Rehabilitative ultrasound imaging: understanding the technology and its applications

Comparison of erector spinae and gluteus medius muscle thickness and activation in individuals with and without low back pain

BACKGROUND

Dysfunctional patterns of the erector spinae (ES) and gluteus medius (GM) muscles often accompany episodes of low back pain (LBP). Rehabilitative ultrasound imaging (RUSI) has been used to measure ES and GM muscle thickness, however such measurements have not been compared in individuals with and without LBP.

OBJECTIVES

To compare ES and GM muscle thickness and change in thickness utilizing RUSI in individuals with and without LBP.

DESIGN

Cross-sectional comparison.

METHODS

A volunteer sample of 60 adults with (n = 30) and without (n = 30) LBP was examined. Thickness measurements of the ES and GM at rest and during contraction were obtained by using RUSI during a single session. Statistical comparison was performed using ANCOVA. The demographic variable age was used as a covariate in the primary comparative analysis.

RESULTS

Mean difference for age between groups was 5.4 years (95% CI: 1.85, 8.94, p = 0.004). Average ODI score was 32.33±6.58 and pain level of 5.39±0.73 over the last 24 h in the symptomatic group. There was a statistically significant difference in the percent thickness change in both the ES, mean difference = -3.46 (95% CI: -6.71, -0.21, p = 0.039) and GM, mean difference = -1.93 (95% CI: -3.85, -0.01, p = 0.049) muscles between groups.

CONCLUSIONS

Individuals with LBP may have reduced percent thickness change of the ES and GM muscles when compared to asymptomatic individuals.

Automated analysis of pectoralis major thickness in pec-fly exercises: evolving from manual measurement to deep learning techniques

This study addresses a limitation of prior research on pectoralis major (PMaj) thickness changes during the pectoralis fly exercise using a wearable ultrasound imaging setup. Although previous studies used manual measurement and subjective evaluation, it is important to acknowledge the subsequent limitations of automating widespread applications. We then employed a deep learning model for image segmentation and automated measurement to solve the problem and study the additional quantitative supplementary information that could be provided. Our results revealed increased PMaj thickness changes in the coronal plane within the probe detection region when real-time ultrasound imaging (RUSI) visual biofeedback was incorporated, regardless of load intensity (50% or 80% of one-repetition maximum). Additionally, participants showed uniform thickness changes in the PMaj in response to enhanced RUSI biofeedback. Notably, the differences in PMaj thickness changes between load intensities were reduced by RUSI biofeedback, suggesting altered muscle activation strategies. We identified the optimal measurement location for the maximal PMaj thickness close to the rib end and emphasized the lightweight applicability of our model for fitness training and muscle assessment. Further studies can refine load intensities, investigate diverse parameters, and employ different network models to enhance accuracy. This study contributes to our understanding of the effects of muscle physiology and exercise training.

Exploring fascial properties in patients with depression and chronic neck pain: An observational study

BACKGROUND

Depressive disorder and chronic pain are prevalent conditions that often co-occur. The myofascial fascial continuum has been hypothesized to contribute to both conditions. However, limited research exists on the specific association between fascial properties and chronic pain and depression.

OBJECTIVE

This study aims to investigate the properties of the deep fascia of the M. trapezius and their relationship with depression, chronic neck pain, and cervical spine mobility.

METHOD

This study compared fascial properties between two groups: individuals with depression and chronic neck pain, and healthy individuals. Fascial thickness, elasticity, and stiffness were measured as primary outcomes using standardized techniques such as ultrasound imaging and compliance meter. Statistical analyses were conducted to identify potential differences and correlations in fascial properties between the two groups.

RESULT

Significant differences emerge in stiffness, tone, and fascia thickness in the deep fascia, alongside identified correlations between depression, chronic pain, and these variables.

CONCLUSION

The study highlights the impact of depression and chronic pain on fascial properties, emphasizing the need for further research in this domain to unravel the intricate connections and potential implications for treatment strategies.

Effect of a Multimodal Supervised Therapeutic Exercise Program on Quality of Life, Pain, and Lumbopelvic Impairments in Women With Endometriosis Unresponsive to Conventional Therapy: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effectiveness of "Physio-EndEA", a multimodal nine-week supervised exercise intervention, on quality of life, pain, and lumbopelvic impairments in women with endometriosis unresponsive to conventional therapy.

DESIGN

Parallel-group randomized controlled trial. Outcomes were measured at baseline, post-intervention, and at 1 year.

SETTING

Two Public University Hospitals.

PARTICIPANTS

This trial included 31 women with endometriosis (N=31) randomly allocated to "Physio-EndEA" group (n=16) or control group (n=15). Four participants dropped out of the study for causes unrelated to the intervention.

INTERVENTIONS

The "Physio-EndEA" program consisted of a 1-week lumbopelvic stabilization learning phase followed by an 8-week phase of stretching, aerobic, and resistance exercises focused on the lumbopelvic area. It was sequentially instructed and supervised by a trained physiotherapist (with volume and intensity progression) and adapted daily to the potential of each participant. Control group received the usual treatment stipulated by their gynecologist.

MAIN OUTCOME MEASURES

The primary outcome was quality of life. Secondary outcomes were pain intensity, pressure pain thresholds, pain-related catastrophic thoughts, abdominal and back strength, lumbopelvic stability, and muscle architecture.

RESULTS

Adherence rate was 90.6% and mean (±standard deviation) satisfaction was 9.44±0.73 out of 10. No remarkable health problems were reported during the trial. In comparison with controls, the quality of life was improved post-intervention and at 1 year in the Physio-EndEA group with large effect sizes (d>0.80). This group also evidenced: a reduced intensity of dyspareunia, catastrophic thoughts; an increase in pelvic, lumbar, and distal pressure pain thresholds; increases in abdominal and back strength and lumbopelvic stability; and increased thickness of transversus abdominis (right side) and width of lumbar multifidus (left side).

CONCLUSION

A 9-week program of multimodal supervised therapeutic exercise is a feasible and effective intervention to improve QoL in women with endometriosis. This program also offers benefits in terms of pain/sensitization and lumbopelvic impairments.

Scoping Review of Curricula and Pedagogical Approaches for Physiotherapist Performed Point of Care Ultrasonography

Purpose

This study collates and maps physiotherapy pre- and post-licensure curricula and pedagogical approaches for point of care ultrasonography (POCUS).

Method

We used a standardized scoping review methodology and reporting framework. A total of 18,217 titles and abstracts, and 1,372 full text citations were screened, with 209 studies classified as physiotherapist performed POCUS.

Results

Of the 209 studies, 15 evaluated pre- and post-licensure curricula and pedagogical approaches. Seventy-two to 98% of pre-licensure programs reported including theoretical knowledge of POCUS and 44-45% reported practical teaching or competency assessment. In post-licensure studies of POCUS, 0-61% of physiotherapists reported training for POCUS. All studies of post-licensure pedagogical approaches included an assessment of theoretical knowledge of POCUS, but only one study included a practical assessment of competency. There was considerable variability in POCUS methods and duration of pedagogical approaches. Except for one study, all pedagogical approaches reported improvement in theoretical knowledge.

Conclusion

Progress in physiotherapy-specific, standardized, competency-based curricula and pedagogical approaches in POCUS has been limited, with minimal research available, and considerable variability both pre- and post-licensure. These findings could be used to advocate for the inclusion of POCUS in pre- and post-licensure physiotherapy curriculum, and suggest a need for clear guidelines from regulatory colleges and licensing bodies, and a common terminology for physiotherapist performed POCUS. Future directions for research include a systematic review of the psychometric properties of physiotherapist performed POCUS within and across anatomical areas, an assessment of value of different forms of training, and an evaluation of the impact of physiotherapist performed POCUS on patient outcomes.

Clinical Utility of Ultrasound Imaging for Measuring Anterior Thigh Thickness after Anterior Cruciate Ligament Injury in an Individual Patient to Assess Postsurgery Outcome

The present study investigated the clinical utility of ultrasound imaging (USI) for assessing changes in an individual's quadriceps muscle and subcutaneous fat (SF) thickness of the anterior thigh and their relative proportions. A patient was studied prior to and after anterior cruciate ligament reconstruction (ACLR) surgery and during rehabilitation. This case study involved an 18-year-old female recreational athlete with a complete tear of the anterior cruciate ligament (ACL). Tissue thickness (SF and quadriceps muscle) was measured from transverse USI of the anterior thigh before surgery, at weekly intervals during 12 weeks of postsurgery, and then every 2 weeks for the following 12 weeks (total of 21 measurement sets). Statistically significant differences presurgery to postrehabilitation were found for muscle thickness (p = 0.04) and SF tissue thickness (p = 0.04) measurements. There was no difference in muscle to fat ratio (p = 0.08). Changes in measurements greater than the reported minimal detectable change (MDC) demonstrate the sensitivity of the USI technique as an objective tool to assess clinically useful changes in an individual's anterior thigh muscle thickness post-ACLR surgery and during rehabilitation.

