ULTRASONIC THERAPY

• Therapeutic ultrasound is most widely used modalities

in physiotherapy department. It has been used as a
valuable tool in rehabilitation of many different injuries,
to stimulate the repair of soft tissue injuries and to
relieve pain.
• It has been traditionally classified as a deep heating
modality and used primarily to elevate tissue
temperature.
• Ultrasound is not strictly electrotherapy because it is a
mechanical vibration, produced electrically. It has
sometimes been described as micro-massage.
• The meaning of ultra is beyond or extreme.

• Sound is defined as the periodic mechanical

disturbance of an elastic medium such as air.
 Frequency of Ultrasound
• Ultrasonic energy or ultrasound describes any
vibration at a frequency above the audible
sound range, i.e. 20–20000 Hz
• but it is frequencies of a few megahertz that
are typically used in physiotherapy:
• Several different therapies are employed in
range from 0.5 to 5 MHz.
• Majority of ultrasound generators are set at a
frequency of 1 MHz, although there are
ultrasound units that are set at a frequency of
3 MHz .
• A generator that can be set between 1 and 3
MHz affords the therapist the treatment
flexibility.
• Ultrasonic energy generated at 1 MHz is
transmitted through the more superficial
tissue and absorbed primarily in the deeper
tissues at depths of 3 to 5 cm.
• A 1 MHz frequency is most useful in
individuals with a high percentage of
cutaneous body fat and whenever the desired
effects are in the deeper structures.
• At 3 MHz, the energy is absorbed in the more
superficial tissues with a depth of penetration
between 1 and 2 cm.
 Terminology used in u/s
• Near Field/Far Field: The ultrasound beam
delivered from a transducer initially converges
and then diverges (fig.7:12). 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
 Terminology used 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 (V).
 Terminology used in U/S
• Intensity: The power per unit area of the
sound head. This is usually expressed in
Watts/centimeter square.
• Spatial Average Intensity: The average
intensity of the ultrasound output over the
area of the transducer
 Terminology used in u/s
• 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.
 Terminology used in u/s
• 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 minimize its thermal effect
 Terminology used in u/s
• 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.
• EXAMPLES 20% or 1:5 duty cycle, is on 20% of
the time and off 80% of the time. This is
generally delivered 2 ms on, 8 ms off
(Fig.7 -7).
100% duty cycle is on 100% of the time and is
the same as continuous ultrasound.
 Terminology used in u/s
• Frequency: The number of compression-
rarefaction cycles per unit of time, usually
expressed in Cycles per second (Hertz, Hz)
lncreasing the frequency of ultrasound causes
a decrease in its depth of penetration and
concentration of the ultrasound energy in the
superficial tissue
 Terminology used in u/s
Effective Radiating Area (ERA)
The area of the transducer from which the
ultrasound energy radiates (Fig7-11) Because the
crystal does not vibrate uniformly, the ERA is always
smaller than the area of the treatment head.
 Terminology used in U/S
• Absorption: Conversion of the mechanical
energy or ultrasound into heat. The amount of
absorption that occurs in a tissue type at a
specific frequency, is expressed by its
absorption coefficient.
• Reflection: The redirection of an incident
beam away from a reflecting surface at an
angle equal. and opposite to the angle of
incidence (Fig.7 -13)
 Terminology used in U/S
• Refraction: The redirection of a wave at an
interface (see Fig. 7-13). When refraction
occurs, the ultrasound wave enters the tissue
at one angle and continues through the
tissues at a different angle
 Production of Ultrasound
• Ultrasound can be produced by following
ways:
• For 1 MHz machine a vibrating source with a
frequency of one million cycles per second is
needed. This is achieved by using either a
quartz or a barium titanate or a lead zirconate
or nickel-cobalt ferrite crystal. These crystals
deform when subjected to a varying potential
difference, this is called piezoelectric effect.
• There is a source of high frequency current,
which is conveyed by a coaxial cable to a
transducer circuit or treatment head or
applicator or sound head.
• Inside the transducer circuit high frequency
current is applied to the crystal being fused to
the metal front plate of the treatment head.
• Any change in the shape of the crystal cause a
movement of the metal front plate which in
turn produces ultrasonic waves.
 Transmission of Ultrasound
• If ultrasonic beam encounters an interface
between two media and is transmitted, it may
be refracted, i.e. deflected from its original
path as light.

