- Frank`s Hospital Workshop
Contents
1. gonads Small doses cause temporary and high doses permanent spermio oogenesis impairment pregnancy eyes The use of special ophthalmic ultrasound units is restricted to specialised centres In physiotherapy it is contraindicated post laminectomy conditions After laminectomy the spinal cord is not completely covered by the osseous cover and ultrasound application can cause temporary or event permanent paraparesis of lower extremities if the axons of the spinal cord paths are disorganised This is one of the most severe damages in physiotherapy practice and the connection between the physiotherapy application and the condition is obvious bleeding with recent onset any location Ultrasound waves propagate far via body fluids though with significant energetic decrease This can cause for example re occurrence of stubborn epistaxis e g when the ultrasound is applied to a knee page 8 of 16 ULTRASOUND THERAPY USER S GUIDE 1 10 2 Relative brain parenchymatous organs heart There is no reason to apply ultrasound to these organs The brain is covered by the cranium In spite of this there has been reported a case of a patient who irradiated his sinuses while he applied ultrasound to the knee and after a few hours died of massive bleeding into his forehead lobe calcified atheroma plate might have been disturbed The patient must not apply ultrasound to himself herself under any circumstances not even t2. Duty factor 6 to 100 5 of the set value Duty factor defaults 6 25 1 16 12 5 1 8 25 1 4 50 1 2 100 1 1 5 of the set value Time of therapy 0 to 30 minutes 2 of the set value Maximum output power 12W Table of pulse parameters Frequency 10 Hz Frequency 50 Hz Frequency 100Hz Frequency 150 Hz Duty period 100 ms period 20 ms period 10 ms period 6 67 ms factor Pulse Pause Pulse Pause Pulse Pause Pulse Pause length length length length length length length length 50 50 ms 50 ms 10 ms 10 ms 5 ms 5 ms 3 33 ms 3 33 ms 25 25 ms 75 ms 5 ms 15 ms 2 5 ms 7 5 ms 1 67 ms 5ms 10 10 ms 90 ms 2 ms 18 ms ims 9ms 0 67 ms 6 ms 6 6 ms 94 ms 1 2 ms 18 8 ms 0 6 ms 9 4 ms 0 40 ms 6 27 ms 3 2 STEP OF SETTING OF THE ADJUSTABLE VALUES Intensity 0 1 W cm Modulation frequency 10Hz Duty factor 196 Time of therapy 1s page 14 of 16 ULTRASOUND THERAPY USER S GUIDE 3 3 PARAMETERS OF ULTRASOUND HEADS BTL 237 1 13 small head Effective radiation area ERA ERA EN 61689 0 7 cm 20 ERA 21 CFR 1050 0 9 cm 20 Maximum effective intensity 3 W cm 20 Maximum effective acoustic power 2 1 W 20 Radiation frequency 1 MHz and 3 2 MHz 5 Type of beam collimated Beam non uniformity ratio BNR lt 8 Covering grade according to EN 60 529 IP 67 BT
3. conditions In addition this application is not limited by uneven surfaces and ultrasound can be easily applied to these surfaces such as to interphalangeal joints Disadvantages of subaqual application include difficult handling of a special porcelain bath limitation of ultrasound application to acral body parts and the risk of the therapist s hand lesions if the hand is put in water It is strictly prohibited due to reflection and interference of ultrasonic waves against walls of the porcelain bath Some emitter heads even newer are claimed to be water resistant but if they do not have a holder they do not provide safe subaqual ultrasound application Ultrasound can be also applied via a thin walled rubber bag surgical gloves condom filled with boiled water However when using this method it is necessary to eliminate the air gap between the bag and skin use gel and between the emitter head and the bag This method is often perceived as very time consuming ULTRASOUND FREQUENCY Older ultrasound units employ a fixed frequency usually 0 8 1 MHz Newer ones are multifrequency units the selected frequency is determined by the target tissue 1 MHz frequency is used for deep tissues and 3 MHz frequency for superficial tissues 1 4 8 b MODES OF OPERATION continuous It is characterized by heat generated deeply in tissues It is contraindicated in inflamed areas and everywhere else where local warming is undesirable
4. 2 Incu Me 1 9 3 Ultrasound TENS Transcutaneous Electrical Nerve Stimulation esee 8 1 9 3 1 Mechanism of ACIOD eii cite ette vinee De ir eR en PL TERR had a dani we RE QUI EAM danas 8 1 9 3 2 IEEE 8 1 10 Specific Contraindications for Ultrasound Therapy sssseeene en eem eene emen 8 1 10 1 Die qe ce 8 1 10 2 Lum M 9 1 11 Therapy PrescriptoD s c ses iue tpe edle Paene t eie titles ueste Lc e a sey Sadie este Radiant 10 1 12 Instructions for the Patient aaaeeeaa aoaea nnnm rented nne t tenent rennen nter nnn 10 1 13 Treatment Procedure nessun ne ean ee er enc see P epe a ein voe dete eee 10 2 SETUP OF ULTRASOUND GENERATOR essen enne neni nn nnns nin te niin tenni senes rien n nnne ennnen 11 2 1 Setup and Control of Ultrasound Therapy ssssssseeeenene nennen nennen emnes nennen nns 11 2 1 1 BI 11 2 1 1 1 Carrier FreQUuenCy RI 11 2 1 1 2 BICIE E E e DARTE EA Mcr it ta NN md Mec eT ok cet he oe ig ER etd he te ut 11 2 1 1 3 Ica m aTait 11 2 1 1 4 DE re qc MM dM 11 2 1 1 5 Pulse Frequency EE EO 11 2 1 1 6 idisse TL EIE 11 2 1 1 7 Course of Sigrial ities eee dee teet Ee eec A Eee pi e Re ere ne eee 12 2 1 1 8 Physiological Effects
