Therapeutic

Ultrasound
lecture VIII
Dr. Amaal H.M.Ebrahim

Introduction
Therapeutic
ultrasound (US) is
one of the most
common physical
agents used in
rehabilitation.
Ultrasound is a
mechanical not
electric energy.

Introduction
Ultrasound is a form of a caustic vibration
propagated in the form of longitudinal waves
consisting of areas of compression and
rarefaction at frequencies too high and cannot
be heard by human ears

Introduction
Particles of a material, when exposed to a sound
wave will oscillate about a fixed point rather than
move with the wave itself. As the energy within the
second wave is passed to the material it will cause
oscillation of the particles of that material. Clearly
any increase in the molecular vibration in the tissue
can result in heat
generation, and ultrasound can be used to produce
thermal changes in the tissues.

Introduction
Sound waves of audible range are within
frequency 20Hz to 20000Hz. Waves below
these frequencies are called infrasonic
waves.
The amplitude of a longitudinal wave is the
greatest distance which a particle moves from
its rest position.

Introduction
The wave length of longitudinal wave is the
distance from the middle of one compression to
the middle of the next.
If the frequency is 1MHz and the velocity is
about 1500m.s in water and tissue, then the
distance from the compression to
another will be one millionth of 1500m, or 1.5
mm.
At higher frequencies the wave length will be
less.

The Frequency
The frequency of longitudinal wave motion is the number of the
complete waves which pass a fixed point in unit time.
Velocity = Frequency x Wave length.
Most medical applications employ frequencies between 1MHz
and 15 MHz:
1- Physiotherapy equipment has frequency 0.75MHz,
0.87MHz, 1MHz, 1.5MHz, 3MHz.
2- Diagnostic equipment has frequency between 1MHz and
10MHz.
3- Surgical equipment has frequency between 1MHz and
5MHz.

Propagation and speed of

ultrasound waves

The human body processes a characteristic

resistance against the propagation of
ultrasound. Each tissue in the body has a
characteristic impedance (Z).
It is directly proportional to the velocity of
propagation (V) and the density (P) of the
tissue.

Production of US
The brothers, Pierre and Jacques Curie,
discovered that when a quartz crystal is
stressed, a potential difference is produced
across its faces. This is called piezoelectric
effect. In 1917 Langevin discovered that by
vibrating a quartz crystal with a high
frequency alternating current ultrasound
could be produced.

Production of US
Piezoelectric effect: is the ability of some materials
(notably crystals and certain ceramics) to generate an
electric potential in response to applied mechanical
stress. When crystals are deformed (compressed),
they produce small electric charges. The electropiezo
effect (reverse of piezoelectric effect) occurs when an
electrical current passed through a crystal causes the
crystal expand or contract.

Production of US
Using the electropiezo effect, ultrasound units produce high
frequency waves by passing an alternating current through a
piezoelectric crystal. The higher the current's frequency, the
higher the frequency of the ultrasonic output.
Crystal usually vibrates at a natural frequency which depends
largely on its thickness. The frequency of vibration remains
constant for a given generator, but the intensity, in terms of
amplitude can be varied.

The ultrasonic generator

The therapeutic ultrasonic valve generator produces a
high frequency AC from about 0.75MHz to 3MHz. the
resonant frequency of the current is at the same
natural frequency as that
of the crystal. The high frequency current is applied to
the crystal.
In front of the crystal lies the transducer head which is
made to vibrate mechanically by the acoustic
vibration energy of the crystal.

The ultrasonic generator

The transducer or treatment head is a crystal inserted
between two electrodes. The crystal translates the
electrical oscillations directly into mechanical
vibrations which pass through a metal cap into the
body through the coupling medium

The ultrasonic generator

For therapeutic purposes the applicator should have
a radiating surface which is slightly smaller than the
total applicator surface.
This makes it easier to maintain full contact between
the head and the treatment area.

The ultrasonic generator

When the machine is switched on the frequency
energy applied to the crystal is increased to the
required level. The average ultrasonic
intensity is expressed in watts per square centimeter
(w.cm). it is obtained by measuring the total output
of the applicator (power),
and then dividing it by the size of the radiating
surface of the applicator (area). Large applicators are
preferable.

