FOCUSED ULTRASONIC
ENERGY WAVES: BODY
COUNTURING TANPA
LIPOSUCTION
Dr. dr. Liza Widjaja, M.Biomed (AAM), M. Pharm
INTRODUCTION
• Ultrasound is a type of sound waves that transmit energy by alternately
compressing and rarefying material.
• Ultrasound is sound with a frequency greater than 20,000 cycles per
second[Hz].
• Human can hear sound with a frequency of 16 to 20,000Hz,sound with a
greater than this is known as ultrasound.
• Therapeutic ultrasound has a frequency between 0.7 and 3.3
megahertz(MHz) to maximize energy absorption at a depth of 3 to 5 cm of
soft tissue.
PRODUCTION OF ULTRASOUND
• Ultrasound is generated by applying a high – frequency alternating electrical
current to the crystal in the transducer of an ultrasound unit.
• Piezoelectric effect – it is 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 and this alternating compression –
rarefaction is the ultrasound wave.
CONTD.
• Piezoelectricity is the ability to generate electricity in response to a
mechanical force or to change shape in response to an electrical current.
• Commonly used crystals for piezoelectric effect – natural quartz , synthetic
plumbium zirconium titanate (PZT) and barium titanate.
• Ultrasound transducers are usually made up of PZT.
ULTRASOUND TREATMENT PARAMETERS
• Intensity
• Pulsed mark : space ratio
• Reflection of ultrasound
• Transmission of ultrasound
• Attenuation of ultrasound
• Ultrasonic fields
• Coupling media
• Duty Cycle
INTENSITY
• Space averaged intensity – where the average intensity over a specified area
is given, e.g. watts per square centimeter.
• 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 for a specified area.
PULSED MARK : SPACE RATIO
When ultrasound is applied in its pulsed mode, the ratio of the time on to
time off should be expressed.
REFLECTION OF ULTRASOUND
• An ultrasonic travelling through one medium encounters another medium
which will not transmit it , reflection takes place.
• There will always be some reflection at each interface that the ultrasound
beam encounters.
• Acoustic impedence which is ratio between the reflected and transmitted
at an interface.
TRANSMISSION OF ULTRASOUND
• When the ultrasonic beam encounters an interface between two media and
is transmitted, it may be refracted.
• Refraction mainly the deflection from its original path.
ATTENUATION OF ULTRASOUND
• Attenuation is gradual reduction in intensity of ultrasonic beam once it has
left the treatment head.
• Factors that contribute to attenuation –
Absorption – ultrasound is absorbed by the tissues and converted to heat
at that point and it contribute to the thermal effect of ultrasound.
• Scatter - when the normally cylindrical ultrasonic beam is deflected from
its path by reflection at interfaces, bubbles or particles in its path.
CONTD.
• 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 and 2 cm respectively.
ULTRASONIC FIELDS
• Depth of penetration and intensity of ultrasonic beam in the division of the
beam into a near and a far field.
• The extent of the near field depends upon the radius (r) of the transducer
and the wavelength (λ) of the ultrasound in the medium.
• The depth of the near field can be calculated using the formula r2/λ.
• As wavelength and frequency are inversely related, the depth of the near
field varies with the frequency of ultrasound.
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.
DUTY CYCLE
• A continuous wave is on the sound intensity remain constant, where as
pulse wave is intermitantly interupted.
• Pulse wave are further characterized by specifying what fraction of time the
sum is present over one pulse period.
• This fraction is called duty cycle.
duty cycle =duration of pulse /pulse period
TESTING THE APPARATUS
• Prior to any treatment it is sensible to check that there is an output from
the machine.
• This can be done by placing the treatment head just below the water
surface in a suitable container and observing the disturbance (ripples) which
appears.
• The apparatus should be on and off with the treatment head below the
water.
• This, and similar methods, only indicate the presence of an output but to
quantity it, a radiation.
TECHNIQUES OF APPLICATION
• Direct contact Method
• Water Bath Method
• Water Bag Method
DIRECT CONTACT METHOD
• If the surface to be treated is fairly regular then a coupling medium is
applied to the skin in order to eliminate air between the skin and the
treatment head and transmit the ultrasonic beam from the treatment head
to the tissues.
• Large area should be divided and each area treated separately.
WATER BATH METHOD
• When direct contact is not possible because of irregular shape of part or
because of tenderness, a water bath may be used.
• As the part to be treated is immersed in water this can only reasonably be
applied to the hand, ankle and foot.
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 forming a water cushion between the treatment
head and the skin.
APPLICATION
• The treatment head is moved continuously over the surface while even
pressure is maintained in order to iron out irregularities in the sonic field.
• The rate of movement must be slow enough to allow the tissues to deform
and thus remain in complete contact with rigid treatment head but fast
enough to prevent ‘hot spots’ developing when using a high intensity
treatment.
• The pattern of movement can be a series of overlapping parallel strokes,
circles or figures of eight.
CONTD.
DOSAGE
This is the most controversial area when discussing ultrasound because
arguments about whether pulsed or continuous modes should be used and
the intensities of ultrasound required to produce beneficial effects.
DOSAGE IN ACUTE CONDITION
• In any acute conditions treatment applied cautiously to prevent
exacerbation of symptoms.