5. of the head which is selected for calibration blink before start of calibration and shine during calibration page 12 of 16 ULTRASOUND THERAPY USER S GUIDE 2 2 1 2 Finishing of Calibration Take the ultrasound head out of water dry the metal part and press the finish button 2 2 1 3 Saving of Calibration Values To save the values measured during calibration of the head press the save button To quit the ultrasound head calibration function press esc If you decide not to save the measured data e g if the head was not immersed in water after the start of calibration press the esc button to refuse saving After end of calibration start therapy for 1 MHz and 3 MHz e g with the intensity 1 W cm and put the head in water and out of it several times to check the correctness of contact detection ATTENTION If the prescribed procedure of ultrasound head calibration is not followed there may occur damage to the ultrasound generator and the ultrasound head after the start of therapy page 13 of 16 ULTRASOUND THERAPY USER S GUIDE 3 TECHNICAL PARAMETERS 3 1 PARAMETERS OF ULTRASOUND GENERATOR Effective intensity Continuous operation 0 1 to 2W cm 20 for the output intensity higher than 0 2W cm Pulse operation 0 1 to 3Wicm 20 for the output intensity higher than 0 2W cm Working frequency 1 MHz 5 and 3 2 MHz 5 Modulation frequency 10 to 150 Hz 596
6. operating the equipment and a search of educational reading material on the internet 1 1 MECHANISM OF ACTION Mechanical waves of a frequency higher than 20 000 Hz are called ultrasound Application of ultrasound does not generate any electric current in tissues and thus it is classified as mechanotherapy The frequency usually used in physiotherapy is 0 8 3 MHz When the air gap between the emitter head and the body surface is eliminated the emitter head vibrations are transmitted into the tissue and propagate to the depth in the form of longitudinal waves All cells in the path of ultrasonic beam begin to oscillate This causes micro massage followed by transformation of gel into sol jelly structures become liquid transformation of mechanic energy into thermal and deep warming of tissues The amount of generated heat depends on the amount of absorbed energy Other effects of ultrasound degassing of solutions formation of cavities in liquids and local alkalization are negligible with ultrasound doses and intensities used in physical therapy In order to avoid side effects it is important to realize that molecular oscillation occurs not only in the path of ultrasonic beam but also in places that are distant from the area of application as a result of transmission by body fluids This may lead to restoration of former epistaxis or acceleration of menstruation The features of ultrasound beam and its distance from the emitter head det
7. pulsed together with shortening of pulse length there occurs decrease in so called Duty factor As a result thermic effect is suppressed and when Duty factor is below 12 596 1 8 athermic effect can be expected Duty factor DF can be set in pulsed mode of operation Its value states for how many percent of the period duration the ultrasound signal is being generated When setting therapy parameters of BTL units the ratio of ultrasound signal duration to the period length is stated in brackets This ratio is used in parameters of recommended ultrasound therapies of BTL units In case of continuous setting of the parameter only the percentage expression is used Example Duty factor 25 1 4 means that 25 1 4 of the period is ultrasound and the rest of the period is pause page 5 of 16 ULTRASOUND THERAPY USER S GUIDE The same example more detailed With a pulse frequency of 100 Hz the period is 10ms long With DF set to 25 1 4 pulse duration is 2 5 ms and pause is 7 5 ms 1 5 EMITTER HEAD SIZE The size of the emitter head is determined by the Effective Radiating Area ERA 1 cm small head and 4 cm medium head or big head according to some manufacturers The choice of the head depends on the size of the application area Ultrasound application to large areas by a small head is too time consuming difficult for the therapist and the dose is not applied homogeneously Small heads with ERA about 1 cm are used for
8. trigger points scars or for small and uneven surfaces where with an emitter head of standard size the ultrasound would have to be applied subaqually 1 6 APPLICATION TIME Application time varies and largely depends on the stage of disease For acute conditions it is 3 minutes at the beginning for chronic conditions it is usually 5 minutes at the beginning and then it is prolonged using the positive step method Application time for most therapies does not exceed 10 minutes If the application area is x times larger than the ERA of the head application time has to be x times prolonged and dynamic application is used 1 7 INTENSITY For acute conditions start with the intensity of 0 5 W cm in some cases even lower e g in case of trismus 0 2 Wicm on hypertonic fibres of m temporalis The muscle is situated on the bone just below the surface Since the close ultrasound field is used apply very low intensity For chronic conditions the intensity of 0 8 1 0 Wicm is used initially and it is increased according to the patient s reaction the positive step method The ultrasound intensity must not exceed 2 0 W cm in continuous mode and 3 0 W cm in pulse mode It is not recommended to increase in steps two parameters at the same time if you extend application area do not increase intensity and vice versa 1 8 FREQUENCY OF TREATMENTS Recommended frequency of treatments for acute conditions is 5 times a week and for chronic co