Comparison of Muscle Activity and Muscle Thickness According to Knee Flexion Angle during Supine Bridge Exercises using the Abdominal Drawing-in Maneuver on an Unstable Surface

This study evaluated changes in deep trunk muscle thickness and lower extremity muscle activities during bridge exercises with the abdominal drawing-in maneuver. Bridge exercises were conducted on an unstable surface at different knee flexion angles (60º, 90º and 120º), with the aim of identifying more effective angles for bridge exercises. This study included 21 healthy adults, aged 20-27 years. Biceps femoris (BF), rectus abdominis, and rectus femoris activity was measured using surface electromyography. The thicknesses of the transverse abdominis (TrA), external oblique (EO) and internal oblique (IO) muscles were measured. BF (p = 0.000, partial η2 = 0.670) activity increased considerably as the knee flexion angle decreased. TrA (p = 0.000, partial η2 = 0.883) and IO (p = 0.000, partial η2 = 0.892) thickness significantly increased, while EO (p = 0.000, partial η2 = 0.893) thickness decreased as the knee flexion angle decreased. When performing bridge exercises using the abdominal drawing-in maneuver on an unstable surface, the knee flexion angles should be at 120º and 60º to increase trunk stability and lower extremity muscle activity, respectively.

Reliability of sonographic measurements of the ulnar collateral ligament: a multi-rater prospective study

Background

The use of sonography is a cost-effective and reliable method to evaluate upper extremity superficial tissue structural integrity and pathology. Establishing the measurement reliability of widely used diagnostic ultrasound evaluation for musculoskeletal assessment is paramount enhance accurate clinical evaluations. The objective of this study was to establish the inter-rater and intra-rater reliability of select ulnar collateral ligament (UCL) thickness measures at two distinct anatomical locations in intercollegiate baseball athletes using ultrasound imaging (USI).

Methods

This was a prospective cohort study conducted in a university research laboratory and included a total of 17 NCAA Division I baseball athletes (age 20.4 ± 1.43, height = 183.63 cm ± 6.27 cm, mass = 89.28 kg ± 8.24 kg). Two trained clinicians measured UCL mid-substance and apex thickness in the throwing extremity, prospectively, on 5 occasions at 1-month intervals during rest. Intraclass correlation coefficients (ICCs) (model 3,3), associated standard error of measurement, and 95% minimal detectable change in thickness were derived.

Results

Intrarater reliability estimates for operator 1 were 0.90-0.98 (mid-substance) and 0.91-0.99 (apex). Operator 2's values were 0.92-0.97 and 0.93-0.99, respectively. The standard error of measurement (SEM) ranged from 0.045-0.071 cm (mid-substance) and 0.023-0.067 cm (apex). The minimal detectable difference (MDD95) was 0.12-0.20 cm (mid-substance) and 0.07-0.19 cm (apex). Interrater reliability was 0.86-0.96 (mid-substance) and 0.79-0.98 (apex); most ICCs were >0.90. Measurement of UCL thickness at two locations demonstrated very good to excellent reliability with high precision. Using this protocol, two evaluators can obtain consistent UCL measurement at two positions. This finding has significant implications for the clinical evaluation of superficial tissue pathology of the same individual by two experienced practitioners.

Technical aspects of inter-recti distance measurement with ultrasonographic imaging for physiotherapy purposes: the scoping review

BACKGROUND

Inter-recti distance (IRD) measurement using musculoskeletal USI has been used in physiotherapy research, in particular, to investigate pregnancy-related diastasis recti abdominis (DRA) and to seek its effective treatment methods. Severe and untreated diastasis may result in the formation of umbilical or epigastric hernias.

OBJECTIVE

This study aimed to systematically map physiotherapy-related research articles that included descriptions of IRD measurement procedures using USI to present their similarities and differences, and formulate recommendations on the procedure.

DESIGN

A scoping review was conducted according to PRISMA-ScR guidelines, including 49 of 511 publications from three major databases. Publications were selected and screened by two independent reviewers whose decisions were consulted with a third reviewer. The main synthesized data items were: the examinees' body position, breathing phase, measurement sites, and DRA screening methods. The final conclusions and recommendations were the result of a consensus between seven reviewers from four research centers.

RESULTS

Studies used 1-5 measurement sites that were differently determined. IRD was measured at the umbilicus (n = 3), at its superior (n = 16) and/or inferior border (n = 9), and at different levels: between 2 and 12 cm above the umbilicus, or a third of the distance and halfway between the umbilicus and xiphoid (n = 37); between 2 and 4.5 cm below the umbilicus or halfway between the umbilicus and pubis (n = 27). Different approaches were used to screen subjects for DRA.

CONCLUSIONS

The discrepancies between the measurement procedures prevent between-study comparisons. The DRA screening method should be standardized. IRD measurement protocol standardization has been proposed.

CRITICAL RELEVANCE STATEMENT

This scoping review indicates that the inter-recti distance measurement procedures using ultrasound imaging differ between studies, preventing between-study comparisons. Based on the results synthesis, the measurement protocol standardization has been proposed.

KEY POINTS

The inter-recti distance measurement procedures using USI differ between studies. Proposed standardization concerns body position, breathing phase, measurements number per location. Determination of measurement locations considering individual linea alba length is suggested. Recommended locations: umbilical top, ½ of umbilical top-xiphoid, ¼ of umbilical top-xiphoid/pubis distances. Diastasis recti abdominis diagnostic criteria are needed for proposed measurement locations.

Relationship between morphometric and mechanical properties of superficial lumbosacral soft tissue layers in healthy young adults

Introduction: It is commonly considered that myotonometry is a non-invasive method capable of quantifying linear elastic and viscoelastic properties of the myofascial tissue through the application of a weak mechanical impulse to the surface of the skin. However, before the impulse can reach the myofascial tissue, it must cross more superficial tissues such as the skin and subcutaneous tissue (ST). All these superficial tissues have different distributions and organizations of structural components. Therefore, the study aimed to examine the potential relationships between the mechanical and morphometric properties of various superficial soft tissues surrounding the lumbar multifidus muscle (LM). Methods: Myotonometric measurements of dynamic stiffness, logarithmic decrement, and creep, and ultrasonographic measurements of thickness and echogenicity of cutaneous, subcutaneous, perimuscular tissue, and LM were obtained from 50 healthy individuals in the resting prone position and during contralateral arm lift. Results: The most important findings were that in both the relaxed and contracted LM state, the dynamic stiffness strongly negatively (r = -0.69; p < 0.001 in relaxation, r = -0.83; p < 0.001 in contraction) and creep strongly positively (r = 0.79; p < 0.001 in relaxation, r = 0.85; p < 0.001 in contraction) correlated with the thicknesses of the ST. Similar but weaker correlations were noticed between both these measures and the perimuscular tissue thickness. Elasticity was uncorrelated to the thicknesses of the tissues. With LM contraction (change from the relaxed to contracted state), the relative increase in dynamic stiffness was correlated with the relative decrease in dermis (r = -0.51; p < 0.001) and ST (r = -0.47; p = 0.001) thickness, and with the relative increase in LM (r = 0.36; p = 0.010) thickness. Moreover, the relative decrease (thinning) in the ST thickness was correlated with the relative increase in logarithmic decrement (i.e., decrease in soft tissue elasticity, r = -0.37, p = 0.011). The mechanical properties of the soft tissues were not related to their echogenicity. Discussion: In conclusion, the thicker the subcutaneous and perimuscular layers, the lesser the stiffness and the greater the time-dependent deformation to the external force of the tissues surrounding the LM during its relaxation and isometric contraction. Moreover, the greater the thinning of the ST and the thickening of the LM during its contraction, the higher the increase in lumbosacral tissue stiffness and the decrease in elasticity. Therefore, one should consider the thickness of the ST before planning or analyzing the outcomes of myotonometric or other external biomechanical measurements to avoid drawing the wrong conclusions about the mechanical properties of the myofascial tissue.

