Ultrasound measurements of superficial and deep masticatory muscles in various postures: reliability and influencers

Evaluation of the thickness of masticatory muscles in patients with chronic periodontitis by ultrasonography

OBJECTIVES

Periodontitis is one of the most common chronic inflammatory diseases. It causes changes in the biting abilities of individuals. However, periodontal treatment has positive effects on masticatory function. The aim of this study is to determine the effect of periodontitis and periodontal treatment on masticatory abilities by measuring masseter and temporal muscle thicknesses with ultrasonography before and after periodontal treatment in chronic periodontitis patients.

METHODS

The patients included in the study were determined by clinical and radiological examination. The thickness of the masseter and temporal muscles of the patients were measured by ultrasonography. Periodontal measurements and treatments of the patients were completed by a single physician. IBM SPSS 20.0 (IBM Corp., Armonk, NY) statistical program was used for statistical analysis.

RESULTS

A statistically significant difference was found between the values of periodontal measurements before and after treatment (p<0.05). In the ultrasonography measurements of the thickness of masseter and anterior temporal muscles, a statistically significant increase was observed in both rest and contraction values at all time intervals (p<0.05). Muscle thicknesses of male patients were higher than female patients.

CONCLUSIONS

Periodontitis negatively affects the masticatory performance of individuals. Chronic periodontitis patients should be referred for periodontal treatment without wasting time.

The feasibility of visualizing and quantifying muscle changes in postoperative oral cancer patients using Quantitative Muscle Ultrasound (QMUS)

PURPOSE

Quantitative muscle ultrasound (QMUS) is a patient friendly tool for examining orofacial muscles. Resection of tissue can have an effect on the architecture and function of these muscles. The aim of this study is to investigate the feasibility of visualizing and quantifying muscle changes in postoperative oral cancer patients and to relate the findings to tumor and patient characteristics.

METHODS

Adult patients with a resected first primary pT1 or T2 oral squamous cell carcinoma, at least one year post operatively, where included. Ultrasound data were collected of the geniohyoid muscle, digastric muscles, masseter muscle, transverse muscle and genioglossus muscle. Ultrasound images were labeled as clearly visible, questionable or unclear. Of the clear muscles, echogenicity and muscle thickness were measured.

RESULTS

37 patients were included. The masseter muscle was clearly visible in all ultrasound images, both intrinsic tongue muscles had the lowest visibility (45.9%). There was a significant correlation between visibility and tumor localization for the genioglossus (p = 0.029). Age correlated with the visibility of the genioglossus muscle, BMI with the genioglossus and transverse muscles. Echogenicity and muscle thickness of the clearly identified muscles did not differ from normative values.

CONCLUSION

QMUS of orofacial muscles is feasible in postoperative oral cancer patients with relatively small tumor sizes. Tongue resections negatively affected the visibility of the two intrinsic tongue muscles. These preliminary results for particular muscles indicate that the use of ultrasound might be promising in oral cancer patients to help determine targeted goals in post-operative rehabilitation.

Development and Validation of an Ultrasonography-Based Machine Learning Model for Predicting Outcomes of Bruxism Treatments

BACKGROUND AND OBJECTIVES

We aimed to develop a predictive model for the outcome of bruxism treatments using ultrasonography (USG)-based machine learning (ML) techniques. This study is a quantitative research study (predictive modeling study) in which different treatment methods applied to bruxism patients are evaluated through artificial intelligence.

MATERIALS AND METHODS

The study population comprised 102 participants with bruxism in three treatment groups: Manual therapy, Manual therapy and Kinesio Tape or Botulinum Toxin-A injection. USG imaging was performed on the masseter muscle to calculate muscle thickness, and pain thresholds were evaluated using an algometer. A radiomics platform was utilized to handle imaging and clinical data, as well as to perform a subsequent radiomics statistical analysis.

RESULTS

The area under the curve (AUC) values of all machine learning methods ranged from 0.772 to 0.986 for the training data and from 0.394 to 0.848 for the test data. The Support Vector Machine (SVM) led to excellent discrimination between bruxism and normal patients from USG images. Radiomics characteristics in pre-treatment ultrasound scans of patients, showing coarse and nonuniform muscles, were associated with a greater chance of less effective pain reduction outcomes.

CONCLUSIONS

This study has introduced a machine learning model using SVM analysis on ultrasound (USG) images for bruxism patients, which can detect masseter muscle changes on USG. Support Vector Machine regression analysis showed the combined ML models can also predict the outcome of the pain reduction.

Clinicopathological characteristics and typing of multilocular cystic renal neoplasm of low malignant potential

BACKGROUND

Up until now, no research has been reported on the association between the clinical growth rate of multilocular cystic renal neoplasm of low malignant potential (MCRNLMP) and computed tomography (CT) imaging characteristics. Our study sought to examine the correlation between them, with the objective of distinguishing unique features of MCRNLMP from renal cysts and exploring effective management strategies.

AIM

To investigate optimal management strategies of MCRNLMP.

METHODS

We retrospectively collected and analyzed data from 1520 patients, comprising 1444 with renal cysts and 76 with MCRNLMP, who underwent renal cyst decompression, radical nephrectomy, or nephron-sparing surgery for renal cystic disease between January 2013 and December 2021 at our institution. Detection of MCRNLMP utilized the Bosniak classification for imaging and the 2016 World Health Organization criteria for clinical pathology.

RESULTS

Our meticulous exploration has revealed compelling findings on the occurrence of MCRNLMP. Precisely, it comprises 1.48% of all cases involving simple renal cysts, 5.26% of those with complex renal cysts, and a noteworthy 12.11% of renal tumors coexisting with renal cysts, indicating a statistically significant difference (P = 0.001). Moreover, MCRNLMP constituted a significant 22.37% of the patient population whose cysts demonstrated a rapid growth rate of ≥ 2.0 cm/year, whereas it only represented 0.66% among those with a growth rate below 2.0 cm/year. Of the 76 MCRNLMP cases studied, none of the nine patients who underwent subsequent nephron-sparing surgery or radical nephrectomy following renal cyst decompression experienced recurrence or metastasis. In the remaining 67 patients, who were actively monitored over a 3-year postoperative period, only one showed suspicious recurrence on CT scans.

CONCLUSION

MCRNLMP can be tentatively identified and categorized into three types based on CT scanning and growth rate indicators. In treating MCRNLMP, partial nephrectomy is preferred, while radical nephrectomy should be minimized. After surgery, active monitoring is advisable to prevent unnecessary nephrectomy.

Ultrasonographic examination of masticatory muscles in patients with TMJ arthralgia and headache attributed to temporomandibular disorders

This study used ultrasonography to compare the thickness and cross-sectional area of the masticatory muscles in patients with temporomandibular joint arthralgia and investigated the differences according to sex and the co-occurrence of headache attributed to temporomandibular disorders (HATMD). The observational study comprised 100 consecutive patients with TMJ arthralgia (71 females and 29 males; mean age, 40.01 ± 17.67 years) divided into two groups: Group 1, including 86 patients with arthralgia alone (60 females; 41.15 ± 17.65 years); and Group 2, including 14 patients with concurrent arthralgia and HATMD (11 females; 33.00 ± 16.72 years). The diagnosis of TMJ arthralgia was based on the diagnostic criteria for temporomandibular disorders. The parameters of the masticatory muscles examined by ultrasonography were subjected to statistical analysis. The pain area (2.23 ± 1.75 vs. 5.79 ± 2.39, p-value = 0.002) and visual analog scale (VAS) score (3.41 ± 1.82 vs. 5.57 ± 12.14, p-value = 0.002) were significantly higher in Group 2 than in Group 1. Muscle thickness (12.58 ± 4.24 mm) and cross-sectional area (4.46 ± 2.57 cm2) were larger in the masseter muscle than in the other three masticatory muscles (p-value < 0.001). When examining sex-based differences, the thickness and area of the masseter and lower temporalis muscles were significantly larger in males (all p-value < 0.05). The area of the masseter muscle (4.67 ± 2.69 vs. 3.18 ± 0.92, p-value = 0.004) and lower temporalis muscle (3.76 ± 0.95 vs. 3.21 ± 1.02, p-value = 0.049) was significantly smaller in Group 2 than in Group 1. An increase in VAS was significantly negatively correlated with the thickness of the masseter (r =  - 0.268) and lower temporalis (r =  - 0.215), and the cross-sectional area of the masseter (r =  - 0.329) and lower temporalis (r =  - 0.293). The masseter and lower temporalis muscles were significantly thinner in females than in males, and their volumes were smaller in patients with TMJ arthralgia and HATMD than in those with TMJ arthralgia alone. HATMD and decreased masseter and lower temporalis muscle volume were associated with increased pain intensity.

