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Saurab Sharma, MPT
Lecturer, KUSMS
Therapeutic Ultrasound (US)
MSK III b – Cervical and thoracic
Spine
Electrotherapy
Lecture 4
Objectives of session
 At the end of the class, students will be
able to:
 Understand the background of ultrasound
 Explain the transmission, penetration and
absorption of ultrasound
 Explain the effects of ultrasound
 Identify the uses of Ultrasound
 Explain the application of ultrasound
 Identify Precautions and Contraindications
2
Introduction
 Most common modality used- 94% (Pope
et al, 1995)
 Initially used for thermal effects, now
used for its non-thermal effects
3
Ultrasound Transmission
 Does not pass through air (greatest
steal- air impedance)
 Presence of air between skin and
ultrasound head, means probability of
reflection- 99.9%
 Coupling medium required- water, gel,
oil, cream
 Head position- 90 degrees to skin4
Penetration and absorption
 Greater absorption in superficial tissue
than deep
 Half value depth-
 Different for different tissues and
frequencies
 3 MHz- 2 cm
 1 MHz- 4 cm
 Tissue with high protein absorbs more
US
5
Effects
 Thermal
 Non-thermal
Increasing protein content
Blood, fat, nerve, muscle, skin, tendon, (cartilage
and bone)
6
Low Ultrasound Absorption
High
Effects: Thermal
 Absorbed US generates heat. It
depends on:
 Nature of the tissue: high for protein
 Degree of vascularization
 Frequency of US: more frequency more
absorption
 Insufficient to raise temperature to cause
therapeutic changes
7
Effects: Thermal
 Should reduce pain, increase local blood
flow, decrease joint stiffness
 Biologically significant thermal effect can
be achieved by increasing the tissue
temperature to 40 – 45 degrees for at least
5 minutes.
8
Effects: Non- Thermal
 Cavitation
 Acoustic streaming
 Stimulates cell activity, membrane
permeability
 Increases protein synthesis
 Increases secretion from mast cells
 Fibroblast mobility changes
 Acceleration of repair
 Standing waves9
Effects: Tissue Repair
 Three phases of repair process
1. Inflammation
2. Proliferation/ granulation tissue
formation
3. Remodeling
 Effect of US depends on the phase in
which it is used
10
Effects: Tissue Repair:
Phase 1: Inflammation
 Acoustic streaming forces produces
changes in permeability of platelets
membrane causing release of serotonin.
 Serotonin may influence release of other
factors.
 Platelets also contain wound factors
essential for successful repair.
11
Effects: Tissue Repair:
Phase 1: Inflammation
 Single dose of US given soon after
injury can stimulate mast cells to release
histamine.
 Changes in permeability of mast cell to
calcium ion, potassium ions etc.
 Calcium ions act as intracellular signal
for appropriate metabolic response.
12
Effects: Tissue Repair:
Phase 1: Inflammation
 Cavitation is the physical mechanism
responsible
 Cavitation is the likely to occur at lower
frequency, whereas higher frequency
causes heating
 US causes edema to form and resolve
more rapidly accelerating healing process.