Application of ultrasound in preoperative localization diagnosis of checkrein deformity: A retrospective case series

BACKGROUND

Checkrein deformity, is a rare claw toe dynamic deformity of the hallux or great toe. This study investigated the use of diagnostic ultrasound in positioning the accurate injury location causing checkrein deformity and its clinical significance for etiological diagnosis and selection of surgical methods.

METHODS

This retrospective study included patients with confirmed checkrein deformities (according to typical symptoms) at the Department of Traumatic Orthopedics of Tianjin Hospital (Tianjin, China) from March 2017 to July 2021.

RESULTS

A total of 11 patients (8 males and 3 females) with a mean age of 36.7 ± 16.8 (range 19-61) were included in this study. The injuries included six cases of tibia and fibula fracture, one case of single tibia fracture, and one case of single fibula fracture. Four patients were treated with steel plate internal fixation, three patients with intramedullary nailing, and one patient with external fixation. Three patients reported no history of any high-energy trauma or surgery. The ultrasound results showed that seven patients suffered from flexor hallucis longus (FHL) lesions, two patients suffered from flexor digitorum longus (FDL) lesions, and two patients suffered from FHL and FDL lesions. The patients underwent different surgeries tailored to their specific lesions. Toe flexion deformity was completely corrected after operation in all patients. The function of the toes was recovered to varying extent.

CONCLUSION

The results of this study demonstrates that the checkrein deformities can be confirmed by ultrasound. It could be used to determine the adhesions before the operation, acting as guidance while establishing the surgical planning.

Physical Therapists Use of Diagnostic Ultrasound Imaging in Clinical Practice: A Review of Case Reports

Objective

Ultrasound diagnostic imaging (USI) is widely utilized in sports medicine, orthopaedics, and rehabilitation. Its use in physical therapy clinical practice is increasing. This review summarizes published patient case reports describing USI in physical therapist practice.

Design

Comprehensive literature review.

Literature Search

PubMed was searched using the keywords "physical therapy" AND "ultrasound" AND "case report" AND "imaging". In addition, citation indexes and specific journals were searched.

Study Selection Criteria

Papers were included if the patient was attending physical therapy, USI was necessary for patient management, the full text was retrievable, and the paper was written in English. Papers were excluded if USI was only used for interventions, such as biofeedback, or if the USI was incidental to physical therapy patient/client management.

Data Synthesis

Categories of data extracted included: 1) Patient presentation; 2) Setting; 3) Clinical indications; 4) Who performed USI; 5) Anatomical region; 6) Methods of USI; 7) Additional imaging; 8) Final diagnosis; and 9) Case outcome.

Results

Of the 172 papers reviewed for inclusion, 42 were evaluated. Most common anatomical regions scanned were the foot and lower leg (23%), thigh and knee (19%), shoulder and shoulder girdle (16%), lumbopelvic region (14%), and elbow/wrist and hand (12%). Fifty-eight percent of the cases were deemed static, while 14% reported using dynamic imaging. The most common indication for USI was a differential diagnosis list that included serious pathologies. Case studies often had more than one indication. Thirty-three cases (77%) resulted in confirmation of a diagnosis, while 29 case reports (67%) documented significant changes in physical therapy intervention strategies due to the USI, and 25 case reports (63%) resulted in referral.

Conclusion

This review of cases provides details on unique ways USI can be used during physical therapy patient care, including aspects that reflect the unique professional framework.

Activation of Anterolateral Abdominal Muscles During Sling Bridge Exercises: Comparison of Different Pelvic Positions

CONTEXT

Inappropriate activation of the anterolateral abdominal muscles affects the stability of the lumbopelvic zone and increases the appearance of pain and lesion in the area. Therefore, ways to improve its effective contraction are crucial in rehabilitation. The aim of this study was to compare the activation of the transverse abdominis (TrA), internal oblique (IO), and external oblique (EO) muscles in 3 different pelvic positions (down pelvis [DP], horizontal pelvis [HP], and up pelvis [UP]) during sling bridge exercise (SBE) to determinate which position is more effective to promote a correct contraction of the anterolateral abdominal muscles.

DESIGN

Cross-sectional study.

METHODS

Fifteen participants performed 3 variations (DP, HP, and UP) of a one-legged exercise called "supine pelvic lift" on a sling device. The thicknesses of the TrA, IO, and EO were recorded at rest and at the 3 positions using ultrasound imaging. Thickness, change ratio, lateral slide of TrA, and preferential and contraction activation ratio of TrA, IO, and EO were analyzed.

RESULTS

TrA and IO showed greater activation (P = .01) in the UP position than the other pelvic positions. In addition, UP position decreased the activation of the EO (P = .01).

CONCLUSION

Based on the results of this study, SBE in the UP position has the potential to improve normal contraction patterns of the musculature and can be used in future intervention of the lumbopelvic zone.

Abdominal and Pelvic Floor Activity Related to Respiratory Diaphragmatic Activity in Subjects with and without Non-Specific Low Back Pain

One of the advances in physiotherapy in recent years is the exploration and treatment by ultrasound imaging. This technique makes it possible to study the relationship between the musculature of the anterolateral wall of the abdomino-pelvic cavity, the pelvic floor muscles and the diaphragm muscle, among others, and thus understand their implication in non-specific low back pain (LBP) in pathological subjects regarding healthy subjects. Objective: To evaluate by RUSI (rehabilitative ultrasound imaging) the muscular thickness at rest of the abdominal wall, the excursion of the pelvic floor and the respiratory diaphragm, as well as to study their activity. Methodology: Two groups of 46 subjects each were established. The variables studied were: non-specific low back pain, thickness and excursion after tidal and forced breathing, pelvic floor (PF) excursion in a contraction and thickness of the external oblique (EO), internal oblique (IO) and transverse (TA) at rest. Design: Cross-sectional observational study. Results: Good-to-excellent reliability for measurements of diaphragm thickness at both tidal volume (TV) (inspiration: 0.763, expiration: 0.788) and expiration at forced volume (FV) (0.763), and good reliability for inspiration at FV (0.631). A correlation was found between the EO muscle and PF musculature with respect to diaphragmatic thickness at TV, inspiration and expiration, and inspiration at FV, in addition to finding significant differences in all these variables in subjects with LBP. Conclusion: Subjects with LBP have less thickness at rest in the OE muscle, less excursion of the pelvic diaphragm, less diaphragmatic thickness at TV, in inspiration and expiration, and in inspiration to FV.

Protocol and reference values for minimal detectable change of MyotonPRO and ultrasound imaging measurements of muscle and subcutaneous tissue

The assessment of muscle health is of paramount importance, as the loss of muscle mass and strength can affect performance. Two non-invasive tools that have been found to be useful in this are the MyotonPRO and rehabilitative ultrasound imaging, both have shown to be reliable in previous studies many of which conducted by the research team. This study aims to determine the reliability of previously unassessed local body structures and to determine their minimal detectable changes (MDC) to support both researchers and clinicians. Twenty healthy participants were recruited to determine the reliability of seven skin positions out of a previously established protocol. Reliability was determined between three independent raters, and day to day reliability was assessed with one rater a week apart. Intraclass Correlation Coefficients (ICC) between raters and between days for tissue stiffness, tone and elasticity range from moderate to excellent (ICC 0.52–0.97), with most good or excellent. ICCs for subcutaneous thickness between days was good or excellent (ICC 0.86–0.91) and moderate to excellent between raters (ICC 0.72–0.96), in muscles it was moderate to excellent between raters and days (ICC 0.71–0.95). The protocol in this study is repeatable with overall good reliability, it also provides established MDC values for several measurement points.

