PET 4642

Chapter 15: Clinical Therapeutic Ultrasound

Therapeutic Ultrasound
Ultrasound is a __________________ modality capable of producing changes in
tissue through both ___________ and ______________ (mechanical) changes.
The Therapeutic Ultrasound is _________________.
It creates acoustic vibrations of varying frequencies that can cause psychological
effects.
Ultrasound uses ________________ energy.
o Acoustical energy is transmitted by mechanical waves (_____________)
that transmit through a medium.
Depending on the frequency of the waves, ultrasound is used for diagnostic
imaging, therapeutic deep tissue heating, or tissue destruction.
Depending on the parameter, some of the effects of therapeutic ultrasound
include:
o Increased rate ___________________________________________
o Increased blood flow
o Increased ____________________________________
o Breakdown of calcium deposits
o Reduction of Pain and muscle spasm (via alteration of nerve conduction
velocity)
o Changes in ______________________________________
Ultrasound is also used to deliver medication to any subcutaneous tissue.
o This process is called ________________________.
Any sound wave that is above 20,000 hertz is considered Ultrasound.
o The human ear can detect sound waves in between 16,000 20,000 hertz.
Hertz is the number of cycles per unit
o Therapeutic Ultrasound ranges from 750,000 to 3,300,000 Hz.
The clinician describes the range in megahertz. (______________)
Megahertz are one million cycles per second
Production of Ultrasound and Components of an Ultrasound Device
The Ultrasound device is composed of four main parts
o The ____________________: regulates the parameters, it is the big box
o The ___________________: 2-3mm thick synthetic ceramic
The crystal is a transducer that converts electrical energy to
acoustic energy through mechanical deformation of the crystal.
When an alternating current is passed through the crystal, the
crystal expands and contracts, creating a piezoelectric effect
o The ____________________: transfers the acoustic energy from the
crystal to the tissues where it causes the tissue to vibrate.

o The ___________________: is the device that facilitates application of the

ultrasound to the patient
Ultrasound is produced by an ___________________ current, which flows
through a piezoelectric crystal housed in a transducer.
o Alternating Current: the uninterrupted flow of electrons marked by change
in the direction and magnitude of the movement.
o Transducer: A device that converts _______________________________.
o Piezoelectric Crystal: Crystals possessing piezoelectric properties produce
positive and negative electrical changes when the crystal is compressed or
expanded.
The electropiezo effect occurs when an alternating current is
passed through the crystal and the result is ________________ or
___________________ of the crystal.
This effect is used to produce therapeutic ultrasound.
The vibration of the crystal results in the mechanical production of
high-frequency sound waves.
The sound waves influence the tissue to achieve certain
___________________________.

Transmission of Ultrasound
Ultrasound displays the properties of wavelength, frequency, amplitude, and
velocity.
o Velocity = ____________ x _______________
o Shorter wavelengths must have a higher frequency to match the velocity
of a longer wavelength.
o Therapeutic Ultrasound has a frequency from ________ to __________.
o It also has greater amplitude; which means that more energy is delivered
to the body per pulse.
Amplitude (Intensity) is the maximum departure of a wave from
the baseline.
The greater the intensity, the higher the energy delivered to the
tissue
o Because of the high frequency involved in ultrasound, it is necessary to
use a _______________________________ because US is unable to pass
through the air.
This dense medium is called a _______________ medium
(example: US gel)
When the US is used without a coupling medium the air will
reflect the sound waves and potentially crack the crystal.
Types of Waves
o Longitudinal Waves
Particle displacement or vibration occurs _____________ the
direction in which the wave travels.
Example: Bungee cord with person on it.