13
Effects: Tissue Repair
Phase 2: Proliferative phase of
repair
 US may maximize cell proliferation,
causes migration of cells
 US accelerates the rate of angiogenesis
 Continuous mode- 0.5 w/cm2- 20%
increase in collagen
 Pulse US- 0.5 w/cm2- 30% increase in
collagen
14
Effects: Tissue Repair
Phase 2: Proliferative phase of
repair
 Wound contraction is accelerated by US
 Pulsed- 3 MHz, 0.5 w/cm2
 Same degree of contraction can be
achieved by 0.1 w/cm2
15
Effects: Tissue Repair
Phase 3: Remodeling phase of
repair
 US changes the types of collagen from
type III to type I
 Increases tensile strength
 Increase scar mobility
 Enhances functional capacity of scar
tissues
16
Effects: Tissue Repair
Phase 3: Remodeling phase of
repair
 Best results- when if treated immediately
after injury: 0.1w/cm2 for 3 times/week for 2
weeks causes increased tensile strength
and elasticity
 Increases amount of collagen deposits
 Improves the pattern of deposition like
normal tissue
 Lower intensities are better than higher
17
Application of Ultrasound:
Factors to be considered:
 Choice of machine
 Calibration
 Choice of coupling medium
 Frequency
 Intensity
 Mode
 Duration of treatment
 Hazards18
Application of Ultrasound:
Factors to be considered:
 Choice of machine
 Calibration
 Choice of coupling medium
 Frequency
 Intensity
 Mode
 Duration of treatment
 Hazards19
Application of Ultrasound:
Choice of machine
20
Application of Ultrasound:
Factors to be considered:
 Choice of machine
 Calibration
 Choice of coupling medium
 Frequency
 Intensity
 Mode
 Duration of treatment
 Hazards21
Application of Ultrasound:
Factors to be considered:
 Choice of machine
 Calibration
 Choice of coupling medium
 Frequency
 Intensity
 Mode
 Duration of treatment
 Hazards22
Application of Ultrasound:
Factors to be considered:
 Choice of machine
 Calibration
 Choice of coupling medium
 Frequency : 1 MHz vs 3 MHz
 Intensity
 Mode
 Duration of treatment
 Hazards23
Application of Ultrasound:
Factors to be considered:
 Choice of machine
 Calibration
 Choice of coupling medium
 Frequency
 Intensity: Less vs more
 Mode
 Duration of treatment
 Hazards24
Application of Ultrasound:
Factors to be considered:
 Choice of machine
 Calibration
 Choice of coupling medium
 Frequency
 Intensity
 Mode: Pulsed vs continuous
 Duration of treatment
 Hazards25
Application of Ultrasound:
Factors to be considered:
 Choice of machine
 Calibration
 Choice of coupling medium
 Frequency
 Intensity
 Mode
 Duration of treatment
 Hazards26
Application of Ultrasound:
Factors to be considered:
 Choice of machine
 Calibration
 Choice of coupling medium
 Frequency
 Intensity
 Mode
 Duration of treatment
 Hazards27
Application of Ultrasound:
28
Application of Ultrasound:
29
Contraindications, dangers,
precautions
 Consider general contraindications to
Electrotherapy
 Spread of infection to the tissue
 70% alcohol swab reduces infection significantly
 Use it on every patient every time
 Pregnancy- avoid lower thorax, trunk and
pelvic region
 Malignant tissue
 Active epiphysis
 Higher dose US is avoided at fracture sites
30
Clinical application:
 Application in acute ankle sprain:
 Aim?
 Site?
 Type of application?
 Parameters/ doses?
 Evidence?
31
Objectives of session
 At the end of the class, students will be
able to:
 Understand the background of ultrasound
 Explain the Production, transmission,
penetration and absorption of ultrasound
 Explain the effects of ultrasound
 Identify the uses/ Indications of Ultrasound
 Explain the application of ultrasound
 Identify Precautions and Contraindications
32
References
 Kathleen Sluka. Mechanism and Management
of Pain for the Physical Therapist. 2nd Edition.
IASP Press. Wolters and Kluwer. 2016
 Tim Watson. Electrotherapy: Evidence Based
Practice. 2008. Churchill Livingstone. 12th
edition.
 John Low, Ann Reed. Electrotherapy
Explained. Principles and Practice.
