Ultrasound Dose Calculations lecture IX Dr. Amaal H.M.

Ebrahim

Indications and Therapeutic Uses of US

1- Acute and sub-acute traumatic and inflammatory conditions as: soft tissue and sport injuries, occupational injuries, postpartum, surgical wound, episiotomy and bursitis. 2- Adhesions: ultrasonic help resorpaion of adhesions by heating effect and micromassage effect. US is used with adhesions in musculoskeletal injuries and scar tissue problems.

Indications and Therapeutic Uses of US

3- Rheumatic and arthritic conditions as osteoarthritis and rheumatoid nodules. 4- Venous ulcers and pressure sores.

Indications and Therapeutic Uses of US

5- Pain and muscle spasm: pain can be reduced by preventing pain signals from reaching the higher centers by micromassage effect on nerves and increase temperature of the part. US at 1-2 w/cm2 can decrease conduction velocities of the C fibers carrying pain Increase the permeability of the cell membrane, phagocitosis and increase absorption of exudates. US causes release of histamine like substance which cause hyperemia (thermal effect) and relief of pain.

Indications and Therapeutic Uses of US

6- Neuralgia and phantom limb pain. 7- Calcified tendenitis and planter fasciitis. 8- Phonophoresis: is the movement of drugs through skin into the subcutaneous tissues under the influence of ultrasound (as the ultrasound encourage the absorption of the drug). The effect of phonoporesis depends on the effect of particular drug used. To gain more effective phonoporesis, it is better to use low frequency ultrasound.

Contraindication and precautions of therapeutic ultrasound

1- Pregnant uterus to avoid exposure of embryo. 2- Malignant tissues (tuberculosis of lungs or bone). 3- Vascular abnormalities like deep vein thrombosis, embolism, and atherosclerosis.

Contraindication and precautions of therapeutic ultrasound

4- Eyes as high doses may harm the optic nerve, pacemaker, gonads and active epiphyses in children. 5- Haemophilia, there is danger of bleeding. 6- Patients having deep X-ray therapy.

Practical Application of US
Ultrasound generators come in an assortment of configurations. Although they may differ in their appearance, all use the same basic principles. An alternating current is used to cause a piezoelectric crystal to vibrate in the range of 1 to 3.3 MHz.

Practical Application of US
All generators have adjustable treatment timers and have variable output intensities such as the duty cycle and output frequency. Many units also allow for different sized sound heads to be used.

Practical Application of US
Prior to using an ultrasound unit, you should be familiar with the operation of the particular unit you are using and know how to apply ultrasound in a save, effective manner .

Practical Application of US
Also, be familiar with the indications, contraindications, and precautions for the use of therapeutic ultrasound

Practical Application of US
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.

Dose Calculation Stages

The first steps involve the decision as to which machine settings are most appropriately applied to the patients particular problem. The second stage is to bring these into an effective treatment combination. Machine settings : 1- Machine Frequency 2- Pulse Ratio 3- Ultrasound Treatment Intensity 4- Size of the Lesion 5- time of application

1-Machine Frequency
Taking into account that the most frequently available treatment frequencies are 1 and 3MHz, the option between them relates primarily to the effective treatment depth that is required.

1-Machine Frequency
3MHz ultrasound is absorbed more rapidly in the tissues, and therefore is considered to be most appropriate for superficial lesions

1-Machine Frequency
the 1MHz energy is absorbed less rapidly with progression through the tissues, and can therefore be more effective at greater depth.

2- Pulse Ratio
The pulse ratio determines the proportion of time that the machine is ON compared with the OFF time. A pulse ratio of 1:1 for example means that the machine delivers one 'unit' of ultrasound followed by an equal duration during which no energy is delivered. The machine duty cycle is therefore 50

2- Pulse Ratio
The table below indicates the ratios and duty cycle percentages for commonly encountered settings Mode Pulse Ratio Duty Cycle Continuous 100% Pulsed 1:1 50% 1:2 33% 1:3 25% 1:4 20% 1:9 10%

2- Pulse Ratio
It is suggested that pulse ratios of 1:4 are best suited to the treatment of acute lesions, reducing this as the tissue moves towards the chronic state moving through 1:3 and 1:2 to end up with 1:1 or continuous modes. Some machines are unable to deliver the most effective treatment modes and the therapist will need to compromise the treatment dose according to the facilities that are available.