The Effect of Core Exercise Using Online Videoconferencing Platform and Offline-Based Intervention in Postpartum Woman with Diastasis Recti Abdominis

To investigate the efficacy of exercise intervention using a real-time video conferencing platform (ZOOM) on inter-recti distance, abdominal muscle thickness, static trunk endurance, and maternal quality of life, 37 women with diastasis recti between six months and one year postpartum were randomly divided into the online (n = 19) and offline (n = 18) groups. The online group underwent 40-min trunk stabilization exercise sessions twice a week for six weeks, through a real-time video conference platform, while the offline group attended the same program in person. The inter-recti distance and muscle thickness between the abdominal muscles were measured by rehabilitation ultrasound imaging, the Torso endurance test was used to compare the static trunk endurance, and the maternal quality of life questionnaire (MAPP-QOL, score) was applied. Significant improvements were observed in the inter-recti distance between the rectus abdominis, abdominal muscle thickness, static trunk endurance, and maternal quality of life in both groups (p < 0.001); a more significant improvement was observed in the offline group. No significant differences were observed between groups except for the left rectus abdominis thickness and Psychological/Baby and Relational/Spouse-Partner subscale in the maternal quality of life index (p > 0.05). Exercise interventions delivered in a real-time videoconferencing platform are effective at improving the inter-recti distance, trunk stability, and quality of life in postpartum women and may be an alternate to face-to-face intervention.

The Influence of Ultrasound Image Depth and Gain on Skeletal Muscle Echo Intensity

Echo intensity may associate with indicators of skeletal muscle quality, but investigators often use different methodological approaches that may alter echo intensity when acquiring B-mode ultrasound images. We examined the influence of image depth and gain settings on the interpretation of echo intensity. Thirty-six college-aged males and females participated. Ultrasound images of the vastus lateralis were captured in the sagittal plane. Images were captured at depths of 3.0, 3.5, 4.0, 4.5, 5.0, 6.0, and 7.0cm and gain settings of 50 and 60 dB in random order. For both gain settings, echo intensity values were similar between 4.0 and 6.0cm. At a gain of 50dB, 7.0cm demonstrated greater values than all other depths. At a gain of 60dB, 7.0cm displayed greater values compared to all other depths, but 3.0cm displayed lower echo intensity values than other depths. Echo intensity was substantially higher when using a gain of 60dB compared to 50dB (mean difference ≥ 21.7 arbitrary units, d ≥ 3.47). When planning investigations in new research areas, researchers should carefully consider their study-specific image depth. Echo intensity values are stable between depths of 4.0 and 6.0cm, suggesting that changing image depth may not be problematic. Image gain must be kept constant. Novelty Bullets • Optimal approaches for B-mode ultrasound image acquisition of skeletal muscles remain unclear. • Echo intensity is similar between depths of 4.0 and 6.0cm, regardless of image gain. • Investigators should seek to utilize a constant depth setting, but small deviations may be acceptable.

'Physio-EndEA' Study: A Randomized, Parallel-Group Controlled Trial to Evaluate the Effect of a Supervised and Adapted Therapeutic Exercise Program to Improve Quality of Life in Symptomatic Women Diagnosed with Endometriosis

Aim: The ‘Physio-EndEA’ study aims to explore the potential benefits of a therapeutic exercise program (focused on lumbopelvic stabilization and tolerance to exertion) on the health-related quality of life (HRQoL) of symptomatic endometriosis women. Design: The present study will use a parallel-group randomized controlled trial design. Methods: A total of 22 symptomatic endometriosis women will be randomized 1:1 to the Physio-EndEA or usual care groups. The ‘Physio-EndEA’ program will consist of a one-week lumbopelvic stabilization learning phase followed by an eight-week phase of stretching, aerobic and resistance exercises focused on the lumbopelvic area that will be sequentially instructed and supervised by a trained physiotherapist (with volume and intensity progression) and adapted daily to the potential of each participant. The primary outcome measure is HRQoL. The secondary outcome measures included clinician-reported outcomes (pressure pain thresholds, muscle thickness and strength, flexibility, body balance and cardiorespiratory fitness) and patient-reported outcomes (pain intensity, physical fitness, chronic fatigue, sexual function, gastrointestinal function and sleep quality). Discussion: Findings of this study will help to identify cost-effective non-pharmacological options (such as this exercise-based intervention) that may contribute to the improvement of HRQoL in symptomatic endometriosis women.

Respiratory and peripheral muscular ultrasound characteristics in ICU COVID 19 ARDS patients

PURPOSE

Severe cases of coronavirus disease 2019 develop ARDS requiring admission to the ICU. This study aimed to investigate the ultrasound characteristics of respiratory and peripheral muscles of patients affected by COVID19 who require mechanical ventilation.

MATERIALS AND METHODS

This is a prospective observational study. We performed muscle ultrasound at the admission of ICU in 32 intubated patients with ARDS COVID19. The ultrasound was comprehensive of thickness and echogenicity of both parasternal intercostal and diaphragm muscles, and cross-sectional area and echogenicity of the rectus femoris.

RESULTS

Patients who survived showed a significantly lower echogenicity score as compared with those who did not survive for both parasternal intercostal muscles. Similarly, the diaphragmatic echogenicity was significantly different between alive or dead patients. There was a significant correlation between right parasternal intercostal or diaphragm echogenicity and the cumulative fluid balance and urine protein output. Similar results were detected for rectus femoris echogenicity.

CONCLUSIONS

The early changes detected by echogenicity ultrasound suggest a potential benefit of proactive early therapies designed to preserve respiratory and peripheral muscle architecture to reduce days on MV, although what constitutes a clinically significant change in muscle echogenicity remains unknown.

Impaired static postural control correlates to the contraction ability of trunk muscle in young adults with chronic non-specific low back pain: A cross-sectional study

INTRODUCTION

Patients with chronic non-specific low back pain (CNSLBP) were found with impaired postural control in previous studies. Since the trunk muscle take important efforts on core stability, the study aimed to examine the relationships of postural control during stance tasks and the contractility of trunk muscle in young adults with CNSLBP and without.

METHODS

Healthy individuals (n = 25) and individuals with CNSLBP (n = 30) were included. The thickness of the bilateral transversus abdominis (TrA) and lumbar multifidus (MF) was measured during rest and maximal voluntary contraction, and the change percentages (TrA%, MF%) were calculated. Regarding postural control, COP path length and sway area during the stance tasks were measured thrice in each group.

RESULTS

The bilateral TrA% of the CNSLBP group was less than that of the HC group (p < 0.05). The bilateral TrA% of the CNSLBP group was less than that of the HC group (p < 0.05). The bilateral MF% showed no significantly different(p > 0.05) between the two groups. Compared with healthy controls, CNSLBP patients resulted larger path length and sway area of COP during most of static stance tasks. During the EO task in the CNSLBP group, TrA% was found correlate to COP path length (p < 0.05); the right MF% was correlated with COP sway area (p < 0.05). No significant correlations appeared in the healthy controls (p > 0.05).

CONCLUSIONS

Compared with healthy individuals, impaired postural control during static stance with eyes open in patients with CNSLBP was likely to be related to the poor contraction ability of bilateral transversus abdominis and correlated to the normal contraction ability of right lumbar multifidus.

Rehabilitative ultrasound imaging of the levator scapula muscle at rest and during contraction: Technical description and reliability

BACKGROUND

Altered scapular muscle activity is associated with abnormal scapular motions and shoulder pain. Hence, quantification of these activities is a challenging issue.

OBJECTIVES

The purposes of this study were to establish the reliability of measuring levator scapula muscle thickness and to examine how thickness of this muscle changes with contraction.

METHODS

Twenty-one asymptomatic individuals (mean age 22.29 ± 2.17 years) participated in this study. Three separate ultrasound images of the levator scapula muscle were captured at the neck-shoulder junction at rest and during a loaded isometric contraction. The procedures were repeated twice, four to seven days apart to establish intra-rater test-retest reliability. Interclass correlation coefficients (ICC) and standard error of measurement (SEM) were used to determine the reliability, and a paired t-test was performed to examine the difference in muscle thickness between two conditions.

RESULTS

The results demonstrated that intra-examiner reliability was good at rest (ICC = 0.88, SEM = 1.16 mm) and excellent during loaded isometric contraction (ICC = 0.95, SEM = 0.91 mm). Furthermore, the thickness of levator scapula muscle significantly increased from rest to the loaded isometric contraction (Effect size = 1.99, P < 0.001).

CONCLUSION

This study demonstrates that the thickness of the levator scapula muscle can be measured reliably at the neck-shoulder junction. Furthermore, ultrasound measures can reliably detect changes in muscle thickness from rest to a contracted state. Therefore, if the need exists to evaluate muscle morphology before and after any treatment strategy, thickness measurement of levator scapula can be determined reliably using ultrasound.