Comparison of ultrasonography-based masticatory muscle thickness between temporomandibular disorders bruxers and temporomandibular disorders non-bruxers

To compare masticatory muscle thickness in patients with temporomandibular disorders (TMDs) during rest and clenching, and by body position, using ultrasonography. This prospective study included 96 patients with TMD (67 females, 29 males; mean age: 40.41 ± 17.88 years): group 1, comprising 66 patients with TMD without bruxism (TMD_nonbruxer), and group 2, comprising 30 patients with concurrent TMD and bruxism (TMD_bruxer). In patients with TMD, bruxism was correlated with the presence of tinnitus, muscle stiffness, sleep problems, psychological stress, and restricted mouth opening. The masseter muscle significantly thickened during clenching (11.16 ± 3.03 mm vs 14.04 ± 3.47 mm, p < 0.001), whereas the temporalis muscle showed no significant increase in thickness from resting to clenching in an upright position (7.91 ± 1.98 vs 8.39 ± 2.08, p = 0.103). Similarly, during clenching in the supine position, the masseter muscle was significantly thicker compared with rest (11.24 ± 2.42 vs 13.49 ± 3.09, p < 0.001), but no significant difference was observed in temporal muscle thickness (8.21 ± 2.16 vs 8.43 ± 1.94, p = 0.464). In comparison between two groups, the average thickness of the masseter muscle was greater among TMD_bruxers than among TMD_nonbruxers in both the upright and supine positions (all p < 0.05). In the generalized lineal model, female sex (B = - 1.018, 95% confidence interval [CI] - 1.855 to - 0.181, p = 0.017) and bruxism (B = 0.868, 95% CI 0.567 to 1.169, p = 0.048) significantly predicted changes in masseter muscle thickness. Female sex (B = - 0.201, 95% CI - 0.299 to - 0.103, p = 0.011), increased age (B = - 0.003, 95% CI - 0.005 to 0.000, p = 0.038), and muscle stiffness (B = - 1.373, 95% CI - 2.369 to - 0.376, p = 0.007) were linked to decreased temporal muscle thickness. Comparing TMD nonbruxer and bruxer muscle thicknesses in upright and supine positions revealed significant increased thickness in the masseter muscle during clenching but not in the temporalis muscle. Masseter muscle thickness varied significantly by sex, body position, and resting/clenching, notably influenced by bruxism. These findings emphasize the relevance of these factors in clinical examinations of patients with TMD.

Quantitative and qualitative evaluation of the masseter muscle by ultrasonography and correlation with whole body health status

[Purpose] Ultrasonography can be used to non-invasively analyze any cross-section of the human body and to measure tissue elasticity, thickness, and brightness. This study was performed to examine the quantitative and qualitative changes in the masseter muscle at rest and at maximal occlusion, and to evaluate the relationship between these changes and the general health of the individual. [Participants and Methods] The study cohort comprised 30 healthy adults. Correlations between basic participant information (sex, age, height, body weight, body mass index, body fat, maximum bite force, handgrip strength, and tongue pressure) and masseter muscle ultrasonographic data were examined. [Results] Masseter muscle thickness was significantly greater in males than in females. Body weight and body mass index correlated positively with masseter muscle thickness. Body mass index and body fat percentage correlated positively with masseter muscle brightness. Tongue pressure correlated positively with handgrip strength. [Conclusion] Our analyses of muscle thickness and brightness suggest that ultrasonography may be useful in evaluating masseter muscle quantity and quality, and that the condition of the masseter muscle may correlate with the overall health status of the individual.

Impact of obesity on the structures and functions of the stomatognathic system: A morphofunctional approach

OBJECTIVE

The prevalence of obesity is increasing significantly worldwide, raising great concern among health professionals. This observational study evaluated the electromyographic activity and thickness of the masseter and temporalis muscles, in addition to the maximum molar bite force, in obese and eutrophic subjects.

METHODS

Sixty subjects were divided into three groups: I (7-12 years), II (13-20 years), III (21-40 years) and sex: with 10 men and 10 women for each group. Electromyographic recordings of the masticatory muscles were obtained during mandibular tasks. The masticatory muscles thicknesses were obtained at rest and during dental clenching. The maximum molar bite forces were measured on the right and left sides. The difference in outcome measures between the groups and sex was analyzed using Mann-Whitney U test (p < 0.05) and analysis of covariance (ANCOVA).

RESULTS

Electromyographic activity in the masseter and temporal muscles consistently displayed lower levels in obese subjects of both sexes across all three age groups during mandibular tasks. Additionally, greater thickness of the masticatory muscles was observed in obese subjects of both sexes across all three age groups. Obese women in Group II displayed higher values of molar bite force, both on the right and left sides, compared to eutrophic women. On the other hand, women in Group III exhibited higher values of molar bite force on the right side in comparison to eutrophic women.

CONCLUSIONS

This study underscores the potential impact of obesity on the morphofunctional aspects of the stomatognathic system in subjects aged 7 to 40 years.

Determination of masseter and temporal muscle thickness by ultrasound and muscle hardness by shear wave elastography in healthy adults as reference values

OBJECTIVES

The purpose of this study is to prospectively investigate the reference values of masseter and temporal muscle thicknesses by ultrasonography and muscle hardness values by shear wave elastography in healthy adults.

METHODS

The sample of the study consisted of a total of 160 healthy individuals aged between 18 and 59, including 80 women and 80 men. By examining the right and left sides of each participant, thickness and hardness values were obtained for 320 masseter muscles and 320 temporal muscles in total.

RESULTS

The mean masseter muscle thickness was found to be 1.09 cm at rest and 1.40 cm in contraction. The mean temporal muscle thickness was found to be 0.88 cm at rest and 0.98 cm in contraction. The thickness values of the masseter and temporal muscles were significantly greater in the male participants than in the female participants (P < .001). While there were significant differences between the right and left masseter muscle thickness values at rest and in contraction, the values of the temporal muscles did not show a significant difference between the sides. While the resting hardness (rSWE) of the masseter muscle was transversally 6.91 kPa and longitudinally 8.49 kPa, these values in contraction (cSWE) were found, respectively, 31.40 and 35.65 kPa. The median temporal muscle hardness values were 8.84 kPa at rest and 20.43 kPa in contraction. Masseter and temporal muscle hardness values at rest and in contraction were significantly higher among the male participants compared to the female participants (P < .001).

CONCLUSION

In this study, reference values for the thickness and hardness of the masseter and temporal muscles are reported. Knowing these values will make it easier to assess pain in the masseter and temporal muscles and determine the diagnosis and prognosis of masticatory muscle pathologies by allowing the morphological and functional assessments of these muscles, and it will identify ranges for reference parameters.

Dynamic Quantitative Imaging of the Masseter Muscles in Bruxism Patients with Myofascial Pain: Could It Be an Objective Biomarker?