Butterworth Heinemann. 3rd Edition.33

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Therapeutic Ultrasound for Physiotherapy students

  • 1. Saurab Sharma, MPT Lecturer, KUSMS Therapeutic Ultrasound (US) MSK III b – Cervical and thoracic Spine Electrotherapy Lecture 4
  • 2. Objectives of session  At the end of the class, students will be able to:  Understand the background of ultrasound  Explain the transmission, penetration and absorption of ultrasound  Explain the effects of ultrasound  Identify the uses of Ultrasound  Explain the application of ultrasound  Identify Precautions and Contraindications 2
  • 3. Introduction  Most common modality used- 94% (Pope et al, 1995)  Initially used for thermal effects, now used for its non-thermal effects 3
  • 4. Ultrasound Transmission  Does not pass through air (greatest steal- air impedance)  Presence of air between skin and ultrasound head, means probability of reflection- 99.9%  Coupling medium required- water, gel, oil, cream  Head position- 90 degrees to skin4
  • 5. Penetration and absorption  Greater absorption in superficial tissue than deep  Half value depth-  Different for different tissues and frequencies  3 MHz- 2 cm  1 MHz- 4 cm  Tissue with high protein absorbs more US 5
  • 6. Effects  Thermal  Non-thermal Increasing protein content Blood, fat, nerve, muscle, skin, tendon, (cartilage and bone) 6 Low Ultrasound Absorption High
  • 7. Effects: Thermal  Absorbed US generates heat. It depends on:  Nature of the tissue: high for protein  Degree of vascularization  Frequency of US: more frequency more absorption  Insufficient to raise temperature to cause therapeutic changes 7
  • 8. Effects: Thermal  Should reduce pain, increase local blood flow, decrease joint stiffness  Biologically significant thermal effect can be achieved by increasing the tissue temperature to 40 – 45 degrees for at least 5 minutes. 8
  • 9. Effects: Non- Thermal  Cavitation  Acoustic streaming  Stimulates cell activity, membrane permeability  Increases protein synthesis  Increases secretion from mast cells  Fibroblast mobility changes  Acceleration of repair  Standing waves9
  • 10. Effects: Tissue Repair  Three phases of repair process 1. Inflammation 2. Proliferation/ granulation tissue formation 3. Remodeling  Effect of US depends on the phase in which it is used 10
  • 11. Effects: Tissue Repair: Phase 1: Inflammation  Acoustic streaming forces produces changes in permeability of platelets membrane causing release of serotonin.  Serotonin may influence release of other factors.  Platelets also contain wound factors essential for successful repair. 11
  • 12. Effects: Tissue Repair: Phase 1: Inflammation  Single dose of US given soon after injury can stimulate mast cells to release histamine.  Changes in permeability of mast cell to calcium ion, potassium ions etc.  Calcium ions act as intracellular signal for appropriate metabolic response. 12
  • 13. Effects: Tissue Repair: Phase 1: Inflammation  Cavitation is the physical mechanism responsible  Cavitation is the likely to occur at lower frequency, whereas higher frequency causes heating  US causes edema to form and resolve more rapidly accelerating healing process. 13
  • 14. Effects: Tissue Repair Phase 2: Proliferative phase of repair  US may maximize cell proliferation, causes migration of cells  US accelerates the rate of angiogenesis  Continuous mode- 0.5 w/cm2- 20% increase in collagen  Pulse US- 0.5 w/cm2- 30% increase in collagen 14
  • 15. Effects: Tissue Repair Phase 2: Proliferative phase of repair  Wound contraction is accelerated by US  Pulsed- 3 MHz, 0.5 w/cm2  Same degree of contraction can be achieved by 0.1 w/cm2 15
  • 16. Effects: Tissue Repair Phase 3: Remodeling phase of repair  US changes the types of collagen from type III to type I  Increases tensile strength  Increase scar mobility  Enhances functional capacity of scar tissues 16
  • 17. Effects: Tissue Repair Phase 3: Remodeling phase of repair  Best results- when if treated immediately after injury: 0.1w/cm2 for 3 times/week for 2 weeks causes increased tensile strength and elasticity  Increases amount of collagen deposits  Improves the pattern of deposition like normal tissue  Lower intensities are better than higher 17
  • 18. Application of Ultrasound: Factors to be considered:  Choice of machine  Calibration  Choice of coupling medium  Frequency  Intensity  Mode  Duration of treatment  Hazards18
  • 19. Application of Ultrasound: Factors to be considered:  Choice of machine  Calibration  Choice of coupling medium  Frequency  Intensity  Mode  Duration of treatment  Hazards19
  • 21. Application of Ultrasound: Factors to be considered:  Choice of machine  Calibration  Choice of coupling medium  Frequency  Intensity  Mode  Duration of treatment  Hazards21
