ultrasound – 0.5 to 5 MHz
– 1 to 3 MHz
NATURE OF SONIC (SOUND)
WAVES
Sonic waves are series of mechanical compressions and rarefactions in the
direction of travel of the wave, hence they are called longitudinal waves.
The passage of these waves of compression through matter is invisible because it is
the molecules that vibrate about their average position as a result of the sonic wave.
Sound waves will pass more rapidly through material in which the molecules are
close together, thus their velocity is higher in solids and liquids than in gases.
Air – 344 m/s
Water – 1410 m/s
Salt water – 1500 m/s
Muscle – 1540 m/s
GENERATION OF
ULTRASOUND
Piezoelectric property: The property of piezoelectricity, the ability to generate
electricity in response to a mechanical force or to change shape in response to an
electrical current. OR The production of a small e.m.f. across certain substances on
being subjected to external pressure.
A variety of materials are piezoelectric including bone, natural quartz and synthetic
plumbium zirconium titanate (PZT), and barium titanate. At this time, ultrasound
transducers are usually made of PZT because this is the least costly and most
efficient piezoelectric material readily available.
Ultrasound is generated by applying a high-frequency alternating electrical current to
the crystal in the transducer of an ultrasound unit. The crystal is made of a material
with piezoelectric properties causing it to respond to the alternating current by
expanding and contracting at the same frequency at which the current changes
polarity. when the crystal expands it compresses the material in front of it, and when
it contracts it rarefies the material in front of it. This alternating compression-
rarefaction is the ultrasound wave.
TERMINOLOGY IN U.S
Transducer (sound head): A crystal that converts electrical energy into sound. This
term is also used to describe the part of an ultrasound unit that contains the crystal.
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/centimeter squared.
Spatial Average Intensity: The average intensity of the ultrasound output over the
area of the transducer.
Spatial Peak Intensity: The peak intensity of the ultrasound output over the area of
the transducer. The intensity is usually greatest in the center of the beam and lowest
at the edges of the beam.
Beam Non uniformity 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, although
it can be as low as 2:7
Continuous Ultrasound: Continuous delivery of ultrasound throughout the
treatment period.
Pulsed Ultrasound: Delivery of ultrasound during only a portion of the treatment
period. Delivery of ultrasound is pulsed on and off throughout the treatment period.
Pulsing the ultrasound minimizes its thermal effects.
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.
Effective Radiating Area (ERA): The area of the transducer from which the ultrasound
energy radiates. Because the crystal does not vibrate uniformly, the ERA is always smaller
than the area of the treatment head.
NEAR AND FAR FIELD
The ultrasound beam delivered from a transducer initially converges and then
diverges. The near field, also known as Fresnel zone, is the convergent region, and
the far field, also known as the Fraunhofer zone, is the divergent region.
In the near field there is interference of the ultrasound beam causing variations in
ultrasound intensity. In the far field there is little interference, resulting in a more
uniform distribution of ultrasound intensity.
The length of the near field is dependent on the ultrasound frequency and the ERA of
the transducer.
ULTRASOUND REFLECTION &
REFRACTION:
Reflection: The redirection of an incident beam away from a reflecting surface at an
angle equal and opposite to the angle of incidence. Ultrasound is reflected at tissue
interface.
Refraction: The redirection of a wave at an interface. When refraction occurs, the
ultrasound wave enters the tissue at one angle and continues through the tissue at a
different angle.
ABSORPTION
Conversion of the mechanical energy of ultrasound into heat. The amount of
absorption that occurs in a tissue type at a specific frequency is expressed by its
absorption coefficient. The absorption coefficient is determined by measuring the
rate of temperature rise in a homogeneous tissue model exposed to an ultrasound
field of known intensity. Absorption coefficients are tissue and frequency specific.
They are highest for tissues with the highest collagen content and increase in
proportion to the ultrasound frequency.
ATTENUATION
Attenuation: A measure of the decrease in ultrasound intensity as the ultrasound
wave travels through tissue. Attenuation is the result of absorption, reflection, and