We aimed to investigate whether the collaboration of shear wave elastosonography (SWE) and B-mode ultrasonography (US) could be offered as diagnostic tools to assess the presence, severity, and progress of bruxism, as well as a biomarker for the effectiveness of treatment in daily clinical practice. The study was designed as a quantitative evaluation of the masseter muscles (MMs) of the clinically diagnosed bruxism patients suffering from myofascial pain and MMs of the healthy individuals. Clinical examinations were made according to the diagnostic criteria for temporomandibular disorders (DC/TMD), and pain was assessed using a visual analog scale (VAS). Painful MMs with VAS scores ≥ 4 were assigned to Group A, and healthy MMs were assigned to Group B. Also, the MMs of the painful bruxers were analyzed based on wearing occlusal splints. Group A was divided into two subgroups as splint users (Group AI) and non-users (Group AII). All the participants were scanned with dynamic US and SWE to quantify the size and stiffness of the MMs. Measurements of each muscle pair while the jaw is in a resting position (relaxation) and clenching position (contraction) were recorded. The significant differences in stiffness and thickness became visible in the relaxation state. Bruxism patients with myofascial pain had significantly harder and thinner MMs than healthy individuals. During the relaxation, the mean thickness and elasticity values were 9.17 ± 0.40 mm and 39.13 ± 4.52 kPa for Group A and 10.38 ± 0.27 and 27.73 ± 1.92 for Group B, respectively. Also, stiffer MMs were measured in Group AII (38.16 ± 3.61 kPa) than in Group AI (26.91 ± 2.13 kPa). In conclusion, the combination of SWE and US using a dynamic examination technique has the potential to be a valuable tool for the management of bruxism patients suffering from myofascial pain.

Assessing thickness and stiffness of superficial/deep masticatory muscles in orofacial pain: an ultrasound and shear wave elastography study

INTRODUCTION

Sonoelastography has been increasingly used for non-invasive evaluation of the mechanical features of human tissues. The interplay between orofacial pain and regional muscle activity appears clinically paramount, although only few imaging studies have investigated this association. Using shear wave sonoelastography (SWS), this study ascertained whether orofacial pain induced alterations in the stiffness of superficial and deep masticatory muscles.

METHODS

All participants were systematically evaluated for oral/facial-related conditions, including the area and intensity of pain. SWS was applied to measure the stiffness of the bilateral masseter, temporalis, and lateral pterygoid muscles. The association between orofacial pain and muscle stiffness/thickness was investigated using a generalized estimating equation for adjusting the influence of age, sex, laterality, and body mass index on muscle thickness/stiffness.

RESULTS

A total of 98 participants were included in the present study: 48 asymptomatic controls, 13 patients with unilateral pain, and 37 patients with bilateral orofacial pain. The reliability, quantified by the intraclass correlation coefficient for muscle stiffness measurement, ranged from 0.745 to 0.893. Orofacial pain at the individual muscle level was significantly associated with masseter muscle stiffness. A trend of increased stiffness (p = 0.06) was also observed in relation to the painful side of the temporalis muscle. No significant correlation was identified between the numeric rating scales for pain and stiffness measurements.

CONCLUSIONS

SWS provides reliable stiffness measurements for the superficial and deep masticatory muscles. The ipsilateral masseter and temporalis muscles might be stiffer than those on the side without orofacial pain. Future studies using the present sonoelasotography protocol can be designed to investigate the stiffness changes in the target muscles after interventions.

Ultrasonographic reliability and repeatability of simultaneous bilateral assessment of diaphragm muscle thickness during normal breathing

Background

The diaphragm is considered the main muscle involved in breathing and also linked to trunk stabilization functions. Up to date, rehabilitative ultrasound imaging (RUSI) has been the most used technique to evaluate unilaterally the transcostal diaphragm thickness. Nevertheless, the inspiratory activity of both hemi-diaphragms is bilaterally performed at the same time, and its simultaneous evaluation with a thoracic orthosis could improve its assessment as well as its re-education with visual biofeedback of both hemi-diaphragms at the same time. The purpose was to evaluate the reliability and repeatability of simultaneous thickness measurements of both hemi-diaphragms bilaterally during normal breathing using a thoracic orthosis that allowed bilateral fixation of both right and left ultrasound probes.

Methods

The study was conducted in 46 healthy subjects, whose diaphragm thickness was measured bilaterally and simultaneously in the anterior axillary line during relaxed breathing with a designed thoracic orthosis and 2 ultrasound tools. Intra-examiner (same examiner), inter-examiner (2 examiners), intra-session (1 hour) and inter-session (1 week) reliability and repeatability between each pair of measurements of diaphragm muscle thickness were analyzed during normal breathing.

Results

Reliability and repeatability for intra-session evaluations using the thoracic orthosis were excellent to evaluate simultaneous thickness of both hemi-diaphragms by bilateral probes fixation (intraclass correlation coefficient =0.919-0.997; standard error of measurement =0.002-0.007 cm; minimum detectable change =0.006-0.020 cm), without systematic errors (P>0.05) between each pair of measurements. Nevertheless, inter-session evaluations varied from good to excellent using the bilateral probes fixation (intraclass correlation coefficient =0.614-0.984; standard error of measurement =0.006-0.028 cm; minimum detectable change =0.017-0.079 cm), although some systematic errors were presented (P<0.05).

Conclusions

Good to excellent reliability and repeatability was shown for simultaneous thickness measurements of both hemi-diaphragms bilaterally during normal breathing. Despite systematic errors were presented for some inter-examiner assessments, the use of the thoracic orthosis that allowed bilateral fixation of ultrasound probes could be recommended for simultaneous hemi-diaphragms breathing re-education by visual biofeedback.

Ultrasonography for Eating and Swallowing Assessment: A Narrative Review of Integrated Insights for Noninvasive Clinical Practice

Dysphagia is a syndrome of abnormal eating function resulting from a variety of causative diseases, and is associated with malnutrition. To date, the swallowing function has been difficult to examine without the use of invasive and expensive methods, such as the videofluorographic swallowing study or fiberoptic endoscopic evaluation of swallowing. In recent years, progress has been made in the clinical application of ultrasound equipment for the evaluation of body compositions near the body surface, including the assessment of nutritional status. Ultrasound examination is a noninvasive procedure and relatively inexpensive, and the equipment required is highly portable thanks to innovations such as wireless probes and tablet monitoring devices. The process of using ultrasound to visualize the geniohyoid muscle, digastric muscle, mylohyoid muscle, hyoid bone, tongue, masseter muscle, genioglossus muscle, orbicularis oris muscle, temporalis muscle, pharynx, esophagus, and larynx, and the methods used for evaluating these structures, are provided in this study in detail. This study also aims to propose a protocol for the assessment of swallowing-related muscles that can be applied in real-world clinical practice for the diagnosis of sarcopenic dysphagia, which can occur in elderly patients with sarcopenia, and has received much attention in recent years.

The Evaluation of the Relationship between Changes in Masseter Muscle Thickness and Tooth Clenching Habits of Bruxism Patients Treated with Botulinum Toxin A

Background

Bruxism is defined as recurrent masticatory muscle activity. Although there is not an agreed treatment method for bruxism, the application of botulinum toxin A (BT-A) has become a reliable lately. This study aimed to evaluate the correlation between the changes in masseter muscle thickness and clenching habits in bruxism patients treated with BT-A.

Methods

Twenty-five patients, 23 females and 2 males, diagnosed with possible sleep bruxism were included in the study. The Fonseca Anamnestic Index was applied to the patients to determine their clenching habits and depression levels both before the treatment, and 6 months after it. The masseter muscle thickness was measured using ultrasonography before the treatment and 3 months and 6 months after the treatment. All the patients were injected with a total of 50 U of BT-A, 25 U to each masseter.

Results

A statistically significant decrease in masseter muscle thickness was observed in the ultrasonography 3 and 6 months after the BT-A treatment. There was a statistically significant decrease in the Fonseca scores, in which the teeth clenching habits of the patients were evaluated 6 months after the treatment. Although there was a decrease in the depression levels of the patients 6 months after the treatment, this difference was not statistically significant.

Conclusion

When the results of this study were evaluated, it was seen that the BT-A injections are an effective, safe, and side effect-free method in the treatment of bruxism and masseter hypertrophy.