Measurement reliability and cooperative movement of the pelvic floor and transverse abdominal muscles

[Purpose] This study examined the measurement reliability and cooperative movement of the pelvic floor and transverse abdominal muscles. [Participants and Methods] The participants were seven healthy adult females. Transverse abdominal muscle thickness and bladder floor elevation were measured under the following conditions during active exercise and during resistance exercise: the resting state, maximum contraction of the transverse abdominal muscle, maximum contraction of the pelvic floor muscle, and maximum co-contraction of the transverse abdominal and pelvic floor muscles. Measurements were taken at rest and under each exercise condition. [Results] The intraclass correlation coefficients of transverse abdominal muscle thickness and bladder floor elevation showed high reproducibility under all conditions. The maximum contraction of the pelvic floor muscle showed a high correlation with the maximum co-contraction of the transverse abdominal muscle and pelvic floor muscle during resistance exercise. A significant regression line was found between transverse abdominal muscle thickness and bladder floor elevation under all conditions. The regression equation was as follows: transverse abdominal muscle thickness=0.113 bladder floor elevation+0.377 (r²=0.21). [Conclusion] This study demonstrated that the measurement reliability of the transverse abdominal and pelvic floor muscles is high, and that both muscles exhibit cooperative movement.

Assessing Sciatic Nerve Excursion and Strain with Ultrasound Imaging during Forward Bending

Entrapment neuropathies affecting the sciatic nerve tract may adversely affect neural biomechanical features such as excursion and strain. There is a paucity of in vivo evidence examining the effects of forward bending upon sciatic nerve excursion and strain. The purpose of this study was to assess the reliability of ultrasound imaging in measuring sciatic nerve excursion and strain during forward bending movements. Secondary aims were to quantify sciatic nerve excursion and strain during forward bending movements and to assess the relationship between sciatic nerve excursion and movements of the hip and lumbar spine. The reliability of measuring sciatic nerve excursion was high to excellent whilst measurement of sciatic nerve strain was moderate. The amount of hip flexion, during forward bending, was a strong predictor of sciatic nerve excursion. These findings will support clinicians in the assessment and treatment of entrapment neuropathies, in addition to providing a foundation for future research.

Automated semi-real-time detection of muscle activity with ultrasound imaging

Ultrasound imaging (USI) biofeedback is a useful therapeutic tool; however, it relies on qualitative assessment by a trained therapist, while existing automatic analysis techniques are computationally demanding. This study aims to present a computationally inexpensive algorithm based on the difference in pixel intensity between USI frames. During an offline experiment, where data was analyzed after the study, participants performed isometric contractions of the gastrocnemius medialis (GM) muscle, as executed (30% of maximum contraction) or attempted (low force contraction up to a point when the participant is aware of exerting force or contracting the muscle) movements, while USI, EMG, and force data were recorded. The algorithm achieved 99% agreement with EMG and force measurements for executed movements and 93% for attempted movements, with USI detecting 1.9% more contractions than the other methods. In the online study, participants performed GM muscle contractions at 10% and 30% of maximum contraction, while the algorithm provided visual feedback proportional to the muscle activity (based on USI recordings during the maximum contraction) in less than 3 s following each contraction. We show that the participants reached the target consistently, learning to perform precise contractions. The algorithm is reliable and computationally very efficient, allowing real-time applications on standard computing hardware. It is a suitable method for automated detection, quantification of muscle contraction, and to provide biofeedback which can be used for training of targeted muscles, making it suitable for rehabilitation.

Ultrasound Imaging as a Diagnostic Tool to Assess the Functional Status of Muscles after a Spinal Cord Injury

The aim of this study was to evaluate the use of ultrasound imaging (USI) as a diagnostic tool to assess muscle function after a spinal cord injury (SCI). Ultrasound videos of the gastrocnemius medialis muscle were recorded both at rest and during attempted maximum voluntary contraction (MVC) for fifteen participants with a SCI and fifteen able-bodied controls. Measurements were repeated at monthly intervals for participants in the SCI group during their inpatient stay. Differences in muscle echogenicity and thickness were detected between both able-bodied and SCI groups and subgroups of SCI participants, suggesting USI can detect and monitor changes in muscle structure which are characteristic of atrophy. Decreased muscle movement in the SCI groups was also detected during attempted MVC. The ability of USI to distinguish between different levels of function demonstrates the potential of USI as a quantitative tool to assess muscles.

Differences in supraspinatus occupation ratio between the symptomatic, the contralateral asymptomatic shoulder and control subjects: A cross-sectional study

ABSTRACT

The relationship between supraspinatus tendon thickness and the acromiohumeral distance (AHD) at both rest position and shoulder elevation is still to be explored in those with chronic shoulder pain. The aim is to compare supraspinatus occupation ratio (OR) at 0° and 60° of shoulder elevation measured by ultrasound imaging in the symptomatic shoulder, the contralateral asymptomatic shoulder and in healthy subjects. This was across-sectional, observational study. A sample of 56 participants with subacromial pain syndrome in their dominant arm was recruited in 3 different primary care centres. Forty participants without shoulder pain were also recruited. The AHD at 0° and 60° of active shoulder abduction as well as the supraspinatus tendon thickness were measured by ultrasound in these groups. Supraspinatus OR at 60° was significantly greater in symptomatic compared to asymptomatic shoulders (P = .04) and healthy shoulders (P = .008). The percentage of change in supraspinatus OR from rest position to 60° was also greater in symptomatic shoulders when comparing with asymptomatic (P = .01) and healthy shoulders (P = .03). No other statistically significant differences for the rest of comparisons were found. Supraspinatus OR may explain shoulder pain in chronic conditions. Further studies at acute and chronic conditions after a physiotherapy treatment are needed to explore its usefulness in clinical practice.

Comparing muscle thickness and function in healthy people and subjects with upper trapezius myofascial pain syndrome using ultrasonography

BACKGROUND

The reliability of the muscle function using ultrasonography is not reported in patients with myofascial pain syndrome and healthy individuals. The main aim of this study was to compare muscle thickness and function of two matched healthy and patients groups with neck pain due to upper trapezius myofascial pain syndrome.

METHODS

40 subjects (20 healthy and 20 patients) participated in this study. Two examiners measured the upper trapezius thickness and function 3 times by ultrasonography independently in the test and retest sessions.

RESULTS

There were not significant differences between two groups with respect to demographic characteristics. The ICC values were good to excellent for both measurements. There were no significant differences between the two groups, in terms of upper trapezius muscle thickness in rest (p = 0.63), fair (p = 0.75) and normal (p = 0.73) contractions. On the other hand, % rest-thickness fair (p = 0.006), % rest-thickness normal (p = 0.006), % MVC-thickness (p = 0.02) showed significant differences between two healthy and myofascial pain syndrome groups.

CONCLUSIONS

Ultrasonography is a reliable technique used to measure muscle thickness and function. Muscle thickness in rest, fair and normal contractions is not different between the matched groups of healthy people and myofascial pain syndrome subjects. Additionally, muscle function is less in myofascial pain syndrome subjects than healthy people specially % MVC thickness.

LUMINOUS database: lumbar multifidus muscle segmentation from ultrasound images

BACKGROUND

Among the paraspinal muscles, the structure and function of the lumbar multifidus (LM) has become of great interest to researchers and clinicians involved in lower back pain and muscle rehabilitation. Ultrasound (US) imaging of the LM muscle is a useful clinical tool which can be used in the assessment of muscle morphology and function. US is widely used due to its portability, cost-effectiveness, and ease-of-use. In order to assess muscle function, quantitative information of the LM must be extracted from the US image by means of manual segmentation. However, manual segmentation requires a higher level of training and experience and is characterized by a level of difficulty and subjectivity associated with image interpretation. Thus, the development of automated segmentation methods is warranted and would strongly benefit clinicians and researchers. The aim of this study is to provide a database which will contribute to the development of automated segmentation algorithms of the LM.

CONSTRUCTION AND CONTENT

This database provides the US ground truth of the left and right LM muscles at the L5 level (in prone and standing positions) of 109 young athletic adults involved in Concordia University's varsity teams. The LUMINOUS database contains the US images with their corresponding manually segmented binary masks, serving as the ground truth. The purpose of the database is to enable development and validation of deep learning algorithms used for automatic segmentation tasks related to the assessment of the LM cross-sectional area (CSA) and echo intensity (EI). The LUMINOUS database is publicly available at http://data.sonography.ai .