• Treatment should be given with the majority

of waves traveling along the normal (i.e.
perpendicular to the interface between the
media)
 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.
• Air (zero transmission) will infact reflect the
ultrasound beam back into the treatment
head and this could set-up standing wave
which might damage the crystal.
Consequently, the treatment head is never left switched
on when not in contact with a transmitting medium.
• Some coupling medias and their efficiency of
transmission are:
1. Aquasonic gel 72.6%
2. Glycerol 67%
3. Distilled water 59%
4. Liquid paraffin 19%
5. Petroleum jelly 0%
6. Air 0%
 Treatment Parameters
• Ultrasound may be used in a continuous mode
or in pulsed mode.
• In continuous mode, treatment head
continuously produces ultrasonic energy. In
pulsed mode, the periods of ultrasound are
separated by periods of silence.
 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
 TECHNIQUES AND METHOD OF
APPLICATION
• Preparation of Patient
• Skin should be washed and hairs should be
removed. The nature of the treatment, need
for a couplant and stability of the area are all
needs to be explained to the patient.
 Examination and Testing

• Skin surface to be treated should be

inspected; inflammatory skin conditions
should be avoided.
 Preparation of the Part to be Relaxed
• The couplant should be applied to the skin
surface.
Setting Up
• The patient should be in a comfortable
position as skill is needed to apply efficient
ultrasound therapy, ensuring close contact,
appropriate movement and correct angle of
the transducer at all times.
 Instructions and Warnings
• The patient is asked to keep the part still and
relaxed and to report if any increase of pain or
other sensations immediately
 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 emitting
surface must be kept parallel to the skin surface to
reduce reflection and pressed sufficiently firmly to
exclude any air. 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 (Fig. 8.10).
 THERAPEUTIC USES OF U/S
• 1. Uses of ultrasound: Ultrasound is often used
after soft tissue injuries as the mechanical
effects help to remove the traumatic exudates
and reduces the danger of adhesion formation.

• 2. Scar tissue: Scar tissue is made pliable

(capable of bend or twist) by the application of
ultrasound, which allows more effective
stretching of contracted scars
• 3. Chronic edema: The mechanical effects
of ultrasound have an effect on chronic edema
and helps in its treatment.

• 4. Varicose ulcers: Ultrasound is found

effective to promote the healing of varicose
ulcers and pressure sores
• 5. Blood flow: In an investigation of the
effect of continuous ultrasound on blood flow,
a dose of 1.5 W/cm2 for 5 minutes applied to
the forearm did not alter the skeletal muscle
blood flow.
• 6. Bone injuries: Ultrasound in the first and second
week after bony injury can increase bone union, but
given to an unstable fracture during the phase of
cartilage proliferation, it may result in proliferation
of cartilage and therefore decrease in bone reunion.
Ultrasound can also be used in early diagnosis of
stress fractures. A moderate dose applied over the
site of the fracture leads to intense pain, whereas
the same dose applied to the opposite side has no
pain. Thus, ultrasound can identify stress fractures.
• 7. Placebo effect: While the physiological
effects of ultrasound have been discussed in
detail, it can also have significant therapeutic
psychological effects. A number of studies
have demonstrated a placebo effect in
patients receiving ultrasound.
Physiological effects of Ultrasound
• Following ultrasonic therapy the physiological
changes that take place are as follows:
• As the ultrasound waves are absorbed by the
tissues they are converted into heat.
 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.
 The Nonthermal Effects

• Cavitation: This is the oscillatory activity of

highly compressible bodies within the tissues
such as gas or vapor filled voids
• 1. stable
• 2. unstable
 DANGERS OF U/S
• 1. Burns: If continuous beam is used and is allowed to
remain stationary, excess heat can accumulate in the
tissues and eventually leads to burns.
• 2. Cavitation
• 3. Overdose
• 4. Danger to equipment: If the treatment head is
held in the air while switched on, the reflection of the
beam back into the treatment head may set-up
standing waves which could damage the crystal,
consequently the head is never turned on unless it is
contact with the transmitting material.
 Biological effect
• Ultrasound can have some useful effects in all
three stages of repair.
1. Inflammatory
2. Proliferative
3. Remodeling
 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.
 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
 CONTRAINDICATIONS
• 1. Vascular conditions: Conditions such as
thrombophlebitis
• 2. Acute sepsis
• 3. Radiotherapy
• 4. Tumors
• 5. Pregnancy
• 6. Cardiac disease
• 7. Hemorrhage
• 8. Severely ischemic tissue
• 9. Nervous system
• 10. Specialized tissue
• 11. Implants
• 12. Anesthetic area
 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.
• The treatment head is moved in small
concentric circles over the skin in order to
avoid concentration at any one point, keeping
the whole of the front plate in contact with
the patient
• This technique is suitable for areas up to three
times the size of the treatment head.
• Large area should be divided and each area
treated separately. The size of the area and its
exact location should be specified on the
treatment head (Fig. 8.11).
 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.
• A water bath filled with degassed water is used if
possible. Ordinary tap water presents the
problem that gas bubbles dissociate out from the
water, accumulate on the patient skin and the
treatment head, and reflect the US beam.

• If tap water has to be used then the gas bubbles

must be wiped from these surfaces frequently.
• The patient is seated and part is put in water of
a comfortable temperature in such a position
that it is suitably supported (Fig. 8.12).

• The treatment head is placed in the water and

held 1 cm from the skin and moved in small
concentric circles, keeping the front parallel to
the skin surface to reduce reflection to a
minimum.
• If the patient’s hand is to be immersed in the
bath while the application is active, care
should be taken to minimize exposure to any
reflected or scattered ultrasound. This can be
done by wearing a dry knitted glove inside a
water-proof rubber or plastic glove.
 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.
• Rubber bag filled with degassed water can be
used. All visible air bubbles should be
squeezed out before knotting the neck of the
bag to seal it.
• A coupling medium has to be placed both
between the rubber bag and skin and
between the rubber bag and the treatment
head to eliminate any air (Fig. 8.13).
 Dosage
• Three factors which determine ultrasound
dosage are as follows:

1. Size of the treatment area

2. Depth of the lesion from the surface
3. nature of lesion.
 Parameters of Ultrasound
1. Mode
2. Frequency
3. Intensity
4. Duration of treatment.
 Mode
• Continuous mode produces more heat so it is
used for musculoskeletal conditions such as
muscular spasm, joint stiffness, pain, etc.

• Pulsed mode produces less heat so it is used

for soft tissue repair, e.g. tendinitis. For
example, 0.5 W/cm2 pulsed at 1 : 4 deliver the
same energy as 0.1 W/cm2 on a continuous
mode.
 Frequency

• Attenuation increases with increase in

frequency effectively lower frequency
penetrate further.

1. Ultrasonic 3 MHz—superficial tissue

2. Ultrasonic 0.75 to 1 MHz—penetrate deeply.
 Intensity
• Intensity applied is according to the nature of
the lesion.

• For acute and immediate post-traumatic:

0.1 to 0.25 W/cm2
• For chronic and scar tissue:
0.25 to 1 W/cm2.
 Duration of Treatment
• Amount of energy depends on intensity and
duration of treatment. Size of area determine
the treatment time 1–2 minutes for every cm2

Many transducer heads have an area of 5 cm2

and the palm of the small hand is about 50
cm2.
 PHONOPHORESIS
• Phono means sound and phoresis means
migration of the ions through a membrane by
the action of an electric current.
• Phonophoresis is defined as the movement of
the drugs through skin into the subcutaneous
tissues under the influence of ultrasound. It is
otherwise called as sonophoresis or
ultrasonophoresis.