Diagnostic Utility of Temporal Muscle Thickness as a Monitoring Tool for Muscle Wasting in Neurocritical Care

Temporalis muscle (TM) atrophy has emerged as a potential biomarker for muscle wasting. However, its diagnostic utility as a monitoring tool in intensive care remains uncertain. Hence, the objective of this study was to evaluate the diagnostic value of sequential ultrasound- and computed tomography (CT)-based measurements of TM thickness (TMT). With a prospective observational design, we included 40 patients without preexisting sarcopenia admitted to a neurointensive care unit. TMT measurements, performed upon admission and serially every 3−4 days, were correlated with rectus femoris muscle thickness (RFT) ultrasound measurements. Interrater reliability was assessed by Bland Altmann plots and intraclass correlation coefficient (ICC). Analysis of variance was performed in subgroups to evaluate differences in the standard error of measurement (SEM). RFT decline was paralleled by ultrasound- as well as CT-based TMT measurements (TMT to RFT: r = 0.746, p < 0.001; CT-based TMT to ultrasound-based RFT: r = 0.609, p < 0.001). ICC was 0.80 [95% CI 0.74, 0.84] for ultrasound-based assessment and 0.90 [95% CI 0.88, 0.92] for CT-based TMT measurements. Analysis of variance for BMI, Heckmatt score, fluid balance, and agitation showed no evidence of measurement errors in these subgroups. This study demonstrates the clinical feasibility and utility of ultrasound- and CT-based TMT measurements for the assessment of muscle wasting.

Ultrasonographic evaluation of the masseter muscle in temporomandibular disorders patients with myofascial pain: A case-control observational study

OBJECTIVE

To investigate ultrasonographic changes of masseter muscle (MM) in patients with myofascial pain disorder (MPD) and possible correlations with clinical features.

METHODS

The study included 20 MPD patients and 20 healthy volunteers. Masseter muscle thickness (MMT) and the echogenic pattern were ultrasonographically evaluated. The maximum interincisal opening (MIO), duration of symptoms, and pain level were evaluated for correlations with MMT.

RESULTS

At relaxation, MMT was greater in the test group (p < 0.05); however, the percentage of increase in MMT from relaxation to contraction was greater in controls (p < 0.05). In MPD patients, the echogenic pattern differed significantly from controls. In MPD patients, a strong positive correlation was found between MMT and pain level, while a moderate negative correlation was found between MMT and both the duration of symptoms and MIO.

CONCLUSION

Ultrasound is an adjunctive method for complementing the assessment of the MM condition in MPD patients.

Masticatory Muscle Thickness and Activity Correlates to Eyeball Length, Intraocular Pressure, Retinal and Choroidal Thickness in Healthy Women versus Women with Myopia

This study aims to examine the correlations between masticatory and neck muscle thickness and activity versus eyeball length, retinal thickness, choroidal thickness, and intraocular pressure in healthy women versus women with myopia. The study group consisted of 21 women aged 24 years and a control group of 19 women (mean age 23 years). For bioelectrical activity analysis within the temporalis anterior, the superficial part of the masseter muscle, the middle part of the sternocleidomastoid muscle, and the anterior belly of the digastric muscle, an eight-channel BioEMG III electromyograph were used. An M-Turbo ultrasound machine was used to analyze masticatory and neck muscle thickness. The eyeball length was examined by IOL Master 500; choroidal and retinal thickness by Optovue Angiovue; and intraocular pressure by Tono-Pen XL. Refractive errors are related to differences in muscle thickness and electromyographic activity. Bioelectrical activity within the temporalis anterior seems to be associated with ocular length, retinal thickness, and choroidal thickness in women with myopia.

Quantitative Analysis of Dynamic Subacromial Ultrasonography: Reliability and Influencing Factors

Objective: Current imaging methods used to examine patients with subacromial impingement syndrome (SIS) are limited by their semi-quantitative nature and their capability of capturing dynamic movements. This study aimed to develop a quantitative analytic model to assess subacromial motions using dynamic ultrasound and to examine their reliability and potential influencing factors.

Method: We included 48 healthy volunteers and examined their subacromial motions with dynamic ultrasound imaging. The parameters were the minimal vertical acromiohumeral distance, rotation radius, and degrees of the humeral head. The generalized estimating equation (GEE) was used to investigate the impact of different shoulder laterality, postures, and motion phases on the outcome.

Result: Using the data of the minimal vertical acromiohumeral distance, the intra-rater and inter-rater reliabilities (intra-class correlation coefficient) were determined as 0.94 and 0.88, respectively. In the GEE analysis, a decrease in the minimal vertical acromiohumeral distance was associated with the abduction phase and full-can posture, with a beta coefficient of −0.02 cm [95% confidence interval (CI), −0.03 to −0.01] and −0.07 cm (95% CI, −0.11 to −0.02), respectively. The abduction phase led to a decrease in the radius of humeral rotation and an increase in the angle of humeral rotation, with a beta coefficient of −1.28 cm (95% CI, −2.16 to −0.40) and 6.60° (95% CI, 3.54–9.67), respectively. A significant negative correlation was observed between the rotation angle and radius of the humeral head and between the rotation angle and the minimal vertical acromiohumeral distance.

Conclusion: Quantitative analysis of dynamic ultrasound imaging enables the delineation of subacromial motion with good reliability. The vertical acromiohumeral distance is the lowest in the abduction phase and full-can posture, and the rotation angle of the humeral head has the potential to serve as a new parameter for the evaluation of SIS.

Is Real-Time Ultrasound Reliably Able to Determine Kager's Fat Pad Motion during Walking?

The distal calcaneal wedge of the Kager's fat pad (KFP) has the mechanical role of lubricating the region between the Achilles tendon and calcaneus during ankle movements. The purpose of this study was to determine the reliability of real-time ultrasound (RTUS) in visualizing the motion of the KFP during walking in adults. Recordings obtained using RTUS (13-MHz linear array transducer, IOE 323, MyLab 70, Esoate, Genoa, Italy) of the Achilles enthesis region (N = 52) of 47 participants (ranging from 21-79 years in age) while walking on a motorised treadmill at their preferred speed were analysed by three blinded assessors. Motion of the KFP was rated on a 4-point Likert scale (normal to absent). There was good agreement (κ [95% confidence interval] = 0.646 [0.643-0.649]) among the three examiners, with very good agreement (0.823 [0.818-0.828]) when classifying the motion as normal. There was a poor correlation between the motion of the calcaneal wedge and participants' age (0.23-0.32). RTUS provides an adjunct to routine clinical examination to determine if there is normal motion of the calcaneal wedge during walking. This may be of benefit in patients with posterior heel pain for whom abnormal KFP motion is implicated.

Ultrasound Imaging of the Facial Muscles and Relevance with Botulinum Toxin Injections: A Pictorial Essay and Narrative Review

High-resolution ultrasound is preferred as the first-line imaging modality for evaluation of superficial soft tissues, such as the facial muscles. In contrast to magnetic resonance imaging and computed tomography, which require specifically designated planes (axial, coronal and sagittal) for imaging, the ultrasound transducer can be navigated based on the alignment of facial muscles. Botulinum toxin injections are widely used in facial cosmetic procedures in recent times. Ultrasonography is recognized as a useful tool for pre-procedure localization of target muscles. In this pictorial review, we discuss the detailed sonoanatomy of facial muscles and their clinical relevance, particularly with regard to botulinum toxin injections. Furthermore, we have summarized the findings of clinical studies that report ultrasonographic imaging of facial muscles.

Diagnostic value of calcaneal quantitative ultrasound in the evaluation of osteoporosis in middle-aged and elderly patients

To study the correlation between calcaneal quantitative ultrasound (QUS) and dual-energy X-ray absorptiometry (DXA), and analyze the diagnostic value of calcaneal QUS in the evaluation of middle-aged and elderly osteoporosis.We assessed bone mineral density (BMD) at the femoral neck and intertrochanteric of left hip and lumbar spine (L1-L4) sites with DXA and QUS parameters of the right and left calcanei in a cohort of 82 patients over the age of 50 years. Using DXA parameters as the gold standard for the diagnosis of osteoporosis, the correlation coefficient between BMD and QUS parameters was calculated. Receiver operating characteristic curve was generated and areas under the curves were evaluated. Cut-off values for QUS were defined.In men, there was a moderate correlation between calcaneal QUS and proximal femoral BMD (P < .05), but no significant correlation between calcaneal QUS and lumbar BMD (P > .05). In women, calcaneal QUS were moderately correlated with lumbar spine and proximal femoral BMD (P < .05). Using DXA as the gold standard, the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of calcaneal QUS in the diagnosis of osteoporosis were 90.2%, 89.2%, 100%, 100%, and 50.0%, respectively. According to the receiver operating characteristic curve, when the QUS T-score of calcaneum was -1.8, the area under the curve was 0.888, the sensitivity was 73.21%, and the specificity was 92.31% (P < .05). When the QUS T-score of calcaneum was -2.35, the sensitivity was 37.2% and the specificity was 100%.Calcaneal QUS can be used to predict proximal femoral BMD in middle-aged and elderly people, as well as lumbar BMD in women. As a screening method for osteoporosis, calcaneal QUS has good specificity, so it can be recommended to use it as a pre-screening tool to reduce the number of DXA screening. When the QUS T-score of calcaneum is -1.8, it has the greatest diagnostic efficiency for osteoporosis; when the QUS T-score of calcaneum is ≤-2.35, it can be diagnosed as osteoporosis.