CONCLUSION

The development of automated segmentation algorithms based on this database will promote the standardization of LM measurements and facilitate comparison among studies. Moreover, it can accelerate the clinical implementation of quantitative muscle assessment in clinical and research settings.

Exploring the use of ultrasound imaging by physiotherapists: An international survey

BACKGROUND

National surveys in New Zealand, Australia and the United Kingdom suggest ultrasound imaging (USI) use by physiotherapists is increasing. However, concerns exist regarding clarity for scopes of practice, and availability and standardisation of training.

OBJECTIVES

To investigate physiotherapists' understanding of scopes of practice for the use of USI; clarify the professional contexts, clinical uses and levels of training; and identify barriers preventing physiotherapists' USI use.

DESIGN

A cross-sectional, observational survey.

METHODS

An Internet-based survey, offered in 20 different languages, was used including items covering five domains: (1) demographic and professional characteristics; (2) knowledge of scope of practice; (3) USI use; (4) USI training content and duration; and (5) perceived barriers to physiotherapists' use of USI.

RESULTS

1307 registered physiotherapists from 49 countries responded; 30% were unsure of the scope of practice for physiotherapists' USI use. 38% of participants were users of USI, reporting varied contexts and clinical uses, reflected in the broader categories of: (i) biofeedback; (ii) diagnosis; (iii) assessment; (iv) injection guidance; (v) research; (vi) and teaching. The training users received varied, with formal training more comprehensive. 62% were non-users, the most common barrier was lack of training (76%).

CONCLUSION

These findings suggest physiotherapists' USI use is increasing in various contexts; however, there is uncertainty regarding scopes of practice. There are discrepancies in training offered, with a lack of training the most common barrier to physiotherapists' use of USI. International guidelines, including a USI training framework, are needed to support the consistent and sustainable use of USI in physiotherapy.

Panoramic Ultrasound Examination of Posterior Neck Extensors in Healthy Subjects: Intra-Examiner Reliability Study

Previous studies analyzing morphometry of posterior cervical muscles with ultrasound (US) imaging have mainly used Brightness mode (B-mode). Our aim was to investigate the intra-examiner reliability of panoramic US imaging for assessing posterior-lateral cervical muscle layers. Panoramic US images of the neck at C4/C5 level were acquired in 25 asymptomatic subjects (40% women; mean age: 24 years) by an experienced assessor. The cross-sectional area (CSA) of the upper trapezius, splenius, semispinalis, multifidi, rotators, and levator scapulae was measured from panoramic US scans on two separate days. Intra-class correlation coefficients (ICC3,1), standard error of measurement (SEM), minimal detectable change (MDC) and mean, absolute and percent errors were calculated. In general, intra-examiner reliability was excellent with ICC3,1 ranging from 0.978 (trapezius) to 0.993 (semispinalis). The SEM ranged from 0.02 (multifidus) to 0.07 (semispinalis/levator), whereas the MDC ranged from 0.05 (cervical multifidus) to 0.19 (levator/semispinalis). Absolute error was lower than 0.11 cm² (levator/semispinalis). No differences between males and females were found. This study found that intra-examiner/rater reliability of panoramic US imaging was excellent for assessing the CSA of the posterior-lateral neck extensor muscles in asymptomatic subjects. The current findings suggest that panoramic US may be a reliable technique for examining the size of the cervical extensor muscles in both males and females.

Comparison of Ultrasonic Thickness of Masseter Muscle Between Individuals With and Without Severe Forward Head Posture: A Cross-Sectional Study

OBJECTIVE

In this cross-sectional descriptive-analytical study, we sought to compare the ultrasonic thickness of the masseter muscle in people with severe forward head posture vs people without forward head posture, and to determine sex differences in muscle thickness.

METHODS

Thirty-eight volunteers (19 with normal head postures and 19 with severe forward head postures), aged 18 to 35 years, entered the study. The severity of the forward head posture was measured by a plumb line and the craniovertebral angle drawn on the recorded images. Based on the recorded images, the masseter muscle thickness was also measured by a 7.5-MHz linear transducer using an ultrasound device in the seated position with 3 mouth positions (closed, half open, and fully open).

RESULTS

The results showed that the head posture affects masseter thickness significantly (P = .01), with masseter thickness significantly lower in the participants without severe forward head postures compared to those with severe forward head postures in the closed, half-open, and fully open mouth positions (P < .05). Comparing the mean masseter thickness across sexes showed that the masseter muscle is significantly thicker in men compared to women (P = .01).

CONCLUSION

Head posture and thickness of the masseter muscle are linked, as the masseter muscle was thicker in all 3 positions in the participants with severe forward head postures.

Evaluation of cervical spine muscles thickness in patients with cervical vertigo and healthy controls through ultrasonography

[Purpose] Cervical vertigo as a common complaint is associated with some musculoskeletal disorders. However, to date, ultrasonographical parameters of cervical muscles in patients with cervical vertigo have not been investigated. This study was conducted to investigate size of cervical muscles in patients with cervical vertigo compared to healthy controls. [Participants and Methods] Thicknesses of cervical flexor and extensor muscles were evaluated through ultrasonography and results were compared between the patients and healthy controls by Independent Samples t-test or Mann-Whitney U nonparametric test. [Results] Results showed that, thickness of Longus Colli muscle was significantly different between the patients and healthy controls. [Conclusion] According to findings of the study, size of Longus Colli muscle is likely to be associated with etiology of cervical vertigo.

Intra-rater and inter-rater reliability of rehabilitative ultrasound imaging of cervical multifidus muscle in healthy people: Imaging capturing and imaging calculation

BACKGROUND

Studies have analyzed muscle morphometry of cervical multifidus by using ultrasound imaging, but its reliability is not clearly determined.

OBJECTIVE

To investigate intra- and inter-rater reliability of imaging capturing (probe assessment/patient positioning) and imaging calculation (scan assessment) of cervical multifidus cross sectional area (CSA) by considering the assessor's experience in asymptomatic individuals.

DESIGN

Reliability study.

METHODS

The CSA of C4/C5 cervical multifidus was assessed in 16 asymptomatic subjects. Two examiners performed the imaging capture and also repeated the procedure (probe placement/patient positioning) twice with a 10-min period between each. Other two raters conducted imaging calculations of CSA. Intra-examiner imaging capturing reliability, each rater (experienced and novice) calculated multifidus CSA of both images obtained by each examiner. Inter-examiner imaging capturing reliability, each rater calculated the CSA obtained by each examiner at the first imaging attempt. For imaging calculation reliability, each rater calculated multifidus CSA of all images captured by both examiners. Intra-class correlation coefficients (ICC) and standard error of measurement (SEM) were calculated.

RESULTS

Intra- (ICC_3,1 0.988-0.996, SEM 0.3%-0.7%) and inter- (ICC_3,2 0.958-0.965, SEM 2.6%-3.2%) examiner reliability of imaging capturing was excellent. Intra- and inter-rater reliability of imaging calculation was also excellent for both raters (experienced/novice). No significant differences between experienced or novice examiners or testers were found.

CONCLUSIONS

This study found that intra- and inter-examiner/rater reliability of imaging capturing (probe assessment/patient positioning) and imaging calculation (scan assessment) of the cervical multifidus CSA at C4/C5 level was excellent in asymptomatic subjects.

The Effects of Thrust Joint Manipulation on the Resting and Contraction Thickness of Transversus Abdominis in Patients With Low Back Pain: A Randomized Control Trial

OBJECTIVE

To investigate the immediate changes in resting and contracted thickness of the transversus abdominis (TrA) muscle after application of thrust joint manipulation (TJM) vs sham manipulation in participants with low back pain.

METHODS

A pretest-posttest randomized controlled trial design was performed. Consecutive subjects satisfying eligibility criteria completed patient-report outcome baseline measures, pretreatment rehabilitative ultrasound imaging (RUSI) measurements, followed by the randomly assigned intervention then, post-treatment RUSI measurements, and post-treatment & final patient-reported outcome measures. To compare the outcomes of TJM and sham manipulation on the TrA muscle thickness, a 2-by-2 analysis of variance (treatment [TJM and sham manipulation]) by time (pretreatment and post-treatment) was completed for both the TrA muscle thickness at rest and muscle thickness during contraction. Descriptive statistics including independent-sample t tests for continuous variables and χ² tests for categorical variables were used to analyze differences in patient-reported outcome measures between groups.