The ultrasonic generator

As air is not dense enough to transmit ultrasonic
energy, a transmission medium is required to allow
the energy to pass from the sound head to the
tissues. Sound waves cannot exit transducer
when no medium is present. Operating the
ultrasound unit when its head is not in contact with a
transmission medium can damage its
transducer. Many units have sensors that can detect
when there is insufficient coupling and automatically
shut down the generator.

The ultrasonic generator

Once in the bodys tissues, the sound waves cause
the molecules to vibrate, creating various thermal
and mechanical effects. As the ultrasonic energy
passes through the tissue layers and meets different
densities, its energy attenuates.
Ultrasound passes through water-rich tissues and
preferentially heats those tissues
that have a high collagen content.

SOME PHYSICAL PHENOMENA OF

ULTRASOUND
Reflection
When ultrasound passes from one medium to
another it is important to know the acoustic
impedance (Z) of each medium.

SOME PHYSICAL PHENOMENA OF

ULTRASOUND
Reflection
If there is an acoustic
mismatch between the two
media a certain amount of
reflection will occur at the
interface between the media.
If the two media have the
same characteristic acoustic
impedance there will be no
reflection

SOME PHYSICAL PHENOMENA OF

ULTRASOUND
Bone periosteum interface
As periosteum and bone tissue have different acoustic
impedance, about 70% of the energy is reflected,and the balance
(30%) is absorbed by the bone. The total load on the periosteum
is equal to the total incident power plus the reflected power. This
causes shear waves to occur around the periosteum. The particles
of both media oscillate at right angles to the direction of
propagation and, as the wavelength is different in each medium,
the particles move in different directions and cause a shear stress
at the boundary.

SOME PHYSICAL PHENOMENA OF

ULTRASOUND
Bone periosteum interface
This is called a shear stress wave, and is rapidly absorbed at the
periosteum. The periosteum is a vascular, and no cooling effect
occurs, so it quickly heats up and causes a periosteal pain. The
patient will soon complain of the heating sensation, because the
periosteum is temperature-sensitive

SOME PHYSICAL PHENOMENA OF

ULTRASOUND
Tissue-air interface
Reflection also occurs at tissue-air interface.
Here air acts as a reflector, and the ultrasound beam is reflected
back to the surface of the tissue area being treated. Excessive
heating will occur, causing a heating pain in the skin. This can
occur if ultrasound is given to a thin area such as the palm of the
hand.

SOME PHYSICAL PHENOMENA OF

ULTRASOUND
Transducer head-skin interface with an air pocket
If the metal of the ultrasound head and the tissue are
not completely intact with another and there is a small
air pocket, reflection in the transducer head will cause
excessive heating of the head and the skin lead to
danger of burn

SOME PHYSICAL PHENOMENA OF

ULTRASOUND
Refraction
When the angle of the incidence is 15
degree, refraction of a beam is 90 degree
and will run parallel to the interface.
Refraction is deviation that means
ultrasonic energy invades the tissue at
one angle and continues at a different
angle (angle of refraction). Only for
angles of incidence of less than 15
degree will any energy pass into the
tissue refraction occurs particularly
where tendon join bone and lead to
concentration of energy

Transmission of Ultrasound
For ultrasound to be an effective
agent, the US wave must be
transmitted from the unit to the tissue
via a conducting medium.
The most common transmission
mediums include US gel, mineral oil,
lotions, gel pads, and water.
Ultrasound gels and pads appear to be
the best conducting mediums.

Transmission of Ultrasound
. Ultrasound treatments conducted when the target
tissue is immersed in water are often used for areas
with irregular surfaces where it is difficult to
maintain contact on the treatment area. However,
immersed ultrasound is not as effective as
ultrasound applied directly to the tissue via gel

Transmission of Ultrasound
Another consideration with ultrasound is the type of tissue
being treated, or what tissue the US must travel through to
reach the target. Ultrasound energy is absorbed at different
rates by different tissues and this is related to both the water
and protein content of the tissue.