9. 0 100 110 120 130 140 and 150 Hz 2 1 1 6 With Electro If your unit does not contain any generator of electrotherapy the therapy parameters manual settings screen displays button with electro Pressing of this button enables to connect one pole of electrotherapy from the external connector to the case of the ultrasound head and perform combined therapy For information about configuration of output connectors and interconnection of units see the BTL 5000 Series User s Manual If your device contains an electrotherapy generator this button is not displayed and one pole of electrotherapy is automatically connected to the case of the head after starting the combined therapy page 11 of 16 ULTRASOUND THERAPY USER S GUIDE 2 1 1 7 Course of Signal The course of signal button contains a picture informing about the shape of the modulation signal For detailed information about the signal and for the possibility of fine setting of the duty factor press the course of signal button Pulse ms period ms information about the length of the pulse and the period calculated for the set pulse frequency and duty factor Pulse freq Hz information about the set pulse frequency EX Duty factor Hz by the select button it is possible to set the value from 6 to 10096 By pressing the duty factor button you can select one of the preset values See 2 1 1 2 Duty Factor 2 1 1 8 Physiological Effects The symbols of effects u
10. 1er eet netter sade ecd ie dede ne dread e ecrit tener dienen 12 2 1 2 Ultrasound size Ue aa 12 2 2 Specifi Setting rU 12 2 2 1 Ultrasound Head Calibration oo ceeeeeesneee cence ee eeneeeeeeaaaeeeceeeeeeeeneeeeeeaaeeeeeeeeeeeenneeeeeeaeeeeenaeeeenneeeeee 12 2 2 1 1 otart of Calibration s ae Mae a hr vine ie eee a ee re ale 12 2 2 1 2 Finishing of Calibration 5 1 soot eec posite td ed tenes iE de E ue De tienda e qe da doeet 13 2 2 1 3 Saving of Calibration Val ges certior renes rrt te iapa Enait peda apia 13 3 TECHNICAL PARAMETERS eese enne nn trnn nn nenn indie teneis ii tr inse tenni nsn tn ness sa nn anie tener nnns nennt nnne 14 3 1 Parameters of Ultrasound Generator ssssssssseseseeene enne enne enne en nennen nnne nennen nennen 14 3 2 Step of Setting of the Adjustable Values sse nennen nnne nne nenne enne nns 14 3 3 Parameters of Ultrasound Heads sssssssssssseeeeeneeeenen nenne enne enne nennen eren e nennen nennen 15 4 ACCESSORIES saiia ee 16 page 2 of 16 ULTRASOUND THERAPY USER S GUIDE 1 USER S GUIDE Continuing education is a very important aspect of healthcare delivery Many excellent resources are today available to expand a user s knowledge about many aspects of ultrasound therapy BTL recommends a thorough review of this guide prior to
11. BIL 5bOOO Ultrasound herapu USER S GUIDE v111z1RK14 01 2003 ULTRASOUND THERAPY USER S GUIDE CONTENTS 1 Bi eXciuzmec 3 1 1 Mechanism Of Action m mc 3 1 2 Meth ds OfFApplicatioM ienne e a e Deo ac Puteo aeaa a SR R a a e e o a 4 1 2 1 According to Application Area and Movement of the Emitter Head cccccceeceeceeeeseeneeeeeeeeeeseesenaeees 4 1 2 2 According to Application Area inerte iioii ice ehe f eee e e Ege oct n n ene escent ithe 5 1 2 3 According to Contact Between Emitter Head and Body Surface sssssseseeeee 5 1 3 Ultrasound Frequengy MP 5 1 4 Modes of Op 6ratlon ae a aaea Dare Ri dal a ute co a SPUR Lee aaa ae a A Es 5 1 5 Emitter a Ele ESA E E EA T E A A E 6 1 6 Application Time eisa Ani dan eee i die hen E AE a a e 6 1 7 luci 6 1 8 Frequency of Treatments iieri tentent tno creant Lorie eode Ibo gn adr aaae aene ed ant Y eund einingi aigis 6 1 9 Combined Therapy ier e tete Rd teen e eet tee ote ta irte eire 6 1 9 1 Ultrasound Low frequency Current ssssssesseseeeenene nennen nemen enne ener rennen nennen nns 6 1 9 1 1 Mechanism of Action iiir eee eee ere ENTE enc pee e ee 7 1 9 1 2 lucu MOL PIPER 7 1 9 2 Ultrasound Amplitude Modulated Mid frequency Currents 2 pole Interference esses 7 1 9 2 1 Mechanism of Action 1 9 2