Energy is produced by the _____________ and

_______________ of the cord.
Within a longitudinal wave pathway, there are regions of:
___________________: areas of high molecular density
and high pressure as the molecules are squeezed together.
___________________: areas of lower molecular density
as the molecules are pulled apart.
The pressure changes transmit the energy within the tissue and
produce physiological effects.
US waves pass through soft tissue as __________________ waves.
o Transverse (shear) Wave
The molecules are transferred, or vibrate, in a direction
perpendicular to that is which the wave is traveling.
The longitudinal wave becomes a transverse wave as it bounces
back or rebounds when it hits ______________.
These waves are only found when US hits bone. They cannot pass
through fluids.
Attenuation
o Ultrasound transducers produce a sound wave at a preset frequency.
o As these waves pass through various tissue types, attenuation occurs as a
result of ____________, ______________, and ___________ of the wave.
Reflection occurs when the wave cannot pass through the next
density.
The wave strikes the tissue and reverses its direction.
Refraction is the bending of waves as a result of change in speed of
a wave as it enters a medium or different density.
When moving from low-density areas to high-density areas
the speed decreases.
Absorption occurs by the tissue collecting the waves energy and
changing it into kinetic energy within the cell.
The kinetic energy is causing movement, which creates
heat.
o Each time the wave is partially reflected, absorbed, or refracted, the
remaining energy available to deeper tissue is _________________.
o The ability of acoustic energy to penetrate or be transmitted depends on
the type of tissue being treated.
Tissue that is high in water content: ________________________
Fat: Energy is absorbed very little and is transmitted to deeper
tissue
Dense tissue that is high in protein: _________________________
Muscle: Energy is absorbed in high amounts
Peripheral Nerves: Energy is absorbed at twice the rate as muscle
Superficial Bone: energy is absorbed more effectively that any
other type of tissue

Crystal Characteristics
o Another consideration that determines how well the US will penetrate into
the tissue is _____________________________.
o The quality of the crystal is determine by the effective radiating area and
by the beam non-uniformation ratio
o Effective Radiating Area
The US sound heads are available in different sizes and with
different crystal vibrating frequencies.
The ERA of the sound head is the surface area that transmits a
sound wave from the crystal to the tissue.
The treatment area effectively exposed to the ultrasonic
energy is limited to _______________________________.
ERA is the portion of the transducer surface area that actually
produces ultrasound waves and is described in terms of
____________________
The most energy is concentrated at the center of the head; no
energy is produced in the outermost part of the sound head.
The size of the sound head does not indicate the actual radiating
surface area.
o Beam Non-uniformity Ratio
The beam of an ultrasound is not completely uniform; they have
________________________.
The pressure of the sound field is non-uniform when it is closer to
the transducer head.
It forms peaks of high intensity and valleys of low
intensity.
o This area is called _____________ or Fresnel zone.
o It is the US beam used for therapeutic purposes.
This occurs because the transducer head acts as if there are
bunches of tiny little heads acting together, with each head
producing its own sound wave.
As the distance from the head increases the waves begin to interact
to produce a more unified beam.
The BNR is an indicator of the varying intensity within an
ultrasound beam.
It is the _________________ intensity across the beam.
An optimal BNR is ___________ (this indicates a smooth line).
The lower the BNR, the more uniform the output and the lower the
change of developing hot spots
__________________ are areas at tissue interfaces that may
become overheated from too much energy being concentrated in
one area.

Treatment Parameters

o Mode
o _____________
o Intensity
o _________________________
o Treatment area size
Mode: Thermal vs. Non-Thermal
o Duty Cycle
The duty cycle described the ____________ of time that
ultrasound is actually being emitted from the sound head.
A continuous (___%) duty cycle causes primarily thermal effects
A pulsed (ex: ___%, ____%) duty cycle causes primarily
mechanical (non-thermal) effects.
The decision to use thermal vs. non-thermal ultrasound depends on
the stage of healing and the treatment goal.
Non-thermal: __________________
Thermal: _____________________
Frequency
o The output frequency is measured in megahertz and describes the number
of million waves occurring in one second.
o US frequency determines the depth of penetration and the rate of tissue
heating.
o The depth of penetration is described in terms of _______________ layer.
1MHz goes 6cm deep but according to the half-value depth the
highest temperature is at 3cm.
o The depth of penetration is inversely related to the output frequency.
3MHz _________ - superficial tissue
1MHz _________ - deep tissue
o The frequency in therapeutic US produces a relatively cylindrical beam
that has a width smaller than the diameter of the sound head.
o Low-frequency (___MHz) ultrasound has a more divergent beam than
high-frequency (___MHz) ultrasound.
The higher the frequency of the sound waves emitted from the
sound source, the less the sound will diverge (spread out), and thus
a more focused beam of sound is produced.
o The rate of attenuation is _________________ as the frequency of the US
is _______________.
This is because of the molecular friction that the sound wave must
overcome in order to pass through the tissue.
Due to this, the less energy is ultimately available for
deeper tissues
Power and Intensity
o The power produced by the US generator is measured in ____________
(W) and represents the energy produces by the transducer.
Power is a function of pulse width and pulse frequency

