00:00hello everyone this is paul from ortho
00:02eval pal and today i want to talk to you
00:06ultrasound but before i do that i just
00:07want to give you a little background for
00:09those of you who are
00:10new at viewing some of our youtube
00:12videos or listening to my podcast on
00:14ortho eval pal i just want to give you a
00:18who i am what i do um so i'm a physical
00:20therapist have been for over 28 years
00:23and i actually did some teaching for
00:26about five years on therapeutic
00:27modalities for athletic trainers
00:29so i do have a little bit of background
00:31on the use of modalities i've been using
00:34ever since i graduated uh probably using
00:37him a little bit less now than i used to
00:40i still use it and an ultrasound is a
00:44that we use and if we just depended on
00:46one modality alone i think we would all
00:50let me explain a little bit about what
00:53how it works and why we use it
00:56so therapeutic ultrasound is different
00:58than diagnostic ultrasound we're not
01:00going to find kidney stones and babies
01:02and things like that with this type of
01:04um the effect we're trying to do here is
01:07get a little increase in tissue
01:09deep inside the body so different than
01:11putting a hot pack on the skin and
01:14go through the skin through the fat into
01:16the muscle and into the tendons
01:17those deep tissues this actually sends a
01:20sound wave that's a little bit deeper
01:21to help heat those tissues that are
01:24deeper than you would get with a
01:26hot pack so how does ultrasound work
01:30inside of this sound head right here
01:34is a man-made crystal
01:37um i might be able to take this one off
01:43and i say a man-made crystal
01:50you can see in here deep inside there's
01:54it's lead zerkin eight titany it's uh
01:57three elements put together so that when
02:01um it expands and contracts really
02:04and when it does that um that expansion
02:07and contraction will cause a vibrational
02:10and that sound wave will penetrate
02:13and into the tissue so the way i explain
02:17is that when that sound wave goes
02:19through it causes friction to the cells
02:21in the soft tissue just like rubbing
02:22your hands together so the harder and
02:24faster you rub your hands together the
02:26and that can increase that temperature
02:30up to four degrees celsius four
02:34if you use the right parameters now um
02:39so you can increase the tissue that
02:40temperature by doing that you increase
02:42blood flow to the area well
02:44anytime you increase blood flow to the
02:45area that can be helpful in bringing
02:47nutrition to that region
02:48help the healing properties of that
02:52the other thing it can do is increase
02:55of that tissue by warming it up a little
02:59one of the things that you need to
03:00remember is that when you ultrasound a
03:03increase the tissue temperature once you
03:06finish that ultrasound within about
03:08three minutes or so that tissue
03:10temperature will drop back to its normal
03:12and then you lose that ability to make
03:14the tissue a little more extensible
03:17so one of the things that i'm going to
03:21location and how to use your ultrasound
03:23but i also want to get a little more in
03:26you know the types of ultrasounds that
03:28you have out there and sound head size
03:30and whatnot so that you can make your
03:32treatment a little more effective so if
03:35these two ultrasounds the sound heads
03:39are both two different sizes okay so
03:43if you're going to be doing a really
03:44large area let's say you're
03:46doing a quad or piriformis or even a
03:50you're going to want a little bit larger
03:51sound head if you're doing
03:53let's say a decor veins in this area or
03:57just a one specific tendon you're gonna
03:59wanna get into a ultrasound head that is
04:01a little bit smaller like this okay
04:03so you can see the difference in the
04:05size of the sound head so one of the
04:07things you need to remember is that
04:09a ultrasound has an era or an effective
04:13radiating area that means that the sound
04:15does not come out through the whole
04:17sound head it only comes out
04:19of about three quarters of that sound
04:21head so strongest in the middle
04:23and then a little bit less on the
04:24outside so if you would take a look at
04:26the sound wave it makes kind of like a
04:29bell curve like this when it comes out
04:32but the edges don't produce a lot of
04:35when you think that the whole head is
04:37that's touching the skin
04:38is sending sound wave it's not so that's
04:42when you ultrasound an area you should
04:45ultrasound an area any more than two
04:49the size of the sound head okay so let's
04:52say the area that we're doing is right
04:54we want to do about two times that
04:56sounded you don't want to be going all
04:58over the place because
04:59then you'll lose the effectiveness of
05:00that sound wave penetrating into one
05:03so that effective radiating area though
05:05if you keep it in one spot
05:06number one it will burn the patient and
05:08be very very uncomfortable
05:09because of a high concentrated sound
05:14and then you don't get all of the sound
05:16waves coming out of the whole head so
05:18you want to cover that area by
