GUEST EDITORIAL / 73

GUESTEDITORIAL

current perspectives: The clinical application of ultrasound imaging by physical Therapists

In the lastdecade, therehasbeenconsiderablegrowth in theknowledgebase that is the foun-dation of neuromusculoskeletal rehabilitation. In particular, extensive focus has been placed uponidentifying theneuromuscularmechanismsconsistentwithhealthand the specific alterations thatunderliedysfunction.Fromthiswork,ithasbecomeevidentthataprimaryimpairmentseenindys-functionssuchaschroniccervical,lowback,andpelvicgirdlepainisoneofalteredneuromuscularcontrol as opposed to decreased strength or functional capacity1-5. Specifically, there appears to bea trendofevidenceconsistentwithaugmentedactivityof thesuperficialanddiminishedactivityofthedeepmusclesoftheseregions1-8.Alongsidetheevidence,ultrasoundimaging(UI)hasemergedasaclinical tool toaidphysical therapists in thedetectionand treatmentofalteredmotorcontrol9,10.However,aswithallnewtools,debatearisesonissuesofscopeofpractice,thespecificrolethenewtoolcanplayintherehabilitationprocess,andits limitations.

The scope of practice of physical therapy varies from jurisdiction to jurisdiction. The WorldConfederation of Physical Therapy11 has defined physical therapy as “…the assessment and treat-mentofneuromusculoskeletalandcardiorespiratorysystemsof thebodybyphysicalormechanicalmeans, forthepurposeofmaintenanceorrestorationof function,thathasbeenimpairedbyinjuryor disease, for pain management and for the promotion of mobility and health…” This statementclearly verifies that the rehabilitation of movement dysfunction and specifically dysfunction of theneuromusculoskeletalsystemiswithinthescopeofthephysicaltherapyprofession.Italsoconfirmsthataphysical therapist isqualifiedtoestablishaphysical therapydiagnosis,determineanindividu-al’smovementpotential, andplanand implementprograms,usingspecializedknowledge, skills, andtools, for thepreventionor treatmentofmovementdysfunction.UI is simplyonepotential toolandshouldbeviewedassuchinthesamelightas,say,astethoscope.Avarietyofhealthcareprovidersemployastethoscopeduringtheirdailypractice.Dependingontheinformationsought,theiruniqueareaoftraining,andtheirlevelofknowledge,thetoolisuseddifferently.TheusesofUIbyphysicaltherapistsmayvarydependingonthejurisdiction,itsspecificlicensingguidelines,andprofessionalregulation.InarecentreporttotheCollegeofPhysicalTherapistsofBritishColumbia,Canada12,agenericdefinitionregardingtheuseofUIbyphysicaltherapiststhatencompassescurrentclinicaluseshasbeenproposed.Itincludes“…applicationsthatresultinaphysicaldiagnosisofthestructureormovementcharacteristicsofmusclesand/ornervesinrelationtoadjacentstructures…”Atpresent,itisnotwithinthescopeofpracticeofNorthAmericanphysicaltherapiststomakeamedicaldiagnosisofalteredtissuemorphologybasedontheinterpretationof imagingstudies.

Ultrasoundimagingrelatedtomusculoskeletalrehabilitationhasbeenongoingsincethe1980’s13,andinvestigationhasestablishedthatithasaroleasasafe,cost-effective(asopposedtothealterna-tiveofmagneticresonanceimaging),andaccessiblemethodforvisualizingandmeasuringthedeepmusclesofthetrunk14-22.ThevalueofUIfromarehabilitativeperspectiveisthatitallowsfordynamicstudy (real-time images) of muscle groups as they contract. Consequently, the complementary useofUIcanenhancetheclinicalanalysisofthemusculaturesystemandhasbeenadvocatedbyvariousauthors5,9,10,23-27.Inadditiontoitsclinicalutility,numerousstudies17,20-22,28-34haveshownthatUIwith-stands scientific rigorwhenapplied ina thoughtfulmannerand that it isbothavalidand reliable

The Journal of Manual & Manipulative TherapyVol. 14 No. 2 (2006), 73 - 75

74 / The Journal of Manual & Manipulative Therapy, 2006

method toascertainmuscle size (through staticquantitativemeasurementsofmusclewidth, length,depth,cross-sectionalarea,orvolume)andhencecanbeusedasanindicatorofmuscleactivity.

Ultimately the matter of using real-time ultrasound imaging (RTUS) to describe a muscle con-traction is a complex issue. Although changes in static architectural measures tell a portion of thestory,consideredalonetheyprimarilyreflectmusclecapacity.Astheclinicalandscientificinterestinthemusculature system is related toalteredmotorcontrol, it is imperative thatmoreencompassingmethods of describing what is being seen on the ultrasound display are developed. Considering onlythe increase in an architectural measure of a muscle during a task is analogous to considering themaximal amountofEMGactivitywithout taking into account timingor impact onother structures.Furthermore,theinterpretationprocessiscomplicatedbythefactthattheamountofchangeseeninamuscle’sarchitecture(depth,width,andlength)duringacontractiondoesnotnecessarilyrepresenttheintensityoramountofactualmuscleactivity20,35.Thepotentialforadiscrepancyexistsduetospe-cificcharacteristicsof themuscleunder investigation, thenatureandlimitationsof two-dimensionalimaging(e.g.,musclecontractionproducesarchitecturalchangesinthreedimensionsasopposedtothetwodimensionsvisibleonanultrasounddisplay)aswellasthepotentialforachangeinmusclearchi-tectureduetothepresenceofacompetingforceonthemuscle(e.g.,protrusionandretractionoftheabdominalcontentsduringrespirationmayimpactthearchitectureoftheabdominalwallmuscles28,35).Hence,itiscriticalforthosewhoarenewtothetechnologytorealizethatittakestimetoaccumulatetheknowledge,andperfecttheskillsrequiredforaccurateinterpretationandmeasurement.

In the current environment of evidence-based practice and fiscal accountability, it is imperativethat physical therapists be allowed access to the tools that will optimize the effectiveness of theirinterventions. However, as this opportunity arises, it is critical that we not only rise to defend thelogicalinclusionofUIinourscopeofpracticeifchallenged,butthatwedeterminehowthistoolcanbestbenefitourpatients.Contiguoustothistaskistheresponsibilityassociatedwithqualitycontrol,accreditation, and development of policies to ensure the safe and appropriate use of the technologybythemembersofourprofession.AlthoughtheevidencesupportingtheclinicaluseofRTUSisonlybeginning to emerge, there is little doubt that it contributes previously unavailable and unrivaledinformation. Thus, it is my opinion that by incorporating the information available from RTUS withour existing diagnostic and management skills, thoughtful patient selection and as a component ofa multi-modal treatment program, rehabilitation aimed at restoration of neuromuscular function islikelytobeenhanced.

JackieWhittakerBScPT,FCAMT,CGIMS,CAFCIWhittakerPhysiotherapyConsulting#101,12761-16thAveSurrey,BritishColumbiaV4A1N2Canadawww.RTUSPT.com

references1. JullGA,RichardsonCA.Motorcontrolproblemsinpatientswithspinalpain:Anewdirectionfortherapeuticexercises.J

Manipulative Physiol Ther2000;23:115-117.2. HodgesPW,MoseleyLG.Painandmotorcontrolofthelumbopelvicregion:Effectandpossiblemechanisms.J Electromyogr

Kinesiol 2003;13:361-370.3. FallaD,JullG,HodgesPW.Feedforwardactivityofthecervicalflexormusclesduringvoluntaryarmmovementsisdelayed

inchronicneckpain.Exp Brain Res 2004;157:43-48.4. FallaD,BilenkijG,JullG.Patientswithchronicneckpaindemonstratealteredpatternsofmuscleactivationduringper-

formanceofafunctionalupperlimbtask.Spine2004;29:1436-1440.5. RichardsonCA,HodgesPW,HidesJA.Therapeutic Exercise for Lumbopelvic Stabilization: A Motor Control Approach for

the Treatment and Prevention of Low Back Pain.2nded.Edinburgh,Scotland:ChurchillLivingstone,2004.6. ShiradoO,ItoT,KanedaK,StraxTE.Flexion–relaxationphenomenoninthebackmuscles.Acomparativestudybetween

healthysubjectsandpatientswithchroniclowbackpain.Am J Phys Med Rehabil1995;74:139–144.7. NgJKF,RichardsonCA,ParnianpourM,KippersV.EMGactivityoftrunkmusclesandtorqueoutputduringisometricaxial

rotationexertion:Acomparisonbetweenbackpainpatientsandmatchedcontrols.J Orthop Res2002;20:112-121.8. VanDieenJH,CholewickiJ,RadeboldA.Trunkmusclerecruitmentpatternsinpatientswithlowbackpainenhancedthe

GUEST EDITORIAL / 75

stabilityofthelumbarspine.Spine2003;28:834-841.9. HidesJ,RichardsonCA,JullGA,DaviesS.Ultrasoundimaginginrehabilitation.Aust J Physiother 1995;41:187-193.10.StokesM,HidersJ,NassiriDK.Musculoskeletalultrasoundimaging:Diagnosticandtreatmentaidinrehabilitation.Phys

Ther Rev1997;2:73-92.11.WCPTWorldConfederationforPhysicalTherapy.Declaration of Principle and Position Statements.Availableat: http://wcpt.org/common/docs/WCPTPolicies.pdf.AccessedJanuary11,2006.12.WhittakerJL.Recommendations for the Implementation of Real Time Ultrasound Imaging in Physical Therapy Practice:

The Final Report of a College of Physical Therapists of British Columbia, Canada Real Time Ultrasound Imaging Ad Hoc Committee.Vancouver,BC:CPTBC,2004.

13.StokesM,YoungA.Measurementofquadricepscross-sectionalareabyultrasonography:Adescriptionof the techniqueanditsapplicationinphysiotherapy.Physiother Theory Pract1986;2:31-36.

14.BernsteinI,JuulN,GronvallSetal.Pelvicfloormusclethicknessmeasuredbyperinealultrasonography.Scand J Nephrol 1991;137:S131-S133.

15.Hides J, Richardson CA, Jull GA. Magnetic resonance imaging and ultrasonography of the lumbar multifidus muscle;comparisonoftwodifferentmