Use of real-time ultrasound imaging for feedback in rehabilitation

doi:10.1016/S1356-689X(98)80002-7

Manual Therapy

Volume 3, Issue 3, August 1998, Pages 125-131

https://doi.org/10.1016/S1356-689X(98)80002-7 Get rights and content

Summary

Real-time ultrasound imaging is currently used extensively in medicine. It provides a safe, cost-effective and readily accessible method of examination of various organs and tissues. One area where ultrasonography has proved to be useful is investigation of musculoskeletal pathology. Tissues that can be imaged include muscles, tendons, joints, ligaments and bursae. One of the most useful features of real-time ultrasound imaging is that movement of anatomical structures can be observed as it actually occurs. This has allowed development of a new application of real-time ultrasound imaging for rehabilitation that involves observation of muscle contraction to provide feedback. An ability to image deep muscles is an advantage of the technique, and use of ultrasound imaging has been successfully incorporated in assessment and facilitation strategies for the transversus abdominis and multifidus muscles in low back pain (LBP) patients. The objective of this article is to provide a brief review of the principles, advantages and disadvantages of ultrasound imaging and to discuss this new application of real-time ultrasound to rehabilitation. The current use of real-time ultrasound imaging in LBP patients will be described, and future uses in rehabilitation and limitations discussed.

References (40)

ChhemRK et al.
Ultrasonography of the musculoskeletal system
Radiologic Clinics of North America
(1994)
FornageBD et al.
Ultrasound examination of tendons
Radiologic Clinics of North America
(1988)
HidesJA et al.
Ultrasound imaging in rehabilitation
Australian Journal of Physiotherapy
(1995)
HodgesPW et al.
Evaluation of the relationship between the findings of a laboratory and clinical test of transversus abdominis function
Physiotherapy Research International
(1996)
RichardsonCA et al.
Muscle control—pain control. What exercises would you prescribe?
Manual Therapy
(1995)
BersteinI et al.
Pelvic floor muscle thickness measured by perineal ultrasonography
Scandinavian Journal of Urology and Nephrology
(1991)
CresswellAG et al.
Observations on intrabdominal pressure and patterns of abdominal intramuscular activity in man
Acta Physiological Scandinavica
(1992)
DockerMF et al.
The Safe Use of Diagnostic Ultrasound
(1991)
FishP
Physics and Instrumentation of Diagnostic Medical Ultrasound
(1990)
GentileAM
A working model of skill acquisition with application to teaching
Quest
(1972)

HarckeHT et al.

Evaluation of the musculoskeletal system with sonography

American Journal of Roentgenology

(1988)

HidesJA et al.

Diagnostic ultrasound imaging for measurement of the lumbar multifidus muscle in normal young adults

Physiotherapy Theory and Practice

(1992)

HidesJA et al.

Magnetic resonance imaging and ultrasonography of the lumbar multifidus muscle: Comparison of two different modalities

Spine

(1995)

HidesJA et al.

Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain

Spine

(1994)

HidesJA et al.

Multifidus muscle recovery is not automatic following resolution of acute first episode low back pain

Spine

(1996)

HodgesPW et al.

Inefficient muscular stabilisation of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis

Spine

(1996)

HodgesPW et al.

Feedforward contraction of transversus abdominis is not influenced by the direction of arm movement

Experimental Brain Research

(1997)

HodgesPW et al.

Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limbs

Journal of Spinal Disorders

(1998)

KaplanPA et al.

Sonography of the musculoskeletal system

American Journal of Roentgenology

(1990)

KogutBM et al.

Possibilities of using ultrasonography for intravital study of topographic anatomy of the anterior abdominal wall in humans

Arkhiv Anatomii Gistologii Embriologii

(1990)

Cited by (76)

Using real-time ultrasound imaging as adjunct teaching tools to enhance physical therapist students' ability and confidence to perform traction of the knee joint
2018, Musculoskeletal Science and Practice
Citation Excerpt :
Ultrasound imaging is an effective, noninvasive method of generating a visualization of anatomical structures that can provide concurrent visual feedback when performing manual traction techniques. It involves sending short pulses of ultrasound waves into the body and using the reflections received from tissue interfaces to produce images of internal structures(Hides et al., 1998). The brightness mode (B-mode) displays the ultrasound echo as a cross-sectional grey-scale image.
Often, physical therapy students struggle with the skill and the confidence to perform manual techniques for musculoskeletal examination. Current teaching methods lack concurrent objective feedback. Real-time ultrasound imaging (RTUI) has the advantage of generating visualization of anatomical structures in real-time in an efficient and safe manner. We hypothesize that the use of RTUI to augment teaching with concurrent objective visual feedback will result in students' improved ability to create a change in joint space when performing a manual knee traction and higher confidence scores.
Eighty-six students were randomly allocated to a control or an experimental group. All participants received baseline instructions on how to perform knee traction. The control group received standardized lab instruction (visual, video, and instructor/partner feedback). The experimental group received standardized lab instruction augmented with RTUI feedback. Pre-data and post-data collection consisted of measuring participants' ability to create changes in joint space when performing knee traction, a confidence survey evaluating perceived ability and a reflection paper. Joint space changes between groups were compared using a paired t-test. Surveys were analyzed with descriptive statistics and compared using Wilcoxon Rank Sum and for the reflection papers, themes were identified and descriptive statistics reported.
Although there were no statistically significant differences between the control and the experimental group, overall scores improved. Qualitative data suggests students found the use of ultrasound imaging beneficial and would like more exposure. This novel approach to teaching knee traction with RTUI has potential and may be a basis for further studies.
Applying an active lumbopelvic control strategy during lumbar extension exercises: Effect on muscle recruitment patterns of the lumbopelvic region
2017, Human Movement Science
Examine whether implementing an active lumbopelvic control strategy during high load prone lumbar extension exercises affects posterior extensor chain recruitment and lumbopelvic kinematics.
Thirteen healthy adults acquired an optimal active lumbopelvic control strategy during guided/home-based training sessions. During the experimental session electromyography was used to evaluate the activity of the posterior extensor chain muscles during high load trunk/bilateral leg extension exercises with/without application of the strategy. Video-analysis was used to evaluate thoracic/lumbar/hip angles.
Implementing the active lumbopelvic control strategy decreased the lordotic angle during trunk (p = 0.045; −3.2°) and leg extension exercises (p = 0.019; −10°). The hip angle was solely affected during trunk extension (p < 0.001; +9.2°). The posterior extensor chain (i.e. mean of the relative activity of all muscles (%MVIC) was recruited to a higher extent (p = 0.026; +9%) during trunk extension exercises performed with active lumbopelvic control. Applying the strategy during leg extension exercises lead to less activity of longissimus thoracic (p = 0.015; −10.2%) and latissimus dorsi (p = 0.010; −4.4%), and increased gluteus maximus activity (p ≤ 0.001; +16.8%).
When healthy people are taught/instructed to apply an active lumbopelvic control strategy, this will decrease the degree of lumbar (hyper)lordosis and this influences the recruitment patterns of trunk and hip extensors. Hence, the possible impact on predetermined training goals should be taken into account by trainers.
Are regions of the lumbar multifidus differentially activated during walking at varied speed and inclination?
2016, Journal of Electromyography and Kinesiology
Lumbar multifidus is a complex muscle with multi-fascicular morphology shown to be differentially controlled in healthy individuals during sagittal-plane motion. The normal behaviour of multifidus muscle regions during walking has only received modest attention in the literature. This study aimed to determine activation patterns for deep and superficial multifidus in young adults during walking at different speeds and inclination.
This observational cohort study evaluated ten healthy volunteers in their twenties (three women, seven men) as they walked on a treadmill in eight conditions; at 2 km/h and 4 km/h, each at 0, 1, 5, and 10% inclination. Intramuscular EMG was recorded from the deep and superficial multifidus unilaterally at L5. Activity was characterized by: amplitude of the peak of activation, position of peak within the gait cycle (0–100%), and duration relative to the full gait cycle.
Across all conditions superficial multifidus showed higher normalised EMG amplitude (p < 0.01); superficial multifidus peak amplitude was 232 ± 115% higher when walking at 4 km/h/10%, versus only 172 ± 77% higher for deeper region (p < 0.01). The percentage of the gait cycle where peak EMG amplitude was detected did not differ between regions (49 ± 13%). Deep multifidus duration of activation was longer when walking at the faster vs slower speed at all inclinations (p < 0.01), which was not evident for superficial multifidus (p < 0.05). Thus, a significantly longer activation of deep multifidus was observed compared to superficial multifidus when walking at 4 km/h (p < 0.05).
Differential activation within lumbar multifidus was shown in young adults during walking. The prolonged, more tonic activation of deep relative to superficial regions of multifidus during gait supports a postural function of deeper fibres.
The effect of motor control training on abdominal muscle contraction during simulated weight bearing in elite cricketers
2016, Physical Therapy in Sport
Citation Excerpt :
When performing exercises in sitting and standing positions, participants were instructed to maintain a neutral spinal alignment. Participants were provided with feedback using real-time ultrasound imaging (Hides, Richardson, & Jull, 1998; Hides et al., 2012). Dissociation of hip movements from lumbo-pelvic movements was taught in both standing and sitting positions, and participants were encouraged to maintain a neutral lumbar lordosis and thoracic kyphosis (Kiefer, Shirazi-Adl, & Parnianpour, 1997).
To investigate whether motor control training alters automatic contraction of abdominal muscles in elite cricketers with low back pain (LBP) during performance of a simulated unilateral weight-bearing task.
Clinical trial.
26 male elite-cricketers attended a 13-week cricket training camp. Prior to the camp, participants were allocated to a LBP or asymptomatic group. Real-time ultrasound imaging was used to assess automatic abdominal muscle response to axial loading. During the camp, the LBP group performed a staged motor control training program. Following the camp, the automatic response of the abdominal muscles was re-assessed.
At pre-camp assessment, when participants were axially loaded with 25% of their own bodyweight, the LBP group showed a 15.5% thicker internal oblique (IO) muscle compared to the asymptomatic group (p = 0.009). The post-camp assessment showed that participants in the LBP group demonstrated less contraction of the IO muscle in response to axial loading compared with the asymptomatic group. A trend was found in the automatic recruitment pattern of the transversus abdominis (p = 0.08).
Motor control training normalized excessive contraction of abdominal muscles in response to a low load task. This may be a useful strategy for rehabilitation of cricketers with LBP.
Ultrasound in Physiotherapy. Rehabilitative Ultrasound Imaging (RUSI)
2015, Fisioterapia
Training of Transversus Abdominis Activation in the Supine Position With Ultrasound Biofeedback Translated to Increased Transversus Abdominis Activation During Upright Loaded Functional Tasks
2014, PM and R
Citation Excerpt :
One method involves ADM training in symptomatic populations. This clinical instruction approach relies heavily on teaching adults to use the ADM to engage their TrA muscle [2,8,10]. Likewise, the effectiveness of ADM training programs in healthy adult populations during functional loaded tasks has emerged because such training also may lead to the prevention of LBP from injury in this population [1].
To determine whether healthy adults successfully completing transversus abdominis (TrA) muscle activation training in the supine position with clinician and ultrasound (US) imaging feedback increase their TrA activation during lifting and reaching tasks performed in the standing position.
Prospective longitudinal within-subject, repeated-measures (RM) study.
University laboratory.
A total of 19 of 24 asymptomatic adult volunteers met inclusion criteria.
Each adult performed 3 trials of 5 functional tasks before receiving any training. They were then briefed on the abdominal draw-in maneuver via educational materials. Next, each adult received individualized TrA activation training while in the supine position with clinician and US feedback of TrA activation. At 5 minutes after TrA activation training, each adult who met the criterion during training performed 3 trials of these same 5 functional tasks. Tasks were randomized during these test sessions. Adults who returned 5 months later (n = 10) were tested again on 3 trials of 3 of these tasks. No feedback was provided during test sessions. Recorded cine loop images were obtained via US per trial and masked for TrA measurement.
Resting state (minimum thickness) and contraction state (maximum thickness) of TrA were measured per recorded trial by a clinician who was shown to have high reliability. The percentage of change in TrA thickness {[(thickness_max – thickness_min)/ thickness_min] × (100)} was the primary outcome measure. Trial averages were formed per measure per task per test session per adult.
A 2-test sessions (pretraining, 5-minutes post-training) × 5 tasks RM analysis of variance (N = 19) indicated a significant and large effect for test sessions (P < .001, η² = 0.808) and moderate effect for tasks (P = .011; η² = 0.164). Likewise, a 3-test sessions (pretraining, 5-minutes posttraining, 5 months post-training) × 3 tasks RM analysis of variance (n = 10) indicated a significant and large test sessions effect (P < .001, η² = 0.57) and no task effect. Overall, the percent change in TrA thickness increased after the TrA activation training program and was maintained at 5 months; similar patterns of improvement were noted across test sessions and tasks.
Asymptomatic adults successfully completing a short session of TrA activation training in the supine position with US feedback of TrA activation were able to increase their TrA activation during loaded lifting and reaching tasks for at least 5 months.