Comparison of core muscle strengthening exercise and stretching exercise in middle-aged women with fibromyalgia: A randomized, single-blind, controlled study

BACKGROUND

Many studies have reported that exercise is effective for fibromyalgia and various types of exercise are recommended. However, most of exercises lack evidence for fibromyalgia symptoms. We aimed to examine the effect of core muscle strengthening exercise compared to general stretching exercise in fibromyalgia patients.

METHODS

Forty fibromyalgia patients were enrolled. They were provided exercise program twice a week for 4 weeks: core muscle strengthening exercise and general stretching exercise.Outcome measures were Visual Analogue Scale, Borg Scale, fibromyalgia impact questionnaire (FIQ), widespread pain index, Symptom Severity Scale (SS), and balance scale and measured before and after exercise program. Balance function was assessed by checking the distance of sway on soft pad with eyes open (EO) and with eyes closed (EC).

RESULTS

After program, FIQ, SS, EO, and eyes closed showed statistically significant differences in the strengthening group while Visual Analogue Scale, Borg scale, FIQ, widespread pain index, SS showed statistically significant differences in stretching group. And EO showed statistically significant differences in the intergroup analysis.

CONCLUSIONS

Both exercise could improve symptoms of fibromyalgia but showed no significantly better efficiency with intergroup analysis. Only some balance function was improved with core muscle strengthening exercise with significant difference. Our study presents preliminary results regarding the comparison between both exercises for fibromyalgia through a randomized controlled trial.

Ultrasound Imaging of Head/Neck Muscles and Their Fasciae: An Observational Study

Background: Masticatory muscle thickness provides objective measurements of the temporomandibular motor function, which may change in patients with oral myofascial pain. Moreover, they are considered as being part of the craniocervical unit by a crucial relationship with cervical muscles and their fasciae. In this study, we aimed to assess by ultrasound (US) imaging the fasciae of the masseter, temporal, and sternocleidomastoid muscles to understand their mean thickness and eventual variation in relationship with the muscles, sides, and sex.

Methods: We studied 16 healthy volunteers without temporomandibular joint dysfunction. Concerning each subject were evaluated the range of motion of the temporomandibular joint and of the neck, the thickness of muscles and their fasciae of both sides, and the delta of muscle thickness.

Results: All the motor evaluations of the subjects showed normal ranges. The US results showed that the fasciae have a mean thickness of 0.50 ± 0.1 mm, which did not change during muscle contraction. The evaluated muscles presented a symmetry between right and left (p > 0.05), even if the delta of muscle (US) thickness had a huge range between different subjects, for example in the masseter muscle from 0.7 to 4.2 mm.

Conclusions: Ultrasound imaging is a suitable and reliable tool to study the muscles and fasciae of the head and neck region, permitting also the evaluation of the ability of the muscles to contract. Finally, identifying functional asymmetry that could become symptomatic, US imaging could allow an early rehabilitation treatment.

Undescribed Vascular Signatures: A Contraindication to Ultrasound-guided Parasagittal Infraclavicular Block! A Retrospective Observational Study

Background:

The ultrasound-infraclavicular block (US-ICB) is a popular and efficient block for below-elbow surgeries. However, the vascular anatomy of infraclavicular area close to the brachial plexus has remained unresearched. We aimed to explore the presence of aberrant vasculature in the infraclavicular area that could pose a contraindication to US-ICB.

Methods:

In this retrospective observational study, we reviewed the US images of patients undergoing below-elbow surgery under US-ICB. Before performing the block, a scout scan of parasagittal infraclavicular areas was performed and the scan images were saved. The primary objective was to find the prevalence of aberrant vasculature due to which the US–ICB was abandoned. The secondary objective was to understand the pattern and position of the aberrant vessels.

Results:

Out of 912 patients, 793 patients underwent surgery under US–ICB and in 119 patients (13.05%), the USG-ICB was abandoned due to aberrant vasculature close to the brachial cords and intended position of the needle tip. The anomalous vessels were identified in the lower inner, lower outer, and upper outer quadrants around the axillary artery (AA). Some of these vascular structures also had classical patterns which we described as “satellites,” “clamping,” or “hugging” of the AA.

Conclusion:

Anomalous vascular structures in the infraclavicular area were seen in 13.05% of patients planned for US–ICB. We, therefore, recommend, that a thorough scout US scan should be mandatorily performed ICB and in the presence of aberrant vascular structures, an alternative approach to brachial plexus block may be adopted.

Retrospective study of the clinical effect of incobotulinumtoxinA for the management of myofascial pain syndrome in refractory patients

The aim was to evaluate the effectiveness and safety of IncobotulinumtoxinA (IncoA) for the management of myofascial pain syndrome (MPS) in refractory patients. This single-center, observational, retrospective study includes 37 patients. The pain reduction was 4.7 points (95%CI: 5.6 to -3.8) from baseline to one-month post-injection (using a 10-point visual analogue scale). Only 18.9% experienced mild adverse events. In conclusion, IncoA is an effective and safe alternative for the treatment of MPS in refractory patients.

Ultrasound-Guided Measurement of Piriformis Muscle Thickness to Diagnose Piriformis Syndrome

Background: Piriformis syndrome (PS) is a neuromuscular condition caused by the entrapment of the sciatic nerve at the level of the piriformis muscle (PM). Diagnosing PS remains challenging despite recent invasive and non-invasive diagnostic methods. Response to invasive nerve block is still one of the most reliable diagnostic modalities because there is no gold standard test for PS. As early diagnosis may prevent delayed diagnosis that results in chronic somatic dysfunction and muscle weakness, a screening test with high sensitivity could guide clinicians in performing the next appropriate step in diagnosing PS.

Aim: The purpose of this study is to determine the sensitivity, specificity, and best cut-off point of ultrasound-guided PM thickness in PS.

Method: This case-control study was conducted in a general hospital in Tangerang during a 3-month period. We recruited 58 patients clinically diagnosed with PS and 58 healthy patients (without a history of hip and buttock pain) during their visits to the outpatient clinic. All patients underwent ultrasound assessment to measure bilateral PM thickness. Sex, age, body mass index, history of micro-/macro-trauma, and prolonged sitting duration were recorded. Statistical analyses were performed using the Statistical Package for the Social Sciences version 25.

Result: The PS and control groups predominantly comprised female subjects, with mean ages of 51.79 ± 14.10 and 50.09 ± 13.26 years on PS and healthy subjects, respectively. The mean ultrasound-guided PM thickness was higher in PS subjects compared to healthy subjects with mean thicknesses of 1.16 ± 0.13 and 0.85 ± 0.11 cm, respectively (p < 0.05). The area under the receiver operating characteristic curve of the PM was 0.970 (95% confidence interval 0.943–0.998, p < 0.05). The best cut-off point defined by Youden's J index was 0.9950 cm for all PS subjects.

Conclusion: We propose 0.9950 cm as the cut-off point for diagnosing PS by ultrasound, which has the sensitivity and specificity of 94.8 and 87.9%, respectively.