Transmission of Ultrasound
Skin and adipose tissue absorb less acoustic energy than
muscle, tendon, and ligament. Nerve tissue and bone absorb
the greatest amount of US energy. Therefore, you should
consider not only the depth of the tissue to be treated, but
also the type of tissue when determining treatment
parameters

Transmission of Ultrasound
Attenuation: is the progressive loss of the acoustic power as
ultrasonic travels through a medium. The amount of
attenuation varies from tissue to tissue. Attenuation is linear
and inversely proportional to the frequency. If the frequency
is changed from 1MHz to 3MHz the attenuation in muscle
changes from 2% to 6% per millimeter. For a frequency of
3MHz, attenuation is 50%
at 25 millimeter, while at 0.75MHz the attenuation is 50% at
90 millimeter

Transmission of Ultrasound
Absorption of ultrasound: it is generally accepted that absorption of
ultrasound energy takes place at molecular level, the proteins are the
major absorbers. The protein in nerve is sensitive to ultrasound. Muscles
absorb twice as much as fat. The viscosity of the medium opposes the
particle motion, and so absorption of energy occurs. Absorption of
ultrasonic energy depends on the following
1- Acoustic impedance of the tissue.
2- Propagation velocity of sound.
3- Density of tissue.
4- Frequency of ultrasound

Transmission of Ultrasound
5- Protein content.

6- Fat and water content.

7- Angle of incidence of acoustic energy.

8- Viscosity of fluid.

9- Reflection.

10- Refraction.

11- Shear waves.

Pulsed Ultrasound
Most ultrasound generator gives pulsed ultrasound
of 2 ms (2 thousands of second) pulses. The ratio of
pulse time to the off
time is variable from 1:1 to 1:4 modes, or as the duty
cycle, which is the ratio of the pulse time to the total
time of pulse and pulse interval represented as a
percentage

Pulsed Ultrasound
If pulsed ultrasound is applied at a mark
: space ratio of 1:1 the amount of
introduced energy is one-half of that
introduced by continuous ultrasound
applied for the same period of time and
the same intensity.

Pulsed Ultrasound
So the therapist can apply pulsed ultrasound with
the same intensity but with double time of
treatment or double the intensity with the same
time of application to produce the same amount of
ultrasound energy.
Yet the effect is not the same as continuous
ultrasound because with pulsed ultrasound there is
time for the heat to be dissipated by conduction in
the tissues and in the circulating blood. The pulsed
ultrasound is safety because the average heating is
reduced.

Effect of Pulsed Ultrasound

1- Increase rates of ion diffusion across cell
membrane due to increase particle movement
on the either side of the membrane.
2- Increase motion of the phospholipids and
proteins that form the membrane.

Beam Characteristics
Beam Profile

Ultrasound generators
produce an irregularly-shaped
beam. This is caused by the
waves originating from many
individual points on the face of
the transducer. As this energy
travels away from the
transducer, it merges with other
waves forming areas of peak
intensity known as hot spots.

Beam Characteristics
Beam Non Uniformity Ratio
The output intensity presented on the ultrasound
unit's meter represents the average output within the
beam's near field in total watts or W/cm2

Beam Characteristics
Beam Non Uniformity Ratio
The spatial peak intensity, represented by the
spike in the beam, is determined by the
transducer's beam non-uniformity ratio (BNR)

Spatial Average Intensity

Ultrasonic output
may be measured
either in terms of
total watts (W) or
watts per square
centimeter
(W/cm2), the
spatial average
intensity (SAI).

Spatial Average Intensity

In the examples
above, 10 watts
being passed
through an effective
radiating area of 10
cm2 results in a SAI
of 1.0 W/cm2.
Passing 10 watts
through a 5 cm2
ERA doubles the
SAI to 2.0 w/cm

Beam Divergence
An ultrasound beam tends
to diverge as it leaves the
sound head. The degree of
divergence is dependent on
the size of the sound head
and the output frequency.

Beam Divergence
Ultrasound having a frequency of 1 MHz
produces a more divergent beam than 3
MHz ultrasound, which produces a
collimating beam.
Likewise, sound heads having a smaller
ERA produce a more divergent beam
than heads having a larger ERA.