refraction, with absorption accounting for about one-half 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.
STANDING WAVES
Intensity maxima and minima at fixed positions one-half wavelength apart. Standing
waves occur when the ultrasound transducer and a reflecting surface are an exact
multiple of wavelengths apart, allowing the reflected wave to superimpose on the
incident wave entering the tissue. Standing waves can be avoided by moving the
sound head throughout the treatment.
CAVITATION
The formation, growth, and pulsation of gas- or vapor-filled bubbles caused by
ultrasound. During the compression phase of an ultrasound wave, bubbles present in
the tissue are made smaller, and during the rarefaction phase they expand.
Cavitation may be stable or unstable. With stable cavitation, the bubbles oscillate in
size throughout many cycles but do not burst. With unstable cavitation, the bubbles
grow over a number of cycles and then implode. This implosion produces large brief,
local pressure and temperature increases and causes free radical formation.
Stable cavitation has been proposed as a mechanism for the nonthermal therapeutic
effects of ultrasound, while unstable cavitation is thought not to occur at the
intensities of ultrasound used therapeutically.
Micro streaming: Micro scale eddying that takes place near any small, vibrating
object. Micro streaming occurs around the gas bubbles set into oscillation by
cavitation.
Acoustic Streaming: The steady, circular flow of cellular fluids induced by
ultrasound. This flow is larger in scale than with micro streaming and is thought to
alter cellular activity by transporting material from one part of the ultrasound field to
another.
PHONOPHORESIS
The application of ultrasound with a topical drug in order to facilitate transdermal
drug delivery.
In summary ultrasound is a high-frequency sound waves that can be described by its
intensity, frequency, duty cycle, ERA and BNR. It enters the body and is attenuated
in the tissue by absorption, reflection and refraction.
EFFECTS OF ULTRASOUND
Thermal Effects: The thermal effects of ultrasound, including acceleration of metabolic rate,
reduction or control of pain and muscle spasm, alteration of nerve conduction velocity,
increased circulation, and increased soft tissue extensibility, are the same as those obtained
with other heating modalities, except that the structures heated are different.
Ultrasound reaches more deeply and heats smaller areas than most superficial heating agents.
Ultrasound also heats tissues with high ultrasound absorption coefficients more than those
with low absorption coefficients. Tissues with high absorption coefficients are generally
those with a high collagen content, while tissues with low absorption coefficients generally
have a high water content.
Thus, ultrasound is particularly well-suited to heating tendons, ligaments, joint capsules and
fascia while not overheating the overlying fat. Ultrasound is generally not the ideal physical
agent for heating muscle tissue because muscle has a relatively low absorption coefficient;
also most muscles are much larger than the available ultrasound transducers.
THERMAL EFFECTS
Increase in the extensibility of collagen
Decrease in joint stiffness
Reduction of muscle spasm
Modulation of pain
Increased blood flow
Mild inflammatory response
 May help in the resolution of chronic inflammation
NON THERMAL EFFECTS
Ultrasound has a variety of effects on biological processes that are thought to be
unrelated to any increase in tissue temperature. These effects are the result of the
mechanical events Produced by ultrasound, including cavitation, micro streaming,
and acoustic streaming. When ultrasound is delivered in a pulsed mode, with a 20%
or lower duty cycle, the heat generated during the on time of the cycle is dispersed
during the off time, resulting in no measurable net increase in temperature.
NONTHERMAL EFFECTS
Increased cell membrane Stimulation of phagocytosis
permeability Production of healthy granulation
Altered rate of diffusion across cell tissue
membrane Synthesis of protein
Increased vascular permeability Synthesis of collagen
Secretion of cytokines Reduction of edema
Increased blood flow Diffusion of ions
Tissue regeneration
Formation of stronger, more
deformable scar
Ultrasound with a low average intensity has been shown to increase 1. intracellular
calcium
2. increase skin and cell membrane permeability
3. increase mast cell degranulation
4. increase chemotactic factor and histamine release
5. increase macrophage responsiveness
6. increase the rate of protein synthesis by fibroblasts
TECHNIQUES OF APPLICATION
Frequency of treatment
 Acute vs. chronic
 How many treatments should be given?