Treatment of tibial plateau fractures involving the posterolateral column using the extended anterolateral approach

To summarize the surgical technique and clinical effects of the extended anterolateral approach for the treatment of Schatzker type II and Schatzker type V/VI involving the posterolateral column tibial plateau.From January 2015 through December 2018, 28 patients with tibial plateau fractures involving the posterolateral column were included in the study. Among them, 16 patients were Schatzker type II treated using an extended anterolateral approach with lateral tibial locking compression plate fixation. Twelve patients were Schatzker type V or VI treated using an extended anterolateral combined with a medial approach using lateral tibial locking compression plate plus medial locking compression plate fixation. All cases were followed up for 15 to 31 months, with an average follow-up of 22.5 ± 3.7 months. During the follow-up, the tibial plateau angle (TPA), lateral posterior angle (PA) and Rasmussen radiological criteria were used to evaluate the effect of fracture reduction and fixation; the Hospital for Special Knee Surgery score and the range of motion were used to evaluate knee function. Additionally, the Lachman and knee Valgus (Varus) stress tests were used to evaluate anteroposterior and lateral stability of the knee.All fractures healed. At the 12-month follow-up, the Schatzker type II group revealed a mean TPA of 86.38 ± 3.92°, a mean PA of 7.43 ± 2.68°, and a mean Rasmussen radiological score of 16.00 ± 2.06 points. The Schatzker type V/VI group showed a mean TPA of 84.91 ± 3.51°, a mean PA of 9.68 ± 4.01°, and a mean Rasmussen radiological score of 15.33 ± 2.99 points. During the 1-year follow-up, when the postoperative PA was re-measured, the TPA and Rasmussen score of the 2 groups did not change significantly (P > .05). At the last follow-up, the Schatzker type II group showed a knee flexion angle of 110° to 135° and a mean HHS score of 88.37 ± 10.01 points. The Schatzker type V/VI group revealed a knee flexion angle of 100° to 130° and a mean HHS score of 82.17 ± 10.76 points. Additionally, up to the last follow-up, the Lachman and knee Valgus (Varus) stress test results of the 2 groups were negative. No complications were found.The extended anterolateral approach is a good choice to treat tibial plateau fractures involving the posterolateral column.

Determination of Reference Values of the Masseter Muscle Stiffness in Healthy Adults Using Shear Wave Elastography

Shear wave elastography (SWE) is an objective and reliable method for the assessment of muscles and internal organs. Every organ exhibits its own stiffness characteristics and hence requires individual reference values. We aimed to determine the reference values of stiffness of the masseter muscle in healthy adult individuals using SWE. We analyzed the data of 140 participants (74 men, 66 women) with a median age of 50 years. The overall mean elasticity was 10.67 ± 1.77 kPa. The average values were lower by 2.25 kPa (9.15%) in women compared to men (9.48 ± 1.47 kPa vs. 11.73 ± 1.27 kPa; p < 0.0001). The values of stiffness increased with age, with a correlation coefficient of about 0.35 and a p < 0.0001. Age was a significant influencing factor of masseter muscle stiffness. The left and right masseters had similar stiffness. We conclude that stiffness values are significantly lower in women than in men with a difference of 9%. Age significantly influences the stiffness of masseter muscle, and the values of stiffness increase significantly with age, particularly in men. However, further studies are required to determine the precise ranges of stiffness accounting for age and sex in healthy subjects and people with disorders and conditions of the masticatory system.

Value of shear wave elastography combined with the Toronto clinical scoring system in diagnosis of diabetic peripheral neuropathy

To evaluate the diagnostic values of shear wave elastography (SWE) alone and in combination with the Toronto clinical scoring system (TCSS) on diabetic peripheral neuropathy (DPN) in patients with type 2 diabetes mellitus (T2DM).The study included 41 DPN patients, 42 non-DPN patients, and 21 healthy volunteers. Conventional ultrasonography and SWE were performed on the 2 sides of the tibial nerves, and cross-sectional area (CSA) and nerve stiffness were measured. TCSS was applied to all patients. A receiver operating characteristic curve analysis was performed.The stiffness of the tibial nerve, as measured as mean, minimum or maximum elasticity, was significantly higher in patients in the DPN group than the other groups (P < .05). The tibial nerve of subjects in the non-DPN group was significantly stiffer compared to the control group (P < .05). There was no significant difference of the tibial nerve CSA among the 3 groups (P > .05). Mean elasticity of the tibial nerve with a cutoff of 71.3 kPa was the most sensitive (68.3%) and had a higher area under the curve (0.712; 0.602-0.806) among the 3 shear elasticity indices for diagnosing DPN when used alone. When combining SWE with TCSS in diagnosing DPN, the most effective parameter was the EMax, which yielded a sensitivity of 100.00% and a specificity of 95.24%.SWE is a better diagnostic tool for DPN than the conventional ultrasonic parameter CSA, and a higher diagnostic value is attained when combining SWE with TCSS.

Diagnostic Value of Ultrasound in Children with Discoid Lateral Meniscus Using Either an Intracavitary Convex Array Probe or a Linear Array Probe

This prospective study aimed to assess the usefulness of an intracavitary convex array probe (ICAP) in visualizing the lateral meniscus (LM) and improving the diagnostic utility of ultrasound (US) when diagnosing or screening for discoid lateral meniscus (DLM) in children. We included 105 knees (66 patients) that had symptomatic or asymptomatic DLM. We extracted and retrospectively reviewed data regarding patient demographics, medical records, magnetic resonance imaging (MRI), ultrasonographic features and arthroscopic findings. The inner edge of the LM visualized using an ICAP was significantly clearer than that visualized using a linear array probe, and the difference was significant (p < 0.01). The edges were better visualized in patients aged <8 y than in those aged >8 y, and the difference was significant (p < 0.001). The average widths of the LM body using an ICAP and MRI were 19.85 ± 3.63 and 24.46 ± 4.94 mm, respectively, and the wider the meniscal width, the greater was the deviation between the US and MRI measurements, which were positively correlated (r = 0.612, p < 0.001). With the use of MRI measurements and an ICAP, meniscal widths in poorly visualized LMs were greater than those in clearly visualized LMs, but this difference was not significant (p = 0.161). US scans using an ICAP and MRI were highly consistent in assessing the shape of the menisci (κ = 0.849, p < 0.001). US scan using an ICAP is a non-invasive, convenient and low-cost modality for diagnosing or screening for DLM in the pediatric population, especially in children aged <8 y.

Difference in Movement between Superficial and Deep Parts of the Infrapatellar Fat Pad during Knee Extension

(1): The superficial and deep parts of the infrapatellar fat pat (IFP) have different morphological and functional characteristics. Knee pain often occurs during movement, and it is important to clarify the movement of the IFP during knee joint movement. The purpose of this study is to clarify that the movement of the superficial and deep parts of the IFP are different during knee extension in vivo using ultrasonography (US). (2): US was performed on 15 knees of 15 healthy adults. The probe was placed longitudinally at the center of the patellar tendon and the IFP was imaged. Measurements were taken during active extension of the knee from 90 degrees to 10 degrees of knee flexion at a rate of 30 times/min. The captured US videos were analyzed using Flow particle image velocimetry (Flow PIV) fluid measurement software. The region-of-interest (ROI) was set at the superficial part and the deep part of the IFP, and the flow velocity was calculated for each. (3): The flow velocity of the deep part (1.37 ± 0.13 cm/s) of the IFP was significantly faster than that of the superficial part (0.80 ± 0.23 cm/s). (4): Our results show that the flow velocity of the IFP is different between the superficial and deep parts and that US may be a better assessment tool for the movement of the IFP.

Shear wave elastography of the scalene muscles in healthy adults: A preliminary study

The aim of the study is to evaluate the reliability of shear wave elastography to assess the anterior and middle scalene muscles in healthy adult subjects.The study included 60 scalene muscles in 15 healthy subjects. High-resolution ultrasound and shear wave elastography were used to evaluate the anterior scalene and the middle scalene muscles. Stiffness values were measured.The mean shear elastic modulus showed the following values, right anterior scalene muscle 18.83 ± 5.32 kPa, left anterior scalene muscle 21.71 ± 4.8 kPa, right middle scalene muscle 12.84 ± 5.2 kPa, left middle scalene muscle 19.76 ± 5.30 kPa. Positive correlation was noted between the left middle scalene muscle and body mass index (P = .004). No difference in elasticity was noted between the right and left anterior scalene muscles; however, significant difference was noted between the right and left middle scalene muscles (P = .002).The results obtained in our study could be a reference point for future research considering different scalene muscle pathologies.