o Intensity is the strength of the sound wave at a given location within the
tissue being treated.
Intensity is the rate at which energy is being delivered per unit
area.
o Power and Intensity are usually expressed in __________________.
o Intensity is also referred to as Spatial Average Intensity
It is the intensity of the ultrasound beam averaged over the area of
the sound head.
o According to the World Health Organization guidelines
SAI of 3.0 W/cm2 is safe limit for therapeutic treatment
SAI greater than 10W/cm2 are used to destroy tissue surgically
SAI less than 0.1 W/cm2 are used for diagnostic purposes.
There are no definitive guidelines for selecting intensities,
however, if the intensity is too high, tissue damage can occur.
Treatment Length
o It is a mistake to use pre-determined US treatment length as a standard.
o The length of the treatment is determined according to the
_____________________,
Ultrasound frequency,
The ________________, and
The desired temperature increase.
o High frequency US requires a shorter treatment length than lower
frequency US.
o 3MHz heats tissue ________ times faster than 1MHz, thus reducing the
required treatment length by one third.
o The lower the intensity, the longer the treatment time, and vice versa.
o The desired temperature increase is a factor in determining the length of
the treatment.
o Table 15.2 Rates of Muscle Heating Using US (per minute)
INTENSITY (W/CM2)
FREQUENCY 1MHz
FREQUENCY 3MHz
0.5
0.07*F
0.54*F
1.0
0.36*F
1.08*F
1.5
0.54*F
1.62*F
2.0
0.72*F
2.52*F

Size of the treatment area

o It is recommended to treat an area about two to three times the ERA.
Roughly _____ the size of the sound head
o Ultrasound can be applied in either a longitudinal or circular motion

Non-Thermal Effects
Changes within the tissue resulting from the ________________ effects of
ultrasonic energy
Mode: ________ injuries, when increasing the tissue temperature is undesirable

Non-thermal US is administered either by

o Using pulsed output and normal treatment intensity, or
o Using a continuous duty cycle and a low-output intensity
Effects:
o Increased cell membrane permeability
o Increased histamine release
o Altered rates of diffusion across the cell membrane
o Increased vascular permeability
o Increased blood flow and capillary density
o Increased fibroblastic activity
o Stimulation of phagocytosis, increased phagocytic activity
o Production of healthy granulation tissue
o Synthesis of protein and collagen
o Reduction of edema
o Diffusion of ions
o Tissue regeneration, vascular regeneration
o Formation of stronger, more deformable connective tissue.
The non-thermal effects are thought to originate at ________________
The membranes deform slightly due to a process known as cavitations and microstreaming
o ________________ is the formation of gas-filled bubbles that expand and
contract as a result of ultrasonically induced pressures in tissue fluids.
This process can be negative and positive:
Positive: bubbles expand and contract in response to
regularly repeated pressure changes
o _______________ cavitations
Negative: Tissue can be damaged from increased bubble
volume, implosion, and collapse.
o _____________ cavitations cell damage
o Acoustic Microstreaming is the unidirectional movement of fluids along
the boundaries of cell membrane.
It produces stresses that alter the cells structure and function.
It increases _______________ and changes diffusion rate
across the cell membrane.