05:20doing little circles over the region
05:22okay that's the effective radiating area
05:24the other important thing
05:25about the mechanism of how an ultrasound
05:27works is the beam non-uniformity ratio
05:31and so when you look on a ultrasound
05:35head like this and it should tell you
05:38is or when you purchase an ultrasound
05:40the higher the bnr the better so if you
05:44uh bnr that will make that sound a
05:48over the area that where it comes out it
05:50won't feel so spiky or sharp
05:52some of the old old ultrasounds have
05:55really low bnr's of two to one three to
05:59those can be quite uncomfortable you can
06:01actually burn capillaries
06:03with some of these really old
06:04ultrasounds so it's not a bad idea to
06:06update your ultrasound
06:08take a look at that bnr make sure that
06:09number is really high
06:11so you can get the most effective
06:14ultrasound alone is not a great
06:18just to do on its own but if
06:21you're going to use it as a tool make
06:23sure that you use it as efficiently and
06:25effectively as possible
06:26okay so it's very important that you
06:29the type of tissue that you're
06:31ultrasounding and the depth of the
06:34ultrasounding so if you are doing a
06:36really deep tissue let's say like a
06:39um or a gluteal muscle you want to
06:41really want to heat that tissue nice and
06:43you want to use one megahertz that will
06:45penetrate a lot deeper
06:47if you're doing something like a decor
06:51or the back of the hand maybe a patella
06:55the triceps insertion then you want to
06:58go with three megahertz because that
06:59will give you more of a surface
07:02and that will not penetrate as far down
07:05because if you're close to the bone
07:07you'll get a little discomfort
07:08when you ultrasound that area now
07:12with that in mind so now you know the
07:14depth so using one megahertz for deep
07:16for on the surface um there are
07:19continuous and pulsed ultrasounds that
07:22so if somebody comes in with an acute
07:24injury there's maybe a lot of
07:25inflammation a lot of swelling
07:27you probably want to use a pulsed
07:30i typically use 50 pulsed if it's
07:33you know subacute acute just to help
07:36decrease that inflammation in that area
07:39pulsed ultrasound you want to go a
07:42little bit slower with your ultrasound
07:45uh motion so that you get that pulsating
07:48if you do 50 percent pulse that means
07:50you're gonna get the 50
07:51sound and then it stops 50 sound and it
07:54stops so it's on and off on and off
07:56whereas if you use continuous that sound
07:58wave is continuous all the time
08:02so that continuous is more thermal it's
08:04going to help increase the temperature
08:06you don't want to do that on somebody
08:07who has an acute inflammation or a
08:10you know fresh ankle sprain or something
08:13the other consideration is you know what
08:16are you trying to achieve with your
08:17ultron if you're trying to achieve
08:19you know elasticity of the tissue and
08:21increasing blood flow to the area
08:23then maybe you want to consider
08:24stretching that tissue while you're
08:26doing the ultrasound because remember
08:28that the temperature of the tissue will
08:30decrease about three minutes after
08:32you've done the ultrasound so if you're
08:33doing a plantar fasciitis let's say
08:35underneath the bottom of the foot
08:36i like to stretch the patient into
08:40and extend those toes a little bit and
08:43while i'm doing that ultrasound so that
08:46i can help increase the elasticity of
08:48stretching the achilles or i'm
08:50stretching the extensor mechanism if i
08:52want to increase the mobility of that
08:55i might stretch it as i ultrasound it so
08:58heating it bringing blood flow to it and
09:00stretching all at the same time
09:02so think about that when you're doing
09:05think about the depth of the tissue now
09:07ultrasound cannot penetrate much more
09:08than four centimeters deep if you're
09:11one megahertz at two watts per
09:14so if you think it's going to penetrate
09:17really really deep on
09:19you know somebody who may be a little
09:21overweight or you're trying to get to a
09:24joint or something like that are you
09:26really getting an effective
09:27treatment out of that so remember the
09:31and your parameters that you use when
09:32you're using ultrasound
09:35some of the other things you need to
09:36remember patient comfort
09:39so when you explain that it produces
09:42deep heat patients will oftentimes say
09:45well i don't feel anything so i don't
09:46think this is really effective
09:48um one thing you need to remember is
09:52sensory fibers are more on the surface
09:56this sound wave is being produced deep
09:59okay and you don't have sensory fibers
10:01deep inside your muscles and tendons and
10:04so they're not going to feel that they
10:06may feel a little warming effect
10:08later on as you're you're getting into
10:10six seven maybe eight minutes of doing
10:13because the the sound head is actually
10:14starting to warm up because all those
10:16sound waves are coming through
10:18obviously that sound wave is going to
10:20move those molecules
10:22warm them up and cause a little friction
10:23to the surface of the ultrasound
