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Therapeutic Ultrasound: a Research Based Perspective

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Therapeutic Ultrasound: a Research Based Perspective TherapeuticTherapeutic Ultrasound:Ultrasound: aa ResearchResearch basedbased perspectiveperspective JOSEPH A. GALLO, DSc, ATC, PT Professor Hesser College PTA Program Adjunct Faculty Franklin Pierce College PT Program Clinician Performance Rehab ObjectivesObjectives TherapeuticTherapeutic UltrasoundUltrasound DiscussDiscuss aa ResearchedResearched basedbased perspectiveperspective forfor thethe clinicalclinical applicationapplication ofof USUS ApplyApply researchresearch relatedrelated toto dosingdosing USUS EvaluateEvaluate variousvarious couplingcoupling mediamedia ApplyApply ClinicalClinical ModelModel forfor dosingdosing USUS basedbased onon tissuetissue compositioncomposition andand stagesstages ofof healinghealing DiscussDiscuss indicationsindications andand contraindicationscontraindications PastPast andand PresentPresent IssuesIssues RelatedRelated toto USUS ResearchResearch DeadDead animalanimal ModelsModels (40(40 -- 4545°°CC range)range) FlawedFlawed researchresearch methodsmethods andand designsdesigns ManyMany USUS PracticePractice patternspatterns havehave beenbeen basedbased onon “Journal“Journal ofof anecdotalanecdotal medicine”medicine” BakerBaker KG.KG. PhysPhys TherTher JulyJuly 2001;81:13392001;81:1339-- 13511351 ¾ ProblemProblem ofof placeboplacebo vsvs placeboplacebo studiesstudies ¾ ReasonableReasonable expectationsexpectations UltrasoundUltrasound SinusoidalSinusoidal wavewave ThermalThermal agentagent MechanicalMechanical agentagent DoesDoes notnot fallfall onon electromagneticelectromagnetic spectrumspectrum AcousticalAcoustical spectrumspectrum (above(above 20,00020,000 HZ)HZ) HumanHuman earear hearshears soundsound btwnbtwn 16,00016,000--20,00020,000 BasicBasic OverviewOverview ofof productionproduction ofof USUS A/CA/C fromfrom wallwall PiezoelectricPiezoelectric crystalcrystal crystalcrystal expandsexpands andand contractscontracts resultsresults inin productionproduction ofof soundsound waveswaves vibrationvibration ofof moleculesmolecules withinwithin humanhuman tissuetissue causescauses physiologicphysiologic effectseffects EssentialEssential TerminologyTerminology SpatialSpatial AverageAverage IntensityIntensity (“intensity”(“intensity” W/cmW/cm2)) SpatialSpatial AverageAverage TemporalTemporal AverageAverage IntensityIntensity (SATA):(SATA): describesdescribes thethe netnet intensityintensity delivereddelivered basedbased onon thethe dutyduty cyclecycle selectedselected e.g.e.g. 1.01.0 W/cmW/cm2,, pulsedpulsed 50%,50%, =.5=.5 W/cmW/cm2 ERAERA BNRBNR Frequency:Frequency: ClinicalClinical ImplicationsImplications DepthDepth ofof PenetrationPenetration ¾ 11 MHz…………………DeepMHz…………………Deep (( upup toto 55 cm)cm) ¾ 33 MHz……SuperficialMHz……Superficial ((≤≤ 2.52.5 cm)cm)1 EfficiencyEfficiency ofof heating:heating: 33 MHzMHz heatsheats approxapprox 33 xx’’ss fasterfaster thanthan 11 MHzMHz2 1. Hayes et al JAT 2004;39(3):230-234 2. Draper et al. JOSPT 1995;22:142-150 ApplicationApplication techniquetechnique SizeSize ofof thethe treatmenttreatment area:area: 22--33 x’sx’s