Output Parameters (Continuous and

pulsed US)
Duty Cycle
Ultrasound can be delivered to the body using
continuous (thermal) or pulsed (non-thermal)
modes. The duty cycle is the relationship between
the pulse length (on time) and the pulse interval (off
time)

Output Parameters (Continuous and

pulsed US)
Duty Cycle
Duty cycle is calculated by:

Duty cycle = Pulse length / (Pulse length + Pulse

interval) X100

Higher duty cycles primarily produce thermal

effects within the body. Lower duty cycles result in
predominantly mechanical (non-thermal) effects

Physiological effects of ultrasound

The sonic energy that absorbed from ultrasound
causes oscillation of particles about their mean
position. This sonic energy is converted into heat
energy which is proportional to the ultrasound
intensity and causing thermal effects in the tissues.

Thermal Effects
The thermal effect increases tissue temperature
which must be maintained between 40 and 45C for
at least 5 minutes.
Heating fibrous tissue structures such as joint
capsules, ligaments, tendons and scar tissue can
cause a temporary increase in their extensibility and
hence a decrease in joint stiffness.
Mild heating can reducing pain and muscle spasm
and promoting healing processes.

Non-thermal Effects
a-Cavitation
Is a very small gas bubble filled
voids within the tissues and
body fluids. There are two
types, first, stable cavitations
which are tine bubbles
oscillate to and fro within the
ultrasound pressure waves but
remain intact.

Non-thermal Effects
a-Cavitation
Second, unstable cavitations
(transient or collapsed) are
formation of tiny bubbles with
changing volume at
high intensities. The collapsed
bubbles causing high pressure
and
temperature changes are
resulting in gross damage to
tissue.

Non-thermal Effects
b- Acoustic streaming
As a result of both types of cavitations, there
is a very small localized unidirectional fluid
movement around the vibrating bubbles and
cells called acoustic streaming. These acoustic
streaming is affecting the permeability of cell
membrane leading to alter the rate of
diffusion and permeability of ions across cell
membrane.

Non-thermal Effects
b-Acoustic streaming
For example, calcium which is a second
messenger may result in the stimulation
of healing processes. Also sodium may
alter the electrical activity of nerves
leading to relief pain.

Non-thermal Effects
c-Standing waves
The reflected waves of ultrasound cause
stationary waves with peaks of high pressure
(antinodes) and another with no pressure
(nodes). This pressure pattern causes stasis of
cells in blood stream exposing the epithelium
of the blood vessels to damage, (thrombosis
formation).

Non-thermal Effects
d-Micromassage
Micromassage is a mechanical effect
cause molecules to vibrate, possibly
enhance tissue inter change and affect
tissue mobility.
It can used to reduce edema.

Non-thermal Effects
e-Role of US in Tissue Repair
US plays an important role in enhancement of
tissue repair and reduces of inflammation as
follow :
1- During acute stage (inflammation)
a-US produces gentle agitation of the tissue
fluid causing stimulation of histamine and
other growth factors from mast cells.

Non-thermal Effects
e-Role of US in tissue repair
1- During acute stage (inflammation)
b- US increases calcium ion diffusion across the
cell membrane causing degranulation.
c- US increases the rate of phagocytosis and the
movement of particles and cells.
d- US has a pro-inflammatory action not an
anti- inflammatory action.

Non-thermal Effects
e-Role of US in tissue repair
2- Granulation stage:
Start approximately three days after injury.
a- Connective tissue framework is laid down by
flbroblasts.
b- US promote collagen synthesis (due to increase cell
membrane permeability.
c- US allow the entry of calcium ions for more control of
cellular activity.
d- US encourage the growth of new capillaries in chronic
ischemic tissues.

Non-thermal Effects
e-Role of US in tissue repair
3- Remodeling stage
This stage takes months or years.
a- US can improve the extensibility of mature
collagen (scar tissue).
b- This is believed to occur by promoting the
reorientation of the fibers leading to more
elasticity without loss of strength.