Teaching ultrasound-guided peripheral venous catheter placement through immersive virtual reality: An explorative pilot study

INTRODUCTION

Immersive virtual reality (IVR)-based training is gaining ground as an educational tool in healthcare. When combined with well-established educational methods, IVR can potentially increase competency and autonomy in ultrasound (US)-guided peripheral venous cannulation.The aim of this study was to examine the impact of adding IVR training to a course in US-guided peripheral venous cannulation.

METHODS

Medical students (n = 19) from the University of Southern Denmark with no former standardized US education were recruited to voluntarily participate in a pilot study, designed as a randomized controlled trial. The primary outcome was the proportion of successful peripheral venous cannulations on a phantom. Secondary outcomes included the proportion of surface punctures on the phantom and procedure time. Participants received e-learning on the basic US before randomization to either IVR (n = 10) or no further training (n = 9). The additional IVR training comprised 10 virtual scenarios for US-guided peripheral venous catheter (PVC) placement. Students were subsequently evaluated in peripheral venous cannulation by a blinded assessor.

RESULTS

The proportion of successful peripheral venous cannulations was significantly higher in the IVR group (P ≤ .001). The proportions of successful cannulations were significantly higher in the IVR group compared to the control group for the 1st and 2nd PVC (P = .011, P = .023), but not for the 3rd PVC (P = .087). Similar results were found for the proportion of surface punctures (1st: P ≤ .001, 2nd: P = .001, and 3rd: P = .114). No significant differences in procedure times were found between the groups.

CONCLUSION

This pilot study showed that adding an IVR-based training simulation to an existing e-learning curriculum significantly increased the learning efficacy of US-guided PVC placement for medical students.

Peripheral neuropathy in systemic lupus erythematosus: what can neuromuscular ultrasonography (NMUS) tell us? A cross-sectional study

OBJECTIVE

To evaluate peripheral nerve involvement in patients with SLE with neuromuscular ultrasonography (NMUS) and understand its role in investigating SLE-related peripheral neuropathy.

METHODS

This is an observational cross-sectional study on patients with SLE and healthy controls. Five nerves in each patient were examined bilaterally with NMUS, and the cross-sectional area (CSA) of each nerve at certain sites was estimated. The mean CSA at each site, for each nerve, in each group was statistically analysed and compared between groups.

RESULTS

370 nerves were evaluated in 37 patients. By nerve conduction study (NCS), 36 patients had polyneuropathy (80.6% mixed type, 19.4% sensory). Significant mean CSA enlargement was present among the ulnar nerve at the Guyon's canal and mid-humerus (both p=0.001); tibial nerve at the distal leg and proximal to the tarsal tunnel (p=0.003 and p=0.001, respectively); and peroneal nerve at the popliteal fossa (p=0.042). The mean CSA showed high specificity compared with NCS.

CONCLUSION

Our study shows that CSA could be a complementary tool to NCS for studying peripheral neuropathy in SLE. Furthermore, NMUS provides data on the different pathophysiological aspects of nerve involvement in SLE. Future studies using more than one sonographic parameter in combination with NCS and nerve histopathology are recommended to further investigate SLE-related neuropathy.Trial registration number NCT04527172.

Pre-Operative Femoral Cartilage Ultrasound Characteristics Are Altered in People Who Report Symptoms at 1 year After Anterior Cruciate Ligament Reconstruction

We assessed whether pre-operative femoral cartilage thickness and echo intensity on ultrasound are different between individuals who are symptomatic (n = 6) and asymptomatic (n = 7) at 1 year after a primary unilateral anterior cruciate ligament (ACL) reconstruction (age, 23 ± 4 y; 31% women, 69% men; body mass index, 24.9 ± 3.7 kg/m²). A pre-operative, bilateral ultrasound assessment was used to quantify average thickness and echo intensity in the medial, middle and lateral femoral trochlear regions. An inter-limb ratio (ACL/contralateral limb) was calculated for average thickness and echo intensity. At 1 y after ACL reconstruction, we operationally defined the presence of symptoms as scoring ≤85% on at least two Knee Injury and Osteoarthritis Outcome Score subscales. Independent-sample t-tests and Cohen's d effect sizes were used to compare ultrasound pre-operative inter-limb ratios between participants with and without symptoms at 1 y after ACL reconstruction. For medial femoral cartilage, symptomatic participants had significantly greater average cartilage thickness inter-limb ratios (p = 0.01, d = -1.65) and significantly lower echo intensity inter-limb ratios (p = 0.01, d = 1.72) compared with asymptomatic participants. Middle and lateral femoral cartilage average thickness and echo intensity were not different between symptomatic and asymptomatic participants. These findings provide preliminary evidence that a clinically feasible ultrasound assessment of the femoral trochlear cartilage may be prognostic of self-reported symptoms at 1 y after ACL reconstruction.

Concurrent Validity and Reliability of Manual Versus Specific Device Transcostal Measurements for Breathing Diaphragm Thickness by Ultrasonography in Lumbopelvic Pain Athletes

The use of rehabilitative ultrasound imaging (RUSI) to evaluate diaphragm thickness during breathing in athletes who suffer from non-specific lumbopelvic pain presents some measurement errors. The purpose of this study was to evaluate intra- and inter-sessions, intra- and inter-rater reliabilities, and concurrent validity of diaphragm thickness measurements during breathing using transcostal RUSI with a novel thoracic orthotic device that was used to fix the US probe versus those measurements obtained using manual fixation. A total of 37 athletes with non-specific lumbopelvic pain were recruited. Intra- (same examiner) and inter-rater (two examiners) and intra- (same day) and inter-session (alternate days) reliabilities were analyzed. All measurements were obtained after manual probe fixation and after positioning the thoracic orthotic device to fix the US probe in order to correctly correlate both measurement methods. Both left and right hemi-diaphragm thickness measurements were performed by transcostal RUSI at maximum inspiration, expiration, and the difference between the two parameters during relaxed breathing. Intra-class correlation coefficients (ICC), standard errors of measurement (SEM), minimum detectable changes (MCD), systematic errors, and correlations (r) were assessed. Orthotic device probe fixation showed excellent reliability (ICC = 0.852-0.996, SEM = 0.0002-0.054, and MDC = 0.002-0.072), and most measurements did not show significant systematic errors (p > 0.05). Despite manual probe fixation with a reliability ranging from good to excellent (ICC = 0.714-0.997, SEM = 0.003-0.023, and MDC = 0.008-0.064 cm), several significant systematic measurement errors (p < 0.05) were found. Most significant correlations between both orthotic device and manual probe fixation methods were moderate (r = 0.486-0.718; p < 0.05). Bland-Altman plots indicated adequate agreement between both measurement methods according to the agreement limits. The proposed novel thoracic orthotic device may allow ultrasound probe fixation to provide valid and reliable transcostal RUSI measurements of diaphragmatic thickness during relaxed breathing thus reducing some measurement errors and avoiding systematic measurement errors. It may be advisable to measure diaphragm thickness and facilitate visual biofeedback with respect to diaphragm re-education during normal breathing in athletes with non-specific lumbopelvic pain.

Ultrasound Evaluation of Three Outcome Domains in the Follow-up of Urate-Lowering Therapy in Gout: An Observational Study

This prospective study was aimed at observing the changes in three ultrasound (US) outcome domains (urate deposition, joint inflammation and bone erosion) in gout patients within the 1 y on urate-lowering therapy. The elementary lesions, including tophus, double-contour (DC) sign, aggregates, synovitis and bone erosion of the bilateral knee, ankle and first metatarsophalangeal joints, were evaluated repeatedly by US before and after 3, 6 and 12 mo of treatment, and the effective rates of clearance of tophus, DC sign and aggregates in different time groups were compared. A Global OMERACT-EULAR Synovitis Score (GLOESS) was calculated for these three paired joints to observe the inflammation. Bone erosion was also scored. The correlation between serum uric acid levels and tophus size changes was analyzed. Our results indicated that the decrease in serum uric acid levels was not completely parallel to the decrease in tophus size. For tophus, there was no significant difference in the clearance rate between different time groups (χ² = 1.76, p = 0.392), while for DC sign and aggregates, there were significant differences (χ² = 21.48, p < 0.001, χ² = 7.75, p = 0.018). Meanwhile, GLOESS was significantly lower after 6 mo of therapy (χ² = 32.316, p < 0.001). Additionally, bone erosion had not improved after 1 y of treatment (Z = -1.633, p = 0.102). Thus, US is crucial for assessing response to urate-lowering therapy in gout.