ERAERA SpeedSpeed ofof soundsound head:head: *4*4--88 cmcm perper secondsecond CouplingCoupling IssuesIssues ¾ AirAir ¾ HairHair ¾ UnderUnder waterwater treatmenttreatment * Poster presentation NATA 2004 Baltimore PulsedPulsed USUS MinimizesMinimizes unwantedunwanted heatingheating effectseffects atat aa givengiven intensityintensity proportionalproportional toto thethe dutyduty cyclecycle selectedselected SATASATA intensityintensity isis anan importantimportant considerationconsideration inin dosingdosing PUSPUS Myth:Myth: selectingselecting PUSPUS eliminateseliminates allall heatingheating effectseffects atat allall intensitiesintensities SATASATA StudyStudy (JOSPT(JOSPT JulyJuly 04’)04’) Gallo,Gallo, Draper,Draper, Brody,Brody, FellinghamFellingham TheThe researchresearch questionquestion WhatWhat isis thethe differencedifference inin thethe extentextent ofof tissuetissue heatingheating usingusing thethe followingfollowing USUS parameters?parameters? CUSCUS ((33 MHz,MHz, .5.5 w/cmw/cm2,, 1010 min)min) vs.vs. PUSPUS ((3 MHz, 1.0 w/cm2, pulsed 50%, 10 min) CUS = continuous ultrasound PUS = pulsed ultrasound ResultsResults SATASATA StudyStudy Gastrocnemius Muscle Temperature(°C) Changes (Mean ± SD) and Rate of Heating per Minute (°C/min) During a 10 minute Ultrasound Application Treatment Baseline Peak Change Rate Continuous* 35.5+ .9 38.4+ .8 2.8+ .8 0.28 Pulsed† 35.3+ .7 38.1+ .6 2.8+ .7 0.28 * 0.5 W/cm2 intensity, 100% duty cycle, 3 MHz † 1.0 W/cm2 intensity, 50% duty cycle, 3 MHz ConclusionConclusion SATASATA studystudy PulsedPulsed ultrasoundultrasound cancan heatheat “Inadvertent“Inadvertent overdosingoverdosing ofof acuteacute inflammatoryinflammatory conditionsconditions isis aa possibilitypossibility ifif lowlow enoughenough dutyduty cyclescycles andand spatialspatial averageaverage temporaltemporal averageaverage intensitiesintensities areare notnot selected”selected” PulsedPulsed USUS ((NonthermalNonthermal)) PhysiologicPhysiologic EffectsEffects IncreaseIncrease macrophagemacrophage responsivenessresponsiveness IncreasedIncreased intracellularintracellular calciumcalcium synthesissynthesis IncreasedIncreased skinskin andand cellcell membranemembrane permeabilitypermeability (greater(greater thanthan CUS)CUS) IncreasedIncreased proteinprotein synthesissynthesis byby fibroblastsfibroblasts IncreasedIncreased earlyearly fibroblasticfibroblastic activityactivity leadingleading toto acceleratedaccelerated tissuetissue healinghealing NonthermalNonthermal USUS MechanismMechanism ofof actionaction ResearchResearch onon dosingdosing forfor tissuetissue healinghealing ClinicalClinical recommendationsrecommendations forfor dosagedosage PUSPUS vsvs lowlow dosedose continuouscontinuous USUS (.2(.2 W/cmW/cm2)) PUSPUS advocatedadvocated forfor phonophono CUSCUS MildMild (1(1ºº C)C) toto vigorousvigorous heatingheating ((≥≥44ººC)C) isis achievableachievable ExtentExtent ofof heatheat buildbuild upup dependsdepends on:on: ¾ FrequencyFrequency ¾ IntensityIntensity ¾ DurationDuration ofof treatmenttreatment ¾ TissueTissue compositioncomposition ClinicalClinical ExampleExample ofof PearlsPearls andand PitfallsPitfalls ofof DosingDosing USUS USUS toto PiriformisPiriformis MuscleMuscle forfor DeepDeep HeatingHeating usingusing 1.51.5 W/cmW/cm2 atat 11 MHzMHz Note:Note: AA 44 degdeg CelsiusCelsius netnet increaseincrease oror aa totaltotal tissuetissue temptemp increaseincrease ≥≥ 4040 degdeg CelsiusCelsius isis neededneeded toto optimizeoptimize tissuetissue extensibilityextensibility (Draper/Prentice. Therapeutic Ultrasound. Therapeutic Mod in Sports Med. McGraw-Hill; 1999:207-244) (Warren KG et al. Elong of rat tail tendon:effect of load and temp. Arch Phy Med Rehabil. 