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Manual Therapy 16 (2011) 44e45

Contents lists avai

Manual Therapy

journal homepage: www.elsevier .com/math

3rd International conference on movement dysfunction 2009

Rehabilitative ultrasound imaging for assessment and treatmentof musculoskeletal conditions

Deydre S. Teyhen*

U.S. Army-Baylor University, 3151 Scott Road, Room 1301, ATTN: MCCS-HGE-PT (LTC Teyhen), Fort Sam Houston, TX 78234, USA

a r t i c l e i n f o

Article history:Received 25 March 2010Received in revised form27 June 2010Accepted 29 June 2010

Keywords:Low back painPhysical therapyRehabilitationUltrasound imaging

* Tel.: þ1 210 221 8410; fax: þ1 210 221 7585.E-mail address: deydre.teyhen@us.army.mil.

1356-689X/$ e see front matter Published by Elseviedoi:10.1016/j.math.2010.06.012

1. Background imaging (RUSI) and defined as “a procedure used by physical

Over the past decade, researchers have increasingly identifiedassociations between neuromusculoskeletal disorders such as lowback pain and underlying neuromuscular control deficits (Hodgesand Moseley, 2003). However, reliable and valid non-invasivemeasurement strategies to assess neuromuscular control deficitsthat could be employed in a clinical setting have been scarce.Evidence for the use of ultrasound imaging as a strategy to assistwith these patient populations is growing. The use of ultrasoundtechnology for medical applications began in the 1950s and hasproven to be an effective, safe, non-invasive, and relatively inex-pensive tool for assessing morphologic characteristics and struc-tural integrity of visceral organs and soft tissues. The use ofultrasound to assess muscle morphology and guide rehabilitationdecision-making in physical therapy practice can be traced back tothe late 1960s (Whittaker et al., 2007) and has been found to bereliable and valid (Koppenhaver et al., 2009) for specific musclesduring particular movements. Over the last decade there has beenrapid development of this technique with increased use both byclinicians and researchers.

2. Definition

The use of ultrasound imaging in the rehabilitation of neuro-musculoskeletal disorders has been called rehabilitative ultrasound

r Ltd.

therapists to evaluate muscle and related soft tissue morphologyand function during exercise and physical tasks. RUSI is used toassist in the application of therapeutic interventions aimed atimproving neuromuscular function. This includes providing feed-back to the patient and physical therapist to improve clinicaloutcomes. Additionally, RUSI is used in basic, applied, and clinicalrehabilitative research to inform clinical practice” (Teyhen, 2006).Although b-mode ultrasound imaging is most commonly used forRUSI, other ultrasound technique such as m-mode, high-frame rateultrasound imaging, and elastography may provide additionalbenefits in the assessment of tissue movement and deformation(Whittaker et al., 2007).

3. Clinical assessments

RUSI has been advocated to improve the understanding of therelationship between motor control and function, determine whichpatients may benefit from a specific exercise treatment approach,enhance treatment efficacy via augmented feedback, and docu-ment the benefits of specific exercise treatment approaches. Forspecific muscles and movements, RUSI has been found to be a validmeasure to qualitatively and quantitatively assess muscle structure(morphology) and function (Koppenhaver et al., 2009). From anevaluation perspective, measurements of morphology includevariables such as muscle length, thickness, width, cross-sectionalarea, and pennation angles (Whittaker et al., 2007). Thesemeasurements can be obtained at rest and during contraction andare commonly used as an indirect assessment of muscle activation.

D.S. Teyhen / Manual Therapy 16 (2011) 44e45 45

In our research lab we have been able to determine that those withunilateral low back pain demonstrated a decrease change inmuscular thickness of the transversus abdominis (TrA) muscleduring the abdominal drawing-in maneuver and the active straightleg raise (Teyhen et al., 2009a,b). These measured differences mayrepresent a diminished response of the TrA muscle during thosetasks or an altered recruitment strategy. Qualitative assessment ofmuscular contractions can also provide valuable information; suchas the impact of the muscular contraction on associated structures(i.e., fascia and or organs such as the bladder). The ability to visu-alize these altered strategies helps to inform the clinician regardingunderlyingmotor control deficits andmay lead to improved clinicaldecision making.

One of the clinical utilizations of RUSI is related to prescribinginterventions aimed at addressing these specific motor controlimpairments. For example, deficits in TrA and lumbar multifidusactivation during motor control tasks such as the abdominaldrawing-in maneuver and lumbar multifidus swell can be visuallyappreciated by the patient and the provider. Allowing the patient toactually “see” his or her muscle impairment may result in betterpatient understanding and improved commitment to theirprescribed exercise treatment. Additionally, RUSI can be used asa biofeedback device during specific exercise performance whichhas been shown to result in improved performance and betterretention (Henry and Teyhen, 2007). RUSI can also assist thedevelopment of individualized exercise prescriptions by allowingthe clinician to watch the changes in muscular thickness duringexercise performance to ensure themuscle targeted by the clinicianis effectively recruited by the patient. Visual confirmation of properperformance of the prescribed exercises can lead to more preciseexercise prescriptions, improved exercise progressions, and hope-fully enhanced patient outcomes. Finally, RUSI can also be used to

provide feedback regarding the impact of other interventions suchas manipulation or dry-needling on the neuromotor controlsystem. For example, RUSI could be utilized to measure changespre- and post manipulation to assess the impact of manipulation onresting and contracted muscle thickness.

Disclaimer

The view(s) expressed herein are those of the author(s) and donot reflect the official policy or position of Brooke Army MedicalCenter, the US ArmyMedical Department, the US Army Office of theSurgeon General, the Department of the Army, Department ofDefense or the US Government.

References

Henry SM, Teyhen DS. Ultrasound imaging as a feedback tool in the rehabilitation oftrunk muscle dysfunction for people with low back pain. J Orthop Sports PhysTher 2007;37:627e34.

Hodges PW, Moseley GL. Pain and motor control of the lumbopelvic region: effectand possible mechanisms. J Electromyogr Kinesiol 2003;13:361e70.

Koppenhaver SL, Hebert JJ, Parent EC, Fritz JM. Rehabilitative ultrasound imaging isa valid measure of trunk muscle size and activation during most isometric sub-maximal contractions: a systematic review. Aust J Physiother 2009;55:153e69.

Teyhen D. Rehabilitative ultrasound imaging symposium San Antonio, TX. J OrthopSports Phys Ther May 8e10, 2006;36:A1e3.

Teyhen DS, Bluemle LN, Dolbeer JA, Baker SE, Molloy JM, Whittaker JL, et al. Changesin lateral abdominal muscle thickness during the abdominal drawing-inmaneuver in those with lumbopelvic pain. J Orthop Sports Phys Ther2009a;39:791e8.

Teyhen DS, Williamson JN, Carlson NH, Suttles ST, O’Laughlin SJ, Whittaker JL, et al.Ultrasound characteristics of the deep abdominal muscles during the activestraight leg raise test. Arch Phys Med Rehabil 2009b;90:761e7.

Whittaker JL, Teyhen DS, Elliott JM, Cook K, Langevin HM, Dahl HH, et al. Reha-bilitative ultrasound imaging: understanding the technology and its applica-tions. J Orthop Sports Phys Ther 2007;37(8):434e49.