12. INSTRUCTIONS FOR THE PATIENT Treatment is usually asymptomatic a feeling of moderate warmth can occur A burning sensation during therapy indicates insufficient contact medium it is necessary to add more pain indicates overdose it is necessary to interrupt therapy and consult the prescribed treatment with the physician treatment with lower intensity usually continues after one day break or insufficient movement of the emitter head After the first treatment there may occur temporary worsening Marked subjective and objective improvement should occur not later than after the third application If there is no improvement in acute and subacute states ultrasound therapy should not be continued Telling the patient that improvement will occur after a few months is not professional and it shows that the physician prescribes the treatment for deferring effect waits for self healing processes of the organism If ultrasound is used for treating chronic conditions which is quite rare or for change in mechanical features of treated tissues e g in case of Dupuytren s contracture or plantar aponeurosis related to calcar calcanei significant improvement cannot be expected after the third application If ultrasound application is not followed immediately by a manual therapy improvement cannot be expected even after the tenth application 1 13 TREATMENT PROCEDURE Inform the patient about the procedure Never let patients apply ultrasound to th
13. L 237 4 13 big head Effective radiation area ERA ERA EN 61689 3 2 cm 20 ERA 21 CFR 1050 4 4 cm 20 Maximum effective intensity 3 W cm 20 Maximum effective acoustic power 9 6 W 20 Radiation frequency 1 MHz and 3 2 MHz 5 Type of beam collimated Beam non uniformity ratio BNR lt 8 Covering grade according to EN 60 529 IP 67 page 15 of 16 ULTRASOUND THERAPY USER S GUIDE 4 ACCESSORIES User s Manual User s Guide Head BTL 237 4 13 large Head BTL 237 1 13 small Holder for ultrasound head Ultrasound gel 235ml Ultrasound gel 5l Ultrasound gel 101 Touch pen Mains cable Spare fuse Markers for cables Interconnection cable for combined therapy PVAC 056 page 16 of 16
14. TENS Transcutaneous Electrical Nerve Stimulation In the above mentioned combinations the emphasis is put on myorelaxation therapy of hyperalgesic zones and trigger points In the combination of Ultrasound TENS the expected effect is generally analgesic i e it is used not only for treatment of the above mentioned reflex change areas but also for other kinds of pain It is important to keep in mind mechanisms of ultrasound treatment because not every type of pain can be treated by ultrasound This combination is especially suitable for myalgia post stress reflexive etc and post traumatic pain after per acute condition 24 36 hours after onset during ege artis general therapy relaxation etc The preferable TENS pulses are asymmetric biphasic programs beginning with the numbers 12 15 18 The stimulant effect of the ultrasound head cathode is preserved and at the same time the galvanic effect is eliminated The continuous or possibly random frequency of 100 Hz is used The effect of this combination is better than the effect of the same treatments applied subsequently It is necessary to be aware of all ultrasound contraindications see 1 10 Specific Contraindications for Ultrasound Therapy 1 9 3 1 Mechanism of Action Reduction in the perception of pain positively affects the trophics of the injured area The simultaneous application of ultrasound with consequent increase in capillary permeability improved extravasal liquid a
15. bsorption and thus reduction of pressure increased vasoactive amines secretion and direct effect on the precapillary sphincters are the best prevention against algodystrophic syndrome Please note that beginning with the earliest clinical symptoms of algodystrophy the application of any physical therapy to the porotic area is contraindicated and only segmental technique can be used for example ultrasound electrotherapy applied paravertebrally homolaterally on the segmental level innervating the porotic area 1 9 3 2 Intensity For the ultrasound intensity please see the previous section Intensity of TENS is above threshold sensitive outside the area of reflex changes and above threshold motor level in the area of reflex changes 1 10 SPECIFIC CONTRAINDICATIONS FOR ULTRASOUND THERAPY 1 10 1 Absolute epiphyses of growing bones There is the risk of irreversible damage of the growth zone deformity and permanent impairment Since older types of ultrasound units employed low intensity displayed data did not correspond with the actual energy applied the damage of the growth zones was exceptional and many physicians did not take this contraindication too seriously However modern effective ultrasounds can cause damage of the growth zone especially due to insufficient movement of the emitter head The responsibility lies with the physician who prescribed the therapy as well as with the therapist who performed the contraindicated procedure
16. ecrease in impulse transmission speed in the peripheral nerve where ultrasound is applied As the dividing line between the lowering of conductivity and irreversible nerve damage asymptomatic is very small this method of application is considered dangerous and it is used only exceptionally e g phantom pain Radicular application Ultrasound is applied subsequently to the corresponding spinal root and manifested Head zone For application above the spinal root the same risks and limitations apply as for neural application According to Contact Between Emitter Head and Body Surface Direct contact is provided by a contact medium ultrasound gel This is a common way of ultrasound application and it is not necessary to mention it in ultrasound therapy prescription For combined therapy ultrasound electrotherapy it is recommended to write conductive gel in the prescription because some gels do not conduct electricity The BTL ultrasound gel is conductive if this gel is not available you can use ECG gel or another water based gel instead However never use paraffin oil because it is non conductive and could damage the head Subaqual application This method has a range of advantages It uses mainly the distant ultrasound field where interference does not occur Furthermore there is no need to press the emitter head against the skin in order to maintain sufficient contact this pressure is unpleasant or even painful for post traumatic