  • 22. Application of Ultrasound: Factors to be considered:  Choice of machine  Calibration  Choice of coupling medium  Frequency  Intensity  Mode  Duration of treatment  Hazards22
  • 23. Application of Ultrasound: Factors to be considered:  Choice of machine  Calibration  Choice of coupling medium  Frequency : 1 MHz vs 3 MHz  Intensity  Mode  Duration of treatment  Hazards23
  • 24. Application of Ultrasound: Factors to be considered:  Choice of machine  Calibration  Choice of coupling medium  Frequency  Intensity: Less vs more  Mode  Duration of treatment  Hazards24
  • 25. Application of Ultrasound: Factors to be considered:  Choice of machine  Calibration  Choice of coupling medium  Frequency  Intensity  Mode: Pulsed vs continuous  Duration of treatment  Hazards25
  • 26. Application of Ultrasound: Factors to be considered:  Choice of machine  Calibration  Choice of coupling medium  Frequency  Intensity  Mode  Duration of treatment  Hazards26
  • 27. Application of Ultrasound: Factors to be considered:  Choice of machine  Calibration  Choice of coupling medium  Frequency  Intensity  Mode  Duration of treatment  Hazards27
  • 30. Contraindications, dangers, precautions  Consider general contraindications to Electrotherapy  Spread of infection to the tissue  70% alcohol swab reduces infection significantly  Use it on every patient every time  Pregnancy- avoid lower thorax, trunk and pelvic region  Malignant tissue  Active epiphysis  Higher dose US is avoided at fracture sites 30
  • 31. Clinical application:  Application in acute ankle sprain:  Aim?  Site?  Type of application?  Parameters/ doses?  Evidence? 31
  • 32. Objectives of session  At the end of the class, students will be able to:  Understand the background of ultrasound  Explain the Production, transmission, penetration and absorption of ultrasound  Explain the effects of ultrasound  Identify the uses/ Indications of Ultrasound  Explain the application of ultrasound  Identify Precautions and Contraindications 32
  • 33. References  Kathleen Sluka. Mechanism and Management of Pain for the Physical Therapist. 2nd Edition. IASP Press. Wolters and Kluwer. 2016  Tim Watson. Electrotherapy: Evidence Based Practice. 2008. Churchill Livingstone. 12th edition.  John Low, Ann Reed. Electrotherapy Explained. Principles and Practice. Butterworth Heinemann. 3rd Edition.33

Notas del editor

  1. For maximum transmission of energy, impedence two medium needs to be same.
  2. For maximum transmission of energy, impedence two medium needs to be same. Half value depth- is the depth in the tissues at which half the surface energy is available. Blood and fat has more water and less protein so absorbs least
  3. For maximum transmission of energy, impedence two medium needs to be same.
  4. Biologically significant thermal effect can be achieved by increasing the tissue temp to 40 – 45 degrees for at least 5 minutes.
  5. Biologically significant thermal effect can be achieved by increasing the tissue temp to 40 – 45 degrees for at least 5 minutes.
  6. Histamine is one of the major chemicals that modifies the wound environment at this time after injury.
  7. Histamine is one of the major chemicals that modifies the wound environment at this time after injury.
  8. Histamine is one of the major chemicals that modifies the wound environment at this time after injury.
  9. Type III to type I
  10. Type III to type I
  11. Less intensity for wound healing; more than 1.5 w/cm2 may had adverse events on healing tissues Acute- less than 0.5; chronic less than 1 (0.3- 0.8)
  12. Less intensity for wound healing; more than 1.5 w/cm2 may had adverse events on healing tissues Acute- less than 0.5; chronic less than 1 (0.3- 0.8)
  13. Less intensity for wound healing; more than 1.5 w/cm2 may had adverse events on healing tissues Acute- less than 0.5; chronic less than 1 (0.3- 0.8)
  14. Less intensity for wound healing; more than 1.5 w/cm2 may had adverse events on healing tissues Acute- less than 0.5; chronic less than 1 (0.3- 0.8)
  15. Less intensity for wound healing; more than 1.5 w/cm2 may had adverse events on healing tissues Acute- less than 0.5; chronic less than 1 (0.3- 0.8)
  16. Less intensity for wound healing; more than 1.5 w/cm2 may had adverse events on healing tissues Acute- less than 0.5; chronic less than 1 (0.3- 0.8)
  17. Less intensity for wound healing; more than 1.5 w/cm2 may had adverse events on healing tissues Acute- less than 0.5; chronic less than 1 (0.3- 0.8)
  18. No evidence of harm in pregnancy, avoid to be at safer side
  19. No evidence of harm in pregnancy, avoid to be at safer side