View all citing articles on Scopus

View full text

MasterclassUse of real-time ultrasound imaging for feedback in rehabilitation

Summary

Radiologic Clinics of North America

Radiologic Clinics of North America

Australian Journal of Physiotherapy

Physiotherapy Research International

Manual Therapy

Pelvic floor muscle thickness measured by perineal ultrasonography

Scandinavian Journal of Urology and Nephrology

Observations on intrabdominal pressure and patterns of abdominal intramuscular activity in man

Acta Physiological Scandinavica

The Safe Use of Diagnostic Ultrasound

Physics and Instrumentation of Diagnostic Medical Ultrasound

A working model of skill acquisition with application to teaching

Quest

Evaluation of the musculoskeletal system with sonography

American Journal of Roentgenology

Diagnostic ultrasound imaging for measurement of the lumbar multifidus muscle in normal young adults

Physiotherapy Theory and Practice

Magnetic resonance imaging and ultrasonography of the lumbar multifidus muscle: Comparison of two different modalities

Spine

Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain

Spine

Multifidus muscle recovery is not automatic following resolution of acute first episode low back pain

Spine

Inefficient muscular stabilisation of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis

Spine

Feedforward contraction of transversus abdominis is not influenced by the direction of arm movement

Experimental Brain Research

Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limbs

Journal of Spinal Disorders

Sonography of the musculoskeletal system

American Journal of Roentgenology

Possibilities of using ultrasonography for intravital study of topographic anatomy of the anterior abdominal wall in humans

Arkhiv Anatomii Gistologii Embriologii

Masterclass
Use of real-time ultrasound imaging for feedback in rehabilitation