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Therapeutic Ultrasound for Physiotherapy students

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This lecture intends to provide general outline about the uses, parameters, precautions and contraindications of therapeutic ultrasound for undergraduate physiotherapy students at Kathmandu University School of Medical Sciences, Nepal. After the lecture, students will explore the evidences about current practices of therapeutic ultrasound in various musculoskeletal pain conditions, critically appraise them and present the evidences to the class.

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Therapeutic Ultrasound for Physiotherapy students

  1. 1. Saurab Sharma, MPT Lecturer, KUSMS Therapeutic Ultrasound (US) MSK III b – Cervical and thoracic Spine Electrotherapy Lecture 4
  2. 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. 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. 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. 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. 6. Effects  Thermal  Non-thermal Increasing protein content Blood, fat, nerve, muscle, skin, tendon, (cartilage and bone) 6 Low Ultrasound Absorption High
  7. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 18. Application of Ultrasound: Factors to be considered:  Choice of machine  Calibration  Choice of coupling medium  Frequency  Intensity  Mode  Duration of treatment  Hazards18
  19. 19. Application of Ultrasound: Factors to be considered:  Choice of machine  Calibration  Choice of coupling medium  Frequency  Intensity  Mode  Duration of treatment  Hazards19
  20. 20. Application of Ultrasound: Choice of machine 20
  21. 21. Application of Ultrasound: Factors to be considered:  Choice of machine  Calibration  Choice of coupling medium  Frequency  Intensity  Mode  Duration of treatment  Hazards21
  22. 22. Application of Ultrasound: Factors to be considered:  Choice of machine  Calibration  Choice of coupling medium  Frequency  Intensity  Mode  Duration of treatment  Hazards22
  23. 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. 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. 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. 26. Application of Ultrasound: Factors to be considered:  Choice of machine  Calibration  Choice of coupling medium  Frequency  Intensity  Mode  Duration of treatment  Hazards26
  27. 27. Application of Ultrasound: Factors to be considered:  Choice of machine  Calibration  Choice of coupling medium  Frequency  Intensity  Mode  Duration of treatment  Hazards27
  28. 28. Application of Ultrasound: 28
  29. 29. Application of Ultrasound: 29
  30. 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. 31. Clinical application:  Application in acute ankle sprain:  Aim?  Site?  Type of application?  Parameters/ doses?  Evidence? 31
  32. 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. 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

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