17. emselves It is strictly forbidden Ask the patient about contraindications that may be temporarily present epistaxis menstruation or pregnancy Place the patient in the proper position for the therapy and apply a contact medium Set the prescribed intensity time place the emitter head and switch on the ultrasound Move the emitter head continuously according to the prescribed form of application Ask the patient repeatedly about his her feelings In case of a burning sensation add more contact medium and if pain occurs lower the intensity or interrupt the treatment and inform the physician After the prescribed time elapsed lower the intensity and switch the unit off Most of modern ultrasound units do it automatically 9 Wipe the contact medium off the patient and dry the skin NOaARWN gt e page 10 of 16 ULTRASOUND THERAPY USER S GUIDE 2 SETUP OF ULTRASOUND GENERATOR 2 1 SETUP AND CONTROL OF ULTRASOUND THERAPY On the therapy parameters screen it is possible to select ultrasound or ultrasound sequences 2 1 1 Ultrasound 2 1 1 1 Carrier Frequency Select 1 MHz or 3 MHz The frequency 1 MHz is used for deeper located manual setting tissues therapy pulse frequence ultrasound Continuous carrier E TCAS o with FEES 2 1 1 2 Duty Factor AREE noe duty factor HF par of m Duty factor is the percentage ratio of the pulse length to the period 2090 riam M SM LL z length the value in the brack
18. ency of 50 Hz MF component of DD currents If you want to enhance myorelaxation of deeply located muscles by simultaneous increase in temperature use continuous ultrasound On the contrary if increase in temperature is contraindicated use pulsed ultrasound with a higher Duty factor For Duty factor see 1 4 Modes of Operation 1 9 2 2 Intensity The initial intensity for continuous ultrasound Duty factor 1 1 is 0 4 0 6 W cm the initial intensity for pulsed ultrasound with Duty factor 1 2 1 4 is 0 5 1 0 Wicm the initial intensity for pulsed ultrasound with Duty factor 1 8 1 16 is 1 0 1 3 Wicm The AMP intensity is chosen according to the desired effect Mainly analgesic effect of amplitude modulation about 100 Hz is reached by above threshold sensitive intensity optimal myorelaxation effect of 150 180 Hz modulation is reached with the intensity at threshold motor level The patient must not feel pain or burning sensation during application not even in the place of hyperalgesic zone or trigger point If pain occurs lower the ultrasound intensity immediately record it to the patient s card and send the patient to his her physician for immediate check up In order to eliminate burning sensation in the trigger point area lower the intensity of mid frequency component or add the contact medium It is not necessary to inform the patient s physician page 7 of 16 ULTRASOUND THERAPY USER S GUIDE 1 9 3 Ultrasound
19. ermine the ultrasound field as being either close or distant Close ultrasound field is characterized by low beam divergence and big intensity variations due to interferential effects The length of close field is directly proportional to effective radiation area ERA see below of the emitter head and inversely proportional to frequency For example the length of close field with 4 cm ERA emitter head and 1 MHz frequency is approximately 10 cm and for the emitter head with 1 cm ERA and 1 MHz frequency it is approximately 2 cm Distant ultrasonic field is characterized by increasing beam divergence gradual decrease of intensity and almost no interferential effects Therapeutic effects take place mainly in the close field The ultrasonic beam in the close field has significant interferential effects interference of applied and reflected waves both constructive and destructive It results in non homogenous ultrasonic beam where peak levels of intensity local increase of intensity caused by constructive interference may be many times higher than the pre set value Beam Non uniformity Ratio BNR states how many times the peaks of intensity exceed the pre set values This value characterizes an ultrasound head with a given frequency The BNR value of a good quality ultrasound head is lower than 5 It means that if the pre set intensity of the unit is 1 W cm the intensity in any part of the ultrasonic beam is not higher than 5 W cm T
20. ets states the ratio between the pulse UU LO W em2t wee alle Jh I length and the period length If the duty factor is set to 100 1 1 the ultrasound works in so called continuous mode In the pulse mode it is EET possible to select the duty factor from the following values 6 25 1 16 00 00 msly D 12 5 1 8 25 1 4 and 50 1 2 For description of finer setting of the duty factor and more detailed description of the output signal course see 2 1 1 7 The thermic effects of ultrasound differ according to the duty factor value Continuous ultrasound duty factor 100 i e 1 1 causes deep warming of tissues while pulsed ultrasound 50 1 2 and 25 1 4 has only slight thermic effects and for the values 12 5 1 8 and 6 25 1 16 the thermic effect is totally zero 2 1 1 3 Intensity Intensity can be set within the range from O 1W cm to 2W cm for the continuous mode and from 0 1W cm to 3W cm for the pulse mode If the continuous mode is set and then there is set an intensity higher 1 than 2W cm the equipment sets duty factor to 5096 Similarly if there is set an intensity from 2 1W cm to 3W cm and then the duty factor is set to 100 the equipment limits the intensity to 2Wlcm 2 1 1 4 Time Time of therapy can be set within the range from 00 01 to 30 00 min sec 2 1 1 5 Pulse Frequency Pulse frequency can be selected from the following values continuous 10 20 30 40 50 60 70 80 9
21. he BNR of older ultrasound heads and some newer ones some manufacturers do not mention the BNR value is often 20 or even more The Effective Radiating Area ERA is always smaller than the actual surface area of the emitter head the ERA is determined by the size of the piezoelectric crystal or ceramic table that generates ultrasound by oscillating The ultrasound dose power emitted to a surface area is therefore related to the ERA and not to the actual surface area of the emitter head The phenomena of ultrasound refraction and reflection are caused by ultrasound wave transmission from one tissue into another and by different transmission speed in these tissues When applying ultrasound it is necessary to eliminate the air gap between the emitter head and the skin Therefore modern ultrasound heads have built in optic and or acoustic check of insufficient contact possibly with automatic termination of application time countdown page 3 of 16 ULTRASOUND THERAPY USER S GUIDE Due to interference in the close ultrasound field it reaches the highest level in the place of soft tissue bone boundary up to 35 ultrasonic beam power increases constructive interference or decreases destructive interference In order to avoid tissue lesions at peak levels of intensity it is necessary to move the emitter head continuously As a result of reflection and constructive interference local increase in intensity and temperature may occur
22. nditions 3 times a week It is advisable to change frequency during one set of treatments for example 3 times a day then 3 times every other day The total number of treatments varies according to the individual condition It can range from a single application before myoskeletal surgery up to 9 applications over a 3 week period for chronic conditions 1 9 COMBINED THERAPY Combined therapy is simultaneous application of two or more kinds of energy Common diadynamic currents with simultaneous application of galvanic and pulse low frequency currents can be also considered as combined therapy Typical combinations are ultrasound low frequency currents ultrasound amplitude modulated mid frequency currents ultrasound TENS For combined therapy we recommend using of CV mode of electrotherapy 1 9 1 Ultrasound Low frequency Currents This combination can be applied by using one BTL Combi unit for example BTL 5810 S Combi or by interconnection of two single units BTL 5000 Sono and BTL 5000 Puls The current with adjustable intensity is brought to the page 6 of 16 ULTRASOUND THERAPY USER S GUIDE covering metallic plate of the emitter head The other electrode most usually a plate electrode is placed contralaterally so that both the ultrasound field and low frequency currents are brought to the treatment area 1 9 1 1 Mechanism of Action When using appropriate low frequency current 100 200 Hz myorelaxati
23. nstipation increased tendency to catch colds 1 2 METHODS OF APPLICATION 1 2 1 According to Application Area and Movement of the Emitter Head Static application The head is fixed to the treated area by a special holder and it is not moved Due to the above mentioned adverse effects it is the least suitable form of application Semistatic application is used when the application area corresponds to the ERA of the emitter head The therapist continuously moves the emitter head in spiral along the perimeter of an imaginary circle Dynamic application the application area is bigger than the ERA of the emitter head The therapist moves the emitter head in spirals in the treatment area The application time is prolonged proportionally according to how many times is the application area bigger than the ERA of the head page 4 of 16 ULTRASOUND THERAPY USER S GUIDE 1 3 2 3 According to Application Area Local application Ultrasound is applied to the affected area It is the most common way of application particularly suitable for local muscle spasms chronic post traumatic edemas etc Segmental application Ultrasound is applied to the outflows of nerve radices of the affected area e g Sudeck syndrome Morbus Reynauld etc The application is paravertebral and homolateral in the area of C5 Th for pathologies of upper limbs and in the L3 S4 area for lower limbs Neural application is based on the effect of d