RESULTS

Sixty-seven eligible participants agreed to participate. No significant interactions were identified for either muscle thickness at rest or contraction.

CONCLUSION

This study did not support the hypothesis that manipulation would result in greater changes in TrA thickness at rest or during contraction in participants with low back pain. Based on prior research that identified subgroups of participants likely to respond to manipulation, future research should include participants more likely to respond favorably to TJM. This study was a priori registered with clinicaltrails.gov (NCT02558855).

Intra-rater reliability of transversus abdominis measurement by a novice examiner: Comparison of "freehand" to "probe force device" method of real-time ultrasound imaging

A "free hand" real-time-ultrasound method is commonly applied to measure transversus abdominis. Potentially, this increases transversus abdominis measurement error due to uncontrolled variability in probe to skin force, inclination, and roll, particularly for novice examiners. This single-group repeated-measures reliability study compared the intra-rater reliability of transversus abdominis thickness and activation measurement by a novice examiner between free hand and a standardized probe force device method. The examiner captured ultrasound videos of transversus abdominis in a single session in healthy participants (n =  33). Free hand ultrasound featured uncontrolled probe force, inclination, and roll, while probe force device method ultrasound standardized these parameters. Images of transversus abdominis at rest and contracted were measured and transversus abdominis activation calculated. Intraclass correlation coefficient, coefficient of variation, standard error of measurement, and worthwhile differences were calculated. The probe force device method resulted in greater reliability (intraclass correlation coefficient = 0.75-0.96) and lower measurement error (coefficient of variation = 8.89-28.7%) compared to free hand (intraclass correlation coefficient = 0.63-0.93; coefficient of variation = 6.52-29.4%). Reliability was good for all measurements except free hand TrA-C, which was moderate. TrA-C had the lowest reliability, followed by contracted thickness of the transverse abdominis, with resting thickness of the transverse abdominis being highest. Worthwhile differences were lower using a probe force device method versus free hand for resting thickness of the transverse abdominis and contracted thickness of the transverse abdominis and similar for TrA-C. Standardization using probe force device method ultrasound to measure transversus abdominis improved intra-rater reliability in a novice examiner. Use of a probe force device method is recommended to improve reliability through reduced sources of measurement error. Probe force device method intra- and inter-rater reliability in examiners of varying experience, in clinical populations, and to visualize other structures merits exploration.

Automatic Characterizations of Lumbar Multifidus Muscle and Intramuscular Fat with Fuzzy C-means based Quantization from Ultrasound Images

BACKGROUND

Low Back Pain (LBP) is a common disorder involving the muscles and bones and about half of the people experience LBP at some point of their lives. Since the social economic cost and the recurrence rate over the lifetime is very high, the treatment/rehabilitation of chronic LBP is important to physiotherapists, both for clinical and research purposes. Trunk muscles such as the lumbar multifidi is important in spinal functions and intramuscular fat is also important in understanding pain control and rehabilitations. However, the analysis of such muscles and related fat require many human interventions and thus suffers from the operator subjectivity especially when the ultrasonography is used due to its cost-effectiveness and no radioactive risk.

AIMS

In this paper, we propose a fully automatic computer vision based software to compute the thickness of the lumbar multifidi muscles and to analyze intramuscular fat distribution in that area.

METHODS

The proposed system applies various image processing algorithms to enhance the intensity contrast of the image and measure the thickness of the target muscle. Intermuscular fat analysis is done by Fuzzy C-Means (FCM) clustering based quantization.

RESULTS

In experiment using 50 DICOM format ultrasound images from 50 subjects, the proposed system shows very promising result in computing the thickness of lumbar multifidi.

CONCLUSION

The proposed system have minimal discrepancy(less than 0.2 cm) from human expert for 72% (36 out of 50 cases) of the given data. Also, FCM based intramuscular fat analysis looks better than conventional histogram analysis.

Use of Cine Loops and Structural Landmarks in Ultrasound Image Processing Improves Reliability and Reduces Error in the Assessment of Foot and Leg Muscles

OBJECTIVES

Foot and leg muscle strength and size are crucial to proper function. It is important to assess these characteristics reliably. Our primary objective was to compare the measurement of still images to cine loops. The secondary purpose was to determine interoperator and intraoperator reliability between operators of different experience levels using video clips and internal and external landmarks.

METHODS

Twelve healthy volunteers participated in our study. Internal (navicular tuberosity) and external (lateral leg length at 30% and 50% from the knee joint line) landmarks were used. Two operators each captured and later measured still and cine loop images of selected foot and leg muscles.

RESULTS

The 12 participants included 8 male and 4 female volunteers (mean age ± SD, 23.5 ± 1.9 years). Good to excellent intraoperator and interoperator reliability was seen (intraclass correlation coefficient range of 0.946-0.998). The use of cine loops improved the intraclass correlation coefficients for both intraoperator and interoperator reliability (0.5%-4% increases). The use of cine loops decreased the intraoperator standard error of the measurement and limits of agreement of the novice operator (decreases of 45%-73% and 24%-51%, respectively), and these became comparable to those of experienced operators using still images. The interoperator standard errors of the measurement dropped by 42% to 53%, whereas the limits of agreement dropped by 27% to 40%. No substantial changes were noted in the tibialis anterior across reliability metrics.

CONCLUSIONS

Improved protocols that take advantage of using internal bony landmarks and cine loops during both the image-gathering and measurement processes improve the reliability of research examining muscle size changes in the lower leg or foot associated with muscle changes due to exercise, injury, disuse, or disease.

Nanoparticles-mediated Brain Imaging and Disease Prognosis by Conventional as well as Modern Modal Imaging Techniques: a Comparison

BACKGROUND

Multimodal imaging plays an important role in the diagnosis of brain disorders. Neurological disorders need to be diagnosed at an early stage for their effective treatment as later, it is very difficult to treat them. If possible, diagnosing at an early stage can be much helpful in curing the disease with less harm to the body. There is a need for advanced and multimodal imaging techniques for the same. This paper provides an overview of conventional as well as modern imaging techniques for brain diseases, specifically for tumor imaging. In this paper, different imaging modalities are discussed for tumor detection in the brain along with their advantages and disadvantages. Conjugation of two and more than two modalities provides more accurate information rather than a single modality. They can monitor and differentiate the cellular processes of normal and diseased condition with more clarity. The advent of molecular imaging, including reporter gene imaging, has opened the door of more advanced noninvasive detection of brain tumors. Due to specific optical properties, semiconducting polymer-based nanoparticles also play a pivotal role in imaging tumors.

OBJECTIVE

The objective of this paper is to review nanoparticles-mediated brain imaging and disease prognosis by conventional as well as modern modal imaging techniques.

CONCLUSION

We reviewed in detail various medical imaging techniques. This paper covers recent developments in detail and elaborates a possible research aspect for the readers in the field.

Ultrasound assessment of extensor pollicis brevis tendon excursion in different wrist positions in healthy people

STUDY DESIGN

Cross-sectional, observational study.

INTRODUCTION

There is little reported on the in vivo mechanics and behavior of extensor pollicis brevis (EPB) in relation to wrist position. Wrist position is known to significantly influence tendon excursion and therefore function of the digits. Ultrasound imaging (USI) can be used to assess in vivo tendon behavior and excursion. An improved knowledge of the excursion of the EPB tendon is important in understanding normal tendon mechanics and potentially pathological tendon disorders such as de Quervains tenosynovitis.

PURPOSE OF THE STUDY

To assess the reliability of using USI to measure EPB tendon excursion and to quantify EPB tendon excursion in 3 wrist positions.

METHODS

USI with speckle-tracking analysis were utilized to assess 49 normal EPB tendons (25 subjects). Tendon excursion was measured in wrist flexion (45°), wrist neutral and wrist extension (45°) on 2 different occasions.

RESULTS

The within- and between-session reliability of using USI to quantify EPB tendon excursion was "excellent" and "high," respectively. Wrist position had a significant influence on EPB tendon excursion (P ≤ .05). EPB excursion in the neutral wrist position was statistically greater than the other 2 positions (P < .05).

DISCUSSION

EPB tendon excursion has been shown to be dependent on the wrist positions of flexion and extension. The measures are notably lower than those found in cadaver studies; however, they follow a similar pattern with greatest excursion occurring in the neutral wrist position and least in flexion. This information is useful for EPB tendon rehabilitation and in consideration of biomechanics and pathogenesis of disorders that affect EPB tendon.