• Initial stage - Low dose 0.25 to 0.5 Wcm–2 Time 2–3 minutes
• Progression unnecessary if condition improves
• Failure case 0.25 to 0.5 Wcm–2 Time 4–5 minutes or 0.8 Wcm–2 Time 2–3
minutes.
• It may also possible to select different M :S pulse ratio and use: 1 : 7 for very
acute 1 : 1 for less acute.
DOSAGE IN CHRONIC CONDITIONS
• Chronic condition may be treated with pulsed or continuous mode.
• The maximum intensity of ultrasound which should be used is that which
produces mildly perceptible warmth.
• This usually occurs around 2 W/cm2. Initially low dose is tried. Intensity 0.8
W/cm2, time 4 minutes.
• Maximum dose of ultrasound: 2 Watts/cm2 for 8 minutes.
PHYSIOLOGICAL EFFECTS OF ULTRASOUND
• Thermal effects - As the ultrasound waves are absorbed by the tissues they
are converted into heat. The amount of heat developed depends upon:
1. Absorption of the tissues, e.g. protein absorbs ultrasound more effectively
and therefore produces much heat.
2. The number of times the treatment head passes over the part.
3. The efficiency of circulation through the insonated tissues.
4. When using continuous ultrasound, the amount of heat developed is directly
proportional to the intensity and duration of insonation.
CONTD.
5. 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.
6. Reflection of ultrasound at a tissue interface produces a concentration of
heating effect at a specific point.
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 - oscillatory activity of highly compressible bodies within the
tissues such as gas or vapour filled voids.
- Stable Cavitation - Stable cavitation occurs when bubbles oscillate to
and fro within the ultrasonic pressure waves but remain intact.
- Microstreaming is the unidirectional movement of fluids along the
boundaries of the cell. Due to microstreaming, permeability of cell membrane
and direction of movement of molecules into the cells is influenced.
- Unstable Cavitation - This occurs when the volume of the bubbles
changes rapidly and then collapse.
CONTD.
CONTD.
• Mechanical or Micro - massage Effect - 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 and pain.
• Biological Effects - Ultrasound can have some useful effects in all three
stages of repair.
1. Inflammatory: Ultrasound probably increases the fragility of lysosome
membrane, and thus enhances the release of their contained enzymes. These
enzymes will help to clear the area of debris and allow the next stage to
occur.
CONTD.
2. Proliferative: Fibroblasts and myofibroblasts may have Ca++ ions driven into
them by the ultrasound. This increases their mobility and encourages their
movement toward the area of repair. The fibroblasts are stimulated to
produce the collagen fibers to form scar and myofibroblasts contract to pull
the edges together.
3. Remodeling: Ultrasound has been shown to increase the tensile strength of
the scar by affecting the direction, strength and elasticity of fibers which make
up the scar easier.
USES OF ULTRASOUND
• Recent injuries and inflammation
• Scar tissue
• Chronic indurated edema
• Pain
• Dermal ulcers
• Surgical skin incisions
• Resorption of calcium deposits
• Bone fractures
CONTRAINDICATIONS
• Malignant tumor
• Pregnancy
• Cardiac disease
• Radiotherapy
• Joint cement
• Vascular conditions
• Acute sepsis
• Eyes
• Reproductive organs
• Radiotherapy
DANGERS
• Burns: If continuous beam is used and is allowed to remain stationary,
excess heat can accumulate in the tissues and eventually leads to burns.
• Cavitation: Especially unstable cavitation is dangerous and has been
described previously.
• Overdose: Excessive dose may cause an exacerbation of symptoms.
RESEARCHES
1. Effect of therapeutic ultrasound on range of motion and stretch pain.(
Journal of Physiotherapy2013)
method – 3 MHz ultrasound with an intensity of 1.0 W/cm2 and a duty
cycle of 100% for 10 min.
result – the effect include the both thermal and non – thermal effects on
the range of motion and stretch pain there is significant decrease in pain after
application of ultrasound.
2. Intensity dependent effect of pulsed and continuous therapeutic ultrasound
on endothelial function.( International Journal of Therapy And Rehabilitation
2019)
CONTD.
method – 15 participants were evaluated over 2 days with different
intensities and used both mode of treatment, duty cycle 20% with 1 Mhz over
brachial artery for 5 minutes.
results – both modes ultrasound waveforms promote endothelial –
dependent vasodilation but it is dose dependent increase in vasodilation at
intensities from 0.4 w/cm2 to 1.2 w/cm2.
3. Effects of therapeutic ultrasound and manual physiotherapy in shoulder
impingement syndrome in volleyball players.(Journal of Islamabad Medical and
Dental College 2017)
CONTD.
method – 5 min. of treatment, intensity 1 w/cm2 for 14 weeks with exercise
session of 30 min and frequency is 1 MHz.
results – ultrasound with the manual and exercises therapy showed significant
improvement at 14 weeks.
4.Efficacy of ultrasound massage therapy as an adjuvant pain control modality
in TMDs: A clinical study(Journal of Indian Academy of Oral Medicine &
Radiology 2018)
method – ultrasound frequency was taken 1 MHz with pulse setting 1:1 for 8
min. once a week for 4 comparative weeks
CONTD.
US massage therapy in TM pain disorder is effective and showed significant
improvement in pain as well as in mouth opening, before and after treatment.
It is considered as a potent and independent therapeutic modality in relieving
TMJ pain disorders.
BEFORE & AFTER
Thank You