24. o areas easy to reach peripheral nerves situated on the bone just below the surface It mainly concerns n ulnaris in the elbow area volar areas of the wrist inguines areas under external and internal ankles etc In all of the above mentioned areas the constructive interference stationary waves results in local increase in intensity peaks of intensity and thus prolongation of impulse transmission and irreversible destruction of nerve fibres without damaging muscular fibres Myeline covers of damaged nerves are usually preserved bony projections located under the skin spinous projections of spondyles ankles condyles epicondyles This contraindication is very often ignored Ultrasound can be used for treatment of epicondylitis but this is true only in case of applying ultrasound to a specific muscular group extensoric in lateral epicondylitis flexoric in ulnar epicondylitis Direct ultrasound application to a painful attachment often causes increased pain but it more often leads to the process of chronification the same effect as in the case of repeated local application of corticosteroids Similarly direct ultrasound application to spine often results in stubborn periosteum pain around spinal projections emphysema bronchiectasis ultrasound application to the chest area menstruation Ultrasound application is absolutely contraindicated in lower abdomen area When applying ultrasound to other areas it is advi
25. o sol due to transformation of fibrinogen into fibrin haematomas and edemas change into gel ultrasound dissolves this gel and speeds up resorption As the transformation of fibrinogen into fibrin is a basis of healing process scar formation it is not advisable to apply ultrasound for peracute post traumatic conditions e Improvement of tissue regeneration capabilities as a result of the above mentioned effects Ultrasound has also several non therapeutic effects that can have negative impact such as e Tissue lesion Mechanic and or thermic tissue lesion can occur when the intensity is too high Especially sensitive is the nervous system peripheral nerve situated right on the bone interference below the surface close field Impulse transmission speed in the corresponding nerve decelerates then occurs total reversible impulse transmission blockage and finally irreversible disintegration of the neuron myelin coats are preserved Therefore be extremely cautious when applying ultrasound e g on paravertebral muscles after laminectomy when nerve structures lose their natural bone protection Similarly bone projections located just under the skin ankles epicondyles spondyle spines etc are also sensitive e Leukocyte mobility impairment this can be minimized by sufficient movement of the emitter head e Other effects mainly caused by overdosage are decrease in glycaemia increased fatigue nervousness changes in appetite co
26. often does not notice it If the threshold of pain is not reached use the same intensity for the therapy otherwise adjust the intensity of the low frequency component according to the type of current and the desired effect The intensity of the therapy should never be above threshold of pain The size of the indifferent plate electrode should be at least 2x but in practice even up to 10x larger so that sensitive feelings are located only on the edge of ultrasound application 1 9 2 Ultrasound Amplitude Modulated Mid frequency Currents 2 pole Interference Unlike the previous combination mid frequency currents have no galvanic effects In addition they are better tolerated at the given intensity of subjective feelings higher current intensity can be applied the effect is deeper and hence they can influence reflex changes in deep muscles It is obvious that for application to deeper areas lower ultrasound frequency 1 MHz is chosen Combination of modern BTL units enables to select ultrasound parameters or amplitude modulation Hence these currents can be used for treatment of superficial 3 MHz frequency as well as deep 1 MHz frequency muscles 1 9 2 1 Mechanism of Action is the same as for the combination ultrasound low frequency current see the previous paragraph The optimal myorelaxation is attained with the frequency of 150 180 Hz unlike diadynamic currents myorelaxation effect is not lowered by the stimulant frequ