10:25so they may feel the ultrasound getting
10:28but you should never adjust your
10:31to what the patient feels in regards to
10:33the heat okay and that's something that
10:34people used to do in the past
10:36you don't do that you do you adjust your
10:39parameters to the tissue that you are
10:42explain that to your patients so they
10:44don't have this anticipation that they
10:46a heating effect if you're doing pulsed
10:50you're going to be going a little bit
10:51slower and they may not feel any heat at
10:54when you are ultrasounding the technique
10:57you should not just keep your ultrasound
11:00in one spot if you're doing thermal
11:02ultrasound because that will really hurt
11:04the patient because you're going to
11:06that sound wave in one spot and just
11:09you know a rope that's rubbing on your
11:12hand in one spot for a long time will
11:13cause a burning effect
11:15well this will do the same thing you
11:17won't physically burn the patient but
11:19feel a sensation that is very very
11:22uncomfortable they're not going to like
11:24so it's important that you have this
11:26constant little circular motion
11:28going in that area and you're not going
11:32twice the size of the sound head to be
11:34most effective while you're doing that
11:36if they can't stand the discomfort you
11:38may want to turn it down a little bit
11:39but you don't want to be going really
11:43because that will also be quite
11:44uncomfortable for the patient
11:46so a mini circular motion is important
11:49and if you're doing pulsed ultrasound
11:50you can actually go a little slower
11:53just so that you can focus it on that
11:56make sure you expose the area as well as
11:58you can that you're working on so if
12:00you're doing a rotator cuff let's say
12:02insertion the deltoid's a pretty thick
12:04muscle so you can expose that cuff a
12:06little bit by extending the
12:08shoulder some to work on that area and
12:12that may make it a little bit more
12:14so again i try to make sure that the
12:17location is correct that i'm not
12:19ultrasounding an area that is
12:21too large i'm using the right
12:24frequency so 1 megahertz versus 3
12:28i look at the depth of the tissue in
12:31increase my watts per centimeter squared
12:33so if it's a little deeper tissue you're
12:35going to want to go a little higher with
12:36if it's really surface and near the bone
12:39they won't be able to tolerate that
12:40because that sound wave is going to hit
12:41the bone and bounce back
12:43cause a lot of discomfort there some
12:46people have utilized
12:47therapeutic ultrasound to identify you
12:50know stress fractures or fractured areas
12:52like a metatarsal stress fracture
12:55because that sound wave when you go
12:57slowly over the fracture site
12:59causes the vibration and that vibration
13:01can cause some irritation to the
13:04and if you are going over the area and
13:07then you hit the fracture site they have
13:09a significant amount of pain or a deep
13:11and then you continue on and it's not so
13:14back over it and it's painful again you
13:17may want to suggest that they go to the
13:20or get an x-ray to identify if there
13:23actually is a fracture
13:25it's not a super dependable way of doing
13:28if somebody comes in and they haven't
13:29had an x-ray you could utilize that as a
13:32tool to try to identify if there is a
13:34fracture in that region
13:37what do you use for conducting gels we
13:40just get an ultrasound transmission gel
13:43works fine lotions can work fine there
13:46medicated gels that you can use out
13:48there they call that phonophoresis when
13:51drive medication through the skin into
13:53the tissue and they found that to be um
13:56quite ineffective so i have not done a
13:58phonophoresis treatment
14:00in over 15 years i'd rather do
14:02iontophoresis which i find to be a
14:04little more effective
14:06like i said i do ultrasound with
14:09patients i'm quite selective
14:10i try to keep my programs a little bit
14:13but if you have a lot of tightness or a
14:16lot of muscle soreness
14:17patients can find quite a bit of comfort
14:20by doing therapeutic ultrasound and i
14:23added that one thing to a treatment
14:25program to find a pretty significant
14:27improvement in how they're doing
14:29i don't do it all the time but i do use
14:33adjunctive piece of treatment when i am
14:36when i'm working with patients
14:38trying to think if there's anything else
14:39we need to know about ultrasound um
14:42you know indications you want to make
14:44sure you don't do it
14:45uh trans cerebrally don't do it over the
14:49belly of somebody who is pregnant you
14:51want to avoid doing it over
14:53um a total joint replacement where there
14:58over the cemented area you want to avoid
15:00that you want to avoid doing it over
15:02an area of a pacemaker
15:05try to avoid open wounds if possible
15:08but other than that it's a pretty safe
15:12and again something that i use quite
15:15now if you folks have any questions
15:17about ultrasound or you want to make any
15:19about this video please leave those in
15:21the comments section
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16:00all the great comments you've been
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