1971;52:465-474.) HowHow longlong shouldshould wewe sonatesonate?? “The“The Answer”Answer” 1.51.5 W/cmW/cm2 atat aa freqfreq ofof 11 MHzMHz generatesgenerates aa heatingheating raterate ofof .3.3°°C/minC/min (Draper et al. JOSPT. 1995;22:142-150) .3.3°°CC XX 55 minmin == 1.51.5°°CC .3.3°°CC XX 77 minmin == 2.12.1°°CC .3.3°°CC XX 99 minmin == 2.72.7°°CC .3.3°°CC XX 1212 minmin == 3.63.6°°CC .3.3°°CC XX 1313 minmin == 3.93.9°°CC HeatingHeating raterate ((°°C/min)C/min) fromfrom DraperDraper etet alal JOSPTJOSPT 1995.1995. ClinicalClinical ModelModel forfor DosingDosing CUSCUS ConsiderationsConsiderations StageStage ofof tissuetissue healinghealing DesiredDesired goalgoal ofof treatmenttreatment DepthDepth ofof TargetTarget tissuetissue TargetTarget tissuetissue compositioncomposition TendonTendon studystudy (Chan(Chan etet alal JATJAT 33:2;33:2; 1998)1998) Mild,Mild, moderate,moderate, vigorousvigorous heatingheating EquipmentEquipment (heating(heating ratesrates vary)vary) 4040 degdeg CC thresholdthreshold vsvs NetNet increaseincrease ofof 44 degdeg CC PtPt perceptionperception atat 4040 degdeg CC (Merrick JOSPT, July 2003) Optimal Therapeutic Dosage Violation of tissue Stress healing constraints Tissue Healing No improvement ClinicalClinical DosingDosing ModelModel forfor vigorousvigorous heatingheating TheThe 44 classificationsclassifications DeepDeep musclemuscle SuperficialSuperficial musclemuscle DeepDeep tendon/ligamenttendon/ligament SuperficialSuperficial tendon/ligamenttendon/ligament Heating rate data for muscle from Draper et al JOSPT 1995. ClinicalClinical ModelModel forfor DosingDosing USUS VigorousVigorous HeatingHeating DeepDeep MuscleMuscle (3(3--55 cmcm deep)deep) 9 DutyDuty Cycle:Cycle: 100%100% (continuous)(continuous) 9 Frequency:Frequency: 11 MHzMHz 9 Intensity:Intensity: 1.51.5 W/cmW/cm2 9 HeatingHeating Rate:Rate: .3.3ººC/minC/min 9 Time:Time: 1313 minmin (13(13 minmin xx .3.3°° C/minC/min == 3.93.9°°C)C) • HeatingHeating raterate calculationscalculations maymay varyvary basedbased onon manufacturermanufacturer (Merrick JOSPT July 2003) ClinicalClinical ModelModel forfor DosingDosing USUS VigorousVigorous HeatingHeating SuperficialSuperficial MuscleMuscle ((≤≤ 2.52.5 cm)cm) ¾ DutyDuty Cycle:Cycle: 100%100% (continuous)(continuous) ¾ Frequency:Frequency: 33 MHzMHz ¾ Intensity:Intensity: .5.5 W/cmW/cm2 – 1.01.0 W/cmW/cm2 ¾ HeatingHeating RateRate .3.3°° C/minC/min -- .6.6°° C/minC/min ¾ Time:Time: 1313 minmin atat .5.5 W/cmW/cm2 (.3(.3 xx 13=3.913=3.9ººC)C) 77 minmin atat 1.01.0 W/cmW/cm2 (.6(.6 xx 7=4.27=4.2ººC)C) 9 Caution: 3 MHz heats 3x’s greater than 1 MHz patient feedback over rules all dosage calculations ClinicalClinical ModelModel forfor DosingDosing USUS VigorousVigorous
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