27. on effect of the ultrasound is cumulatively increased This form of combined therapy when using ultrasound of the frequency 3 MHz is used especially for treating localized muscle hypertonia uncoordinated muscle fibres unable of spontaneous relaxation and trigger points in superficially located muscles A certain disadvantage of this combination is a galvanic corrosion effect It applies especially to diadynamic currents and to a certain extent also to monophasic pulse currents This effect is more evident on the emitter head than on the skin However when using higher intensities it is important to be aware of this effect and ensure the patient s safety 1 9 1 2 Intensity The intensity of ultrasound set separately 0 5 0 7 W cm for continuous ultrasound and up to 1 0 W cm for pulsed ultrasound with Duty factor 1 2 or more The intensity of the low frequency component is set according to the aim When locating trigger points set the intensity at threshold sensitive level outside the area of expected reflex changes and then approach this area continuously In the area of hyperalgesic zone the pre set intensity is above threshold sensitive up to below threshold of pain and the patient reports subjective intensification of feelings may even feel pain In the area of trigger points in a muscle the intensity changes to threshold motor level and up to above threshold motor level The pre set intensity causes a motor response The patient
28. particularly in the place of periosteum bone boundary This increase can lead to periosteum pain during ultrasound application If this occurs the intensity must be immediately lowered Ultrasound is primarily absorbed in deeper tissues Since these tissues usually do not include thermoreceptors it is impossible to perceive local rise in temperature The patient feels pain only if the local temperature exceeds 45 C and nociceptive receptors are irritated Most authors agree that a short term rise in local temperature to 45 C is not dangerous In the area of classic inflammation edema erythema local rise in temperature pain or dysfunction additional heat production is contraindicated and thus only pulsed ultrasound athermic can be applied if necessary During peracute phase of post traumatic conditions up to 24 36 hours the pulsed ultrasound application is contraindicated vibrations hinder capillary proliferation and may cause delayed bleeding Local rise in temperature and micro massage have several physiological effects e Improvement of local circulation and thus also metabolism Rise in temperature enhances vasodilatation more evident in continuous ultrasound e Increase in capillary permeability and increased resorption of extravasation fluid e Improvement of local circulation and decrease in orthosympathetic activity resulting in significant muscle relaxation e Decrease in local ischaemia pain e Transformation of gel int
29. sable to tell the patient that the menstruation might increase more common is acceleration of menstruation than metrorrhagia If the case history shows that the ultrasound application might adversely affect menstruation the therapist should refuse to carry out the treatment and suggest that the patient consult it with her physician It is not enough to postpone the ultrasound application after menstruating period when ultrasound indications may not exist anymore blood circulation insufficiency pacemaker cardiovascular diseases cochlear implants metal implants tumours acute inflammations vascular and blood diseases haemophilia generally poor state of health endocrine glands TB page 9 of 16 ULTRASOUND THERAPY USER S GUIDE 1 11 THERAPY PRESCRIPTION Name surname ID number insurance company Diagnosis name and number stage Name of treatment type of device if possible BTL 5000 Sono BTL 5000 Puls BTL 5000 Sono Ultrasound parameters frequency duty factor pulse frequency intensity emitter head size way of application In case of combined therapy parameters of electrotherapy characteristics of current intensity position and size of indifferent electrode Length of application step Frequency of treatments its changes during the set of treatments Total number of treatments Date of check up at the physician s Date of prescription physician s name signature stamp 1 12
30. sed in the equipment have the following meaning analgesic antiedematous antiphlogistic hyperaemic myorelaxation aurmm 2 1 2 Ultrasound Sequence This function enables to run sequences selected by the name or number It is also possible to create new sequences or edit the existing ones Since sequence is a series of individual therapies one after another it is obvious that parameters of individual sections must be set when creating the programs For details see chapter USER SEQUENCES in the BTL 5000 Series User s Manual 2 2 SPECIFIC SETTINGS The heads delivered with the BTL 5000 devices are interchangeable This means that the head can be connected to any device of the BTL 5000 series which contains an ultrasound generator and it is not necessary to state the number of the equipment for which the head is designed For optimum detection of the contact between the head and the patient s skin it is necessary to perform calibration of the ultrasound head especially for the extra purchased heads see 2 2 1 Ultrasound Head Calibration The ultrasound head supplied with the equipment were calibrated during manufacturing 2 2 1 Ultrasound Head Calibration When calibrating the ultrasound heads the equipment measures their properties so that optimum evaluation of the contact with the patient s skin is ensured 2 2 1 1 Start of Calibration Put the ultrasound head in water and press the start button The pilot lights
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