Duration of treatment
 Dependent on treatment goal

Keep the transducer moving!!!

COUPLING METHODS
Direct contact
Immersion
 Watch for bubbles

COUPLING MEDIA
 To avoid the impedance(Z) by air
 Best is Aqua sonic gel(water based gel)
TECHNIQUES OF APPLICATION
Note : check equipment before application
DIRECT CONTACT
 Should move concentric circles
 Turn off and on in contact with patients
 Three times the size of treatment head
WATER BATH
 Immerse treatment part in water (without
bubbles)
 Keep the head 1cm from treatment part

35
WATER BAG
 Rubber bag filled with water
 Apply coupling media on bag and treatment area
 Move the US head same like direct method

AB
36
DOSAGE

ACUTE
 Intensity – 0.25 Wcm-2 – 0.5 Wcm-2
 Duration 2-3 Minutes
 Use pulsed mode (Very acute – 1:7 , Acute – 1:1)
CHRONIC
 Intensity 0.8 Wcm-2 – 2 Wcm-2
 Duration upto 4 – 8 Minutes
 Use continuous mode

AB 37
CLINICAL APPLICATION OF
ULTRASOUND
Soft tissue shortening
Pain control
Dermal ulcers
Surgical skin incisions
Tendon injuries
Resorption of calcium deposits
Bone fractures
Carpal tunnel syndrome
Phonophoresis
Plantar warts
Herpes zoster infection
SOFT TISSUE SHORTENING
Soft tissue shortening can be the result of immobilization, inactivity or scarring, and
can cause joint ROM restrictions, pain, and functional limitations. Shortening of the
joint capsule, surrounding tendons, or ligaments is frequently responsible.
The deep heating produced by 1 MHz continuous ultrasound at 1.0 to 2.5W/cm2 has
been shown to be more effective at increasing hip joint ROM instead the superficial
heating produced by infrared radiations when applied in conjunction with exercise.
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
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.

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
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
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
THERMAL
APPLICATIO
NS
 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.
PAIN CONTROL
• ultrasound may control pain by altering its transmission or perception or by
modifying the underlying condition causing the pain. These effects may be the result
of stimulation of the cutaneous thermal receptors or increased soft tissue extensibility
due to increased tissue temperature, the result of changes in nerve conduction due to
increased tissue temperature.
• Continuous ultrasound at 0.5 to 2.0 Wcm2 intensity and 1.5M Hz frequency has also
been reported to be more effective than superficial heating with paraffin or infrared or
deep heating with short waved diathermy for relieving the pain from soft tissue
injuries.
• Continuous ultrasound applied at 1.5 Wcm2 for 3 to 5 minutes for 10 treatments over
a 3-week period followed by exercise has been found to be more effective than
exercise alone in relieving pain and increasing ROM in patients with shoulder pain.
DERMAL ULCERS
• Addition of ultrasound treatment to conventional wound care procedures resulted in
significantly greater reduction in the area of lower extremity varicose ulcers.
Ultrasound was applied pulsed at 20% duty cycle, at 1.0 Wcm2 intensity, 3 MHz
frequency, for 5 to l0 minutes to the intact skin around the border of lower extremity
varicose ulcers 3 times a week for 4 weeks.
SURGICAL SKIN INCISION
The effect of ultrasound on the healing of surgical skin incisions has been studied in
both animals and human subjects. Ultrasound applied at 0.5 W/cm2, pulsed 20%, for
5 minutes daily to full thickness skin lesions in adult rats has been shown to
accelerate the evolution of angiogenesis, a vital component of early wound healing.
Angiogenesis is the development of new blood vessels at an injury site that serves to
reestablish circulation and thus limit ischemic necrosis and facilitate repair. It is
proposed that ultrasound may accelerate the development of angiogenesis by altering
cell membrane permeability, particularly to calcium ions, and by stimulating
angiogenic factors synthesis and release by macrophages.
TENDON INJURIES
•Ultrasound has been reported to assist in the healing of tendons after surgical
incision and repair.
• Enhanced recovery in patients with lateral epicondylitis treated with ultrasound. the
ultrasound was applied pulsed with a 20% duty cycle 1.0 or 2.0 W/cm2 intensity, 1
MHz frequency, for 5 to 10 minutes for 12 treatments over a 4- to 6-week period.
• Greater resolution of calcium deposits, greater decreases in pain, and greater
improvements in the quality of life in patients with calcific tendinitis of the shoulder
treated with ultrasound.
CONTRAINDICATIONS
Malignant tumor
Joint cement/Total joint
replacements
Plastic components
Pacemaker
Thrombophlebitis
Eyes
Areas of decreased temperature
sensation
Areas of decreased circulation
Vascular insufficiencies
Reproductive organs
Acute conditions (continous output)
Tendency to hemorrhage
Over pelvic or lumbar areas in
pregnant or menstruating females
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\Infections
Epiphyseal areas in developing
individuals