Thermal Effects
The physiological changes within the tissue are based on the amount of
______________________ and are the greatest when ultrasound is applied in the
continuous mode.
1MHz will heat 5-6cm deep, it will retain heat twice as long as 3MHz ultrasound
3MHz will heat 2-3cm deep
Pre-heating the area will __________ treatment time required to reach vigorous
heating

To achieve a therapeutic effect through ultrasound heating, the tissue temperature

must be elevated for a minimum _________ minutes.
Effects:
o Increased sensory nerve conduction velocity
o Increased motor nerve conduction velocity
o Increased extensibility of collagen rich structure
o Increased blood flow and metabolism
o Reduction of muscle spasm
o Increased macrophage activity
o Increased collagen deposition
o Enhanced adhesion of leukocytes to damaged endothelial cells
o Decreased joint stiffness
o Diminished pain perception
Optimal heating
o Absolute temperature is not the key but rather how much the temperature
rises above baseline.
o How high do we want to increase the tissue temperature?
Table 15.1: Temperature Increases Theorized to Bring Desired Effects in Tissue
TEMPERATURE INCREASE
EFFECT
1.8*F, mild heating
Increased metabolism, reduces mild
inflammation
3.6*F 5.4*F, moderate heating
Reduced pain and muscle spasm, increases
blood flow, reduces chronic inflammation
7.2*F, vigorous heating
Increases ROM and tissue extensibility,
scar tissue reduction
o Be aware of _____________________.
o Tendon heats faster than muscle.

Clinical Application of Therapeutic Ultrasound

o The Inflammatory Response to Injury
o When injury occurs biological mechanisms ________________
o Ultrasound is theorized to stimulate normal function
US treatments have been shown to stimulate the release of
histamine, which attracts leukocytes to clean the debris from the
area.
o US can be helpful in facilitating inflammation and healing by stimulating
these normal functions.
o The best parameters are:
___% duty cycle, ____ W/cm2, ____minutes, or
_____________ duty cycle, 0.1W/cm2, 5minutes.
o Superficial Wound Healing
o US treatments are used for wound healing because the therapy can
stimulate fibroblasts to produce more collagen.

o
o
o

o US treatments can increase smooth muscle cell activity, which is good to

enhance ____________________________.
Assessing ___________ Fractures
Reducing Muscle Spasms
o It reduces muscle spasms because it reduces the mechanical and chemical
triggers that cause the ______________________ cycle.
Reducing Pain
o The heat produced in US treatments affect the large-diameter myelinated
alpha and beta nerve fibers.
According to the _________________ theory this reduces the pain.
Restoring ROM
o It is theorized that increasing tissue temperature during US treatment
decreases the viscosity of collagen fibers and increases their
___________.
o The increase in temperature will allow the tissue to be stretched with less
potential damage.
o Scar tissue can be softened if treated early enough.
Stretching Connective Tissue
o Collagen tissue is rigid until it is heated; it turns ________________.
o The combination of heating the tissue followed by stretching the tissue can
lead to residual lengthening of the connective tissue.
o It is a good idea to apply US before stretching, joint mobilization,
exercise, or warm-up.
o It is important to stretch the warm tissue. The stretch window is about 510 minutes after application.
The _____________________ is the time period of vigorous
heating when tissues will undergo the greatest extensibility and
elongation.
Treating Chronic Inflammation
o Two key ingredients:
_____________________
_____________________

Application Techniques:
Coupling Media
Direct Contact Application
The Immersion Technique
The Gel Pad Technique
Sound-head Movement
Recoding Treatment Parameters
Be sure to record everything _________________________________.
It is recommended that records and reports should include all parameters that
were used in an US treatment to ensure that:

o The treatment can be ______________________.

o The treatment can be _____________________________________.
o The records can stand alone when challenged.
The parameters that should be recorded include:
o Frequency
o Intensity
o Mode
o Duty cycle
o Type of coupling medium
o Area treated
o Treatment length