CONCLUSION

In vivo EPB tendon excursion measures have been quantified, and wrist position has been found to have an influence on excursion. USI with speckle-tracking analysis are considered to be reliable methods for measuring EPB tendon excursion.

Architectural Changes in the Medial Gastrocnemius on Sonography after Nerve Ablation in Healthy Adults

Architectural changes in healthy muscle after denervation have not yet been reported. This study aimed to investigate architectural changes in the medial head of the gastrocnemius muscle (GCM) after aesthetic tibial nerve ablation in healthy adults using ultrasonography (US). The effects of tibial nerve ablation were verified by visual observation and surface electromyography analysis. US images of medial GCMs were taken by one trained physician using B-mode and real-time US with a linear-array probe before nerve ablation, at 1 week after nerve ablation and at 3 months after nerve ablation in an anatomic standing position with the feet about shoulder-width apart in 19 healthy adults (17 females and 2 males). Muscle thickness was significantly reduced on the left side at 1 week and 3 months after the procedure and on the right side at 3 months after the procedure (p<0.050). Although fascicle length was not significantly changed, pennation angle was significantly reduced on both sides at 3 months after the procedure (p<0.050). Muscle thickness and pennation angle of the muscle fascicle were significantly reduced, although fascicle length was not significantly changed, after tibial nerve ablation in the medial GCM of healthy adults.

Imaging with ultrasound in physical therapy: What is the PT's scope of practice? A competency-based educational model and training recommendations

Physical therapists employ ultrasound (US) imaging technology for a broad range of clinical and research purposes. Despite this, few physical therapy regulatory bodies guide the use of US imaging, and there are limited continuing education opportunities for physical therapists to become proficient in using US within their professional scope of practice. Here, we (i) outline the current status of US use by physical therapists; (ii) define and describe four broad categories of physical therapy US applications (ie, rehabilitation, diagnostic, intervention and research US); (iii) discuss how US use relates to the scope of high value physical therapy practice and (iv) propose a broad framework for a competency-based education model for training physical therapists in US. This paper only discusses US imaging—not ‘therapeutic’ US. Thus, ‘imaging’ is implicit anywhere the term ‘ultrasound’ is used.

The Use of Neuromuscular Ultrasound and NCS/EMG Testing in the Differential Diagnosis of Carpal Tunnel Syndrome and Radiculopathy

BACKGROUND AND PURPOSE

The Neuromuscular ultrasound and Nerve conduction studies/Electromyography (NCS/EMG) are valuable diagnostic tools that examine and diagnose several nerve problems. The purpose of this case report is to describe a diagnostic electrophysiologic evaluation that differentiates between carpal tunnel syndrome (CTS) and radiculopathy in very mild or early stage cases.

CASE DESCRIPTION

The patient was a 30-year-old woman who sustained a tingling sensation in the second and third digits of her left hand, radiating pain in her left upper extremity and occasional neck pain. The patient cannot determine whether her radiating pain starts from the neck to her hand or starts from her hand up to the neck. Physical examination was not conclusive. Neuromuscular ultrasound and NCS/EMG were used to assess the median nerve at the carpal tunnel and the C6-7 nerve roots. A proof of the median nerve injury at the wrist was confirmed. The patient was treated with a night wrist splint.

OUTCOMES

The patient's symptoms were diminished after the use of the night splint for a period of approximately 4 weeks. A follow-up electrodiagnostic evaluation reveals improvement compared to the previous data with no electrophysiologic evidence of a current nerve injury status.

DISCUSSION

Neuromuscular ultrasound and NCS/EMG combined techniques helped in the differential diagnosis between CTS and C6-7 nerve roots radiculopathy. In this case, physical examination could not give an immediate conclusive answer.

Reliability of Real-time Ultrasound Imaging for the Assessment of Trunk Stabilizer Muscles: A Systematic Review of the Literature

Rehabilitative ultrasound (US) imaging is one of the popular methods for investigating muscle morphologic characteristics and dimensions in recent years. The reliability of this method has been investigated in different studies. As studies have been performed with different designs and quality, reported values of rehabilitative US have a wide range. The objective of this study was to systematically review the literature conducted on the reliability of rehabilitative US imaging for the assessment of deep abdominal and lumbar trunk muscle dimensions. The PubMed/MEDLINE, Scopus, Google Scholar, Science Direct, Embase, Physiotherapy Evidence, Ovid, and CINAHL databases were searched to identify original research articles conducted on the reliability of rehabilitative US imaging published from June 2007 to August 2017. The articles were qualitatively assessed; reliability data were extracted; and the methodological quality was evaluated by 2 independent reviewers. Of the 26 included studies, 16 were considered of high methodological quality. Except for 2 studies, all high-quality studies reported intraclass correlation coefficients (ICCs) for intra-rater reliability of 0.70 or greater. Also, ICCs reported for inter-rater reliability in high-quality studies were generally greater than 0.70. Among low-quality studies, reported ICCs ranged from 0.26 to 0.99 and 0.68 to 0.97 for intra- and inter-rater reliability, respectively. Also, the reported standard error of measurement and minimal detectable change for rehabilitative US were generally in an acceptable range. Generally, the results of the reviewed studies indicate that rehabilitative US imaging has good levels of both inter- and intra-rater reliability.

A Comparison of the Abdominal and Lumbar Multifidus Muscle Size in Patients With Lumbar Spondylolisthesis and Healthy Patients at Rest and During Contraction Using Ultrasonography

OBJECTIVE

Using ultrasonography, this study investigated the abdominal and lumbar multifidus muscle size in patients with lumbar spondylolisthesis compared with healthy patients at rest and during contraction.

METHODS

This research was a nonexperimental, analytic case-control study. Ultrasound imaging was used to assess the thickness of the abdominal and lumbar multifidus muscles in 25 healthy patients and 25 patients with spondylolisthesis. For the purpose of this study, both men and women, aged 30 to 70 years, were recruited from physiotherapy clinics affiliated with the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. Measurements were taken at rest and during contraction.

RESULTS

There was a significant difference in abdominal and lumbar multifidus muscle size between the healthy and spondylolisthesic groups, both at rest and contraction (P < .05 in all instances). No significant difference was found between the right and left for all measurements (P > .05).

CONCLUSION

Patients with spondylolisthesis had smaller stabilizer muscle thickness at rest and during contraction compared with the healthy group.

Criterion Validity of Ultrasound Imaging: Assessment of Multifidi Cross-Sectional Area in Older Adults With and Without Chronic Low Back Pain

BACKGROUND AND PURPOSE

Ultrasound (US) imaging may be a cost-conscious alternative to magnetic resonance imaging (MRI), which is the criterion standard for muscle cross-sectional area (CSA) assessment. Within the trunk, when compared with MRI, US has been shown to be valid for assessing lumbar multifidi CSA in younger, asymptomatic individuals. To date, there are no studies validating US for multifidi CSA assessment in older adults or individuals with low back pain. Given age- and pain-related muscle changes, validation of US is needed in these populations. If valid for multifidi CSA assessment, US may be used to evaluate short-term changes in muscle size in response to exercise-based interventions among older adults. The primary objective of this study was to evaluate the validity of US for multifidi CSA assessment as compared with MRI in older adults with and without chronic low back pain (CLBP). The secondary objective was to determine whether a single US image was valid for assessment of multifidi CSA or whether the average of 3 US images should be recommended.

METHODS

Twenty community-dwelling older adults (ie, 10 with and 10 without CLBP), ages 60 to 85 years, were recruited. US images and MRI slices of multifidi muscle were obtained and L4 multifidi CSAs were measured. Intraclass correlation coefficients (ICCs) were calculated to assess agreement between MRI measures and a single US image and MRI measures and the average of 3 US images.

RESULTS AND DISCUSSION

ICC point estimates were excellent for older adults with CLBP for a single US image (ICCs = 0.90-0.97), but ICC point estimates for participants without CLBP ranged from fair to excellent (ICCs = 0.48-0.86). ICC point estimates for the average of 3 US images for both groups were better than for a single image (ICCs = 0.95-0.99).

CONCLUSIONS

For assessment of L4 multifidi CSA, US is a valid alternative to MRI for older adults with and without CLBP. However, limitations of US, such as the inability to quantify intramuscular fat, which may be increased with aging and CLBP, should be considered. CSA measurement of 3 US images, rather than a single image, is recommended.