Sciatic nerve excursion during neural mobilization with ankle movement using dynamic ultrasound imaging: a cross-sectional study

PURPOSE

Ankle movement is used as a sensitizing maneuver for sciatica during neurodynamic techniques. In vivo studies on the sciatic nerve biomechanics associated with ankle movement during different positions of neighboring joints are scarce. The aim of this study was to investigate sciatic nerve excursion during ankle dorsiflexion in different positions in a healthy population.

METHODS

This is a cross-sectional study. High-resolution dynamic ultrasound imaging was used to measure longitudinal excursion of the sciatic nerve in the posterior thigh of 27 healthy participants during ankle dorsiflexion in six positions of the neck, hip, and knee. Both the long and short distance of the nerve excursion were measured. Wilcoxon signed-rank tests were used for data analysis, and Eta squared (r) was used to quantify the effect size.

RESULTS

Ankle dorsiflexion resulted in distal sciatic nerve excursion that was significantly higher in positions in which the knee was extended (median 0.7-1.6 mm) than in positions in which the knee was flexed (median 0.5-1.4 mm) (P ≤ 0.049, r ≥ 0.379). There were no significant differences in nerve excursion between positions where the neck was neutral compared with positions where the neck was flexed (P ≥ 0.710, r ≤ 0.072) or between positions where the hip was neutral compared with positions where the hip was flexed (P ≥ 0.456, r ≤ 0.143).

CONCLUSION

The positions of adjacent joints, particularly the knee, had an impact on the excursion of the sciatic nerve in the thigh during ankle movement.

Ultrasound-guided pulsed radiofrequency of the saphenous nerve in a complex regional pain syndrome patient with lower limb pain

Complex regional pain syndrome is a painful and debilitating syndrome in which the patient presents with disabling pain, edema, and/or vasomotor or sudomotor abnormalities. The mechanism is complex and not well understood. There is no definitive treatment for the condition yet. Pulsed radiofrequency is a minimally invasive, minimal destructive, and safe intervention. It can be used for neuropathic pain. A 40-year-old man with complex regional pain syndrome complained of intractable pain of the lower limb secondary to injury to the saphenous nerve due to a third-degree burn. Conventional medications, epidural block, and sympathetic nerve block provided temporary relief. We performed pulsed radiofrequency of the saphenous nerve for the management of lower limb pain, and the symptoms remained under control at 3 months. To the best of our knowledge, this is the first application of ultrasound-guided pulsed radiofrequency of the saphenous nerve for the management of complex regional pain syndrome.

Myositis ossificans causing ulnar neuropathy: a case report

Myositis ossificans (MO) can compress peripheral nerves and cause neuropathy. We herein describe a patient with ulnar neuropathy caused by MO at the medial elbow. A 28-year-old man with a drowsy mentality and multiple organ damage following a traffic accident was admitted to our hospital. After 3 weeks of postoperative care, the patient’s mental status recovered. However, he complained of severe sharp pain in his left medial forearm and fourth and fifth fingers. He exhibited weak fifth finger abduction and wrist adduction. Severe elbow joint pain was elicited during range-of-motion testing of his left elbow. Ultrasound also showed an edematous, enlarged, hypoechoic ulnar nerve lying above the MO, and the MO outwardly displaced the ulnar nerve. Elbow radiographic examination, computed tomography, and magnetic resonance imaging revealed MO development and compression of the left ulnar nerve. The patient underwent surgery; the following day, his left medial forearm pain completely disappeared with slight improvement in the motor weakness of fifth finger abduction. Ultrasound is a useful tool to easily evaluate the presence of MO and compression of peripheral nerves caused by MO.

Shear wave elastography of the radial nerve in healthy subjects

Objective

This study was performed to examine the sonoelastographic features of the radial nerve in healthy subjects.

Methods

In this observational cross-sectional study, shear wave elastography was used to evaluate the radial nerve. The cross-sectional area and stiffness were measured.

Results

The study included 37 nerves in 20 healthy adult subjects. The mean cross-sectional area of the radial nerve at the arm was 6.1 mm². The mean stiffness of the radial nerve in the short axis was 30.3 kPa, and that in the long axis was 34.9 kPa. The elasticity measurements were significantly different between the long axis and short axis.

Conclusion

The elastic modulus of the radial nerve was studied in healthy subjects and can serve as a reference for future assessment of different radial nerve pathologies.

Musculoskeletal ultrasound for ankylosing spondylitis: A systematic review and meta-analysis

OBJECTIVE

To clarify if musculoskeletal ultrasound (US) would give additional information for the clinical examination to diagnose and evaluate the activity of ankylosing spondylitis (AS).

METHODS

A literature search was performed in PubMed, Embase, Web of Science, the Cochrane Library, Sinomed, Chinese National Knowledge Infrastructure (CINK), and Wanfang databases from their inceptions to May 15, 2020. Studies that examined the musculoskeletal US, which detected sacroiliac joints in people with AS were included. The pooled analyses were performed using Meta Disc version 1.4 software.

RESULTS

A total of 9 studies encompassing 984 participants were included. Statistical analysis suggested an area under the curve (AUC) of 0.9259 (sensitivity 0.86, specificity 0.54) indicating that US had excellent diagnostic test accuracy for AS, an AUC of 0.6441 (sensitivity 0.87, specificity 0.51) indicating that the US did not have a good diagnostic test accuracy for AS activity. A subgroup analysis revealed that the AUC of power Doppler US (PDUS) and color Doppler US (CDUS) was 0.5000 and 0.9274, respectively, indicating that CDUS was superior to PDUS.

CONCLUSION

US, especially CDUS, is a valid and reproducible technique for the diagnosis of AS. While the accuracy of AS activity evaluation of the US is not ideal. It may be considered for routine use as part of the standard diagnostic tools in AS.

Osteomuscular symptoms on motorcycles in the city of Rio Branco, Acre, Brazil, West Amazon

ABSTRACT

Musculoskeletal disorders gradually affect workers in different parts of the world, compromising their occupational health and quality of life. Professionals exposed to these symptoms include the motorcycle taxi driver, whose pain is due to the overuse of the musculoskeletal system and little time to recover it.To identify the prevalence of musculoskeletal symptoms in motorcycle taxi drivers in the city of Rio Branco, Acre, Brazil, West Amazon.Cross-sectional study, involving 296 motorcycle taxi drivers in the city of Rio Branco-Acre, Brazil, male, from December 2016 to February 2017. The Nordic Musculoskeletal Questionnaire was used to collect information related to symptoms (pain, discomfort, or numbness) in the last 7 days of work. For the exclusion criteria were, being female; not reside outside the city of Rio Branco, Acre; having less than 3 months of work activity; not be carrying out their work activities at the time of application of the protocol; be limited by clinical or physical issues at the time of application of the protocol. The data obtained in the questionnaire were entered into the Epidata program (Epidata Association, Odense, Denmark) and then transferred to the STATA 10 statistical program (Stata Corp., College Station), for categorization and statistical analysis.The study population is over 36 years old; most reported having a partner and a higher education level. The average daily working hours of the participants were 12 hours, with the majority working over 12 hours daily. Most of the epidemiological variables factors were associated with musculoskeletal pain when the prevalence and prevalence ratio analyzes were performed. Higher prevalence of musculoskeletal symptoms in the lumbar region is with 17.9%. In the lower limbs, the most affected joint was the ankle (5.7%), followed by the hip (5.07%) and knee (5.07%), respectively. Insomnia was present in 55.35% and self-reported headache in 49.4% of participants.The musculoskeletal disorders generated by the daily service of motorcycle taxi drivers are directly affecting the quality of life of these professionals.