3- Ultrasound Treatment Intensity

The intensity of ultrasound required at the target tissue will vary with the tissue state. The more acute the lesion, the smaller the 'strength' of the ultrasound that is required to achieve/maintain the tissue excitement. The more chronic the tissue state, the less sensitive, and hence the greater the intensity required at the lesion in order to produce a physiological response.

3- Ultrasound Treatment Intensity

It has already been explained that the ultrasound beam is very irregular so a useful measure is the average intensity of the peak and troughs of the sonic field over a specific area (space average intensity).

3- Ultrasound Treatment Intensity

One important factor is that some of the ultrasound energy delivered to the tissue surface will/may be lost before the target tissue (i.e. in the normal or uninjured tissues which lie between the skin surface and the target).

3- Ultrasound Treatment Intensity

In order to account for this, it may be necessary to deliver more at the surface than is required, therefore allowing for some absorption before the lesion, and allowing sufficient remaining ultrasound to achieve the desired effect. By estimating the depth of the target tissue from the surface and knowing the half-value depth, an appropriate intensity can be selected.

3- Ultrasound Treatment Intensity

The rate at which ultrasound is absorbed in the tissues can be approximately determined by the half value depth - this is the tissue depth at which 50% of the ultrasound delivered at the surface has been absorbed.

3- Ultrasound Treatment Intensity

The figures used for these estimates are average values in that it absolute values will vary with the thickness of various tissues (e.g. skin, fat, muscle etc). The average 1/2 value depth of 3MHz ultrasound is taken at 2.5cm and that of 1MHz ultrasound as 4.0 cm.

3- Ultrasound Treatment Intensity

For example, if an intensity of 0.25 W/cm is required for a lesion 40mm deep, using a 1 MHz frequency, the surface intensity would have to be 0.5 W/cm, assuming a half value depth of 40mm.

3- Ultrasound Treatment Intensity

With thin areas like hands it is preferable to reduce the surface intensity because of the possible reflection of US beam from the further skin-air interface.

3- Ultrasound Treatment Intensity

The intensity required at the lesion can be determined from the following table : Tissue State Intensity required at the lesion (W/cm2) Acute 0.1 - 0.3 Sub Acute 0.2 - 0.5 Chronic 0.3 - 0.8

3- Ultrasound Treatment Intensity

Table to indicate the surface intensity (W/cm2) required to achieve a particular intensity at depth using 3MHz ultrasound
Depth of Lesion (cm)

Intensity required at the lesion (W/cm2) 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1

0.5 1.2 1.08 0.96 0.84 0.72 0.6 0.48 0.36 0.24 0.12

1 1.4 1.26 1.12 0.98 0.84 0.7 0.56 0.42 0.28 0.14

2 1.8 1.62 1.44 1.26 1.08 0.9 0.72 0.54 0.36 0.18

3 2.2 1.98 1.76 1.54 1.32 1.1 0.88 0.66 0.44 0.22

4 2.6 2.34 2.08 1.82 1.56 1.3 1.04 0.78 0.52 0.26

3- Ultrasound Treatment Intensity

Table to indicate the surface intensity (W/cm2) required to achieve a particular intensity at depth using 1MHz ultrasound
Depth of Lesion (cm) Intensity required at the lesion (W/cm2) 0.5 1 2 3 4 5 6

1
0.9 0.8 0.7 0.6 0.5

1.13
1.01 0.9 0.79 0.68 0.56

1.25
1.13 1 0.88 0.75 0.63

1.5
1.35 1.2 1.05 0.9 0.75

1.75
1.58 1.4 1.23 1.05 0.88

2
1.8 1.6 1.4 1.2 1

2.25
2.03 1.8 1.58 1.35 1.13

2.5
2.25 2 1.75 1.5 1.25

0.4
0.3 0.2 0.1

0.45
0.34 0.23 0.11

0.5
0.38 0.25 0.13

0.6
0.45 0.3 0.15

0.7
0.53 0.35 0.18

0.8
0.6 0.4 0.2

0.9
0.68 0.45 0.23

1
0.75 0.5 0.25

4-Size of the Lesion

The greater the size of the lesion, the longer the duration of the ultrasound that will be required in order to achieve a particular effect. The most common method to take account of this factor is to estimate the number of times which the ultrasound treatment head to be utilized can be placed over the target tissue.

4-Size of the Lesion

For example, if the large treatment head is used to treat the anterior capsule of the shoulder, it can be estimated that it will fit twice over the target. Similarly, if the small treatment head is applied over the lateral ligament of the elbow, it may only fit once.

4-Size of the Lesion

There is not need to measure the treatment head, it is a matter of estimating the number of time the head fits onto the target tissue rather than a millimeter by millimeter measurement.

5- Time of Application
It is important to considered the length of time for which the ultrasound applied to the tissues. As the head of transducer moved continuously over the treated area it is sufficient to give 1-2minutes for every 10cm. The minimum treatment times are 12minutes and the maximum 10-15minutes and the average would be in the region of 5minutes.

Progression and Timing

Recent injuries and acute conditions should be treated as soon as possible once or twice daily Chronic conditions may be treated on alternating days. Progression is based on the outcome of the previous treatment. If there is objective and subjective improvements, the treatment should be continued at the same dose. If the symptoms are worse the treatment should be reduced or discontinued

Principles of US Application
Adequate transmission of ultrasonic energy to the tissues depends on having couplant that provide a good match of acoustic impedance between the head of transducer and the skin.

Principles of US Application
The couplant substance are gels that become fluid on vibration. Creams which are emulsions of light oils in water, are also widely used. Tap water has been shown to be a satisfactory couplant for ultrasound being significantly better than mineral oil or glycerin.

Principles of US Application
It is very important to move the treatment head continuously relative to the tissues for the following reasons: 1- The ultrasound beam is very irregular in the near zone. 2- The pattern of energy absorption in the tissues is very irregular due to reflection and refraction. 3- Standing waves can be formed leading to temporary stasis of circulating blood cells and to endothelial damage. 4- At high intensities unstable cavitation or excess heating could occur causing tissue damage. Steady movement of the treatment head will even out the dose delivered to the target tissues and will eliminate the risks of damage due to local intensity hot spots.

Methods of Application
1- Direct contact
A- check the ultrasonic output from the machine by placing the head just below the water surface in a suitable container and observing the disturbance appears in water. B- inspect the skin surface will be treated. C- explain the treatment to the patient.

1- Direct contact
D- apply the couplant to the skin surface and/or the treatment head, and put it on the skin before the machine is turned on to avoid damage of head transducer.

1- Direct Contact
E- the treatment head is moved continuously over the surface while even pressure is maintained. The emitting surface must be kept parallel to the skin surface to reduce reflection and pressed sufficiently firmly to exclude any air. F- the movement of the head must be slow enough to allow the tissue to deform fast enough to prevent hot spots developing when using a higher-intensity, continuous-mode treatment. G- With pulsed US used at minimal dosage the movement of head transducer should be so slow as to be almost imperceptible.

Methods of Application
2- Water Bath Application A- US is easily transmitted through water so that little energy is lost. Treatment by this method is valuable because very irregular surfaces and tender areas can be comfortably treated as the treatment head does not exert pressure on the skin. B- Testing the output of the machine and inspect the part will be treated.

Methods of Application
C- the treatment head is placed in water and moved parallel to the surface of the part which is being treated and about 2cm or less away from the skin. D- it is preferable to use degassed water to avoid bubbles formation.

Methods of Application
3- Water bag application
A- used for the irregular surfaces that cannot be placed in water bath. It is a plastic or rubber bag filled with water, forming water cushion between the treatment head and skin. B- the bag is filled with warm water or degassed water. C- the treatment head and the side of the bag in contact with the skin are covered with couplant. D- the treatment head is moved by deforming the bag or by moving over the surface of the bag.

Possible Dangers of US
1- Burns could occur if the heat generated exceeded the physiological ability to dissipate it. 2- Tissue destruction would result from transient cavitations. 3- Blood cell stasis and endothelial damage may occur if there is standing wave formation. The dangers would be more likely with high intensities, continuous mode and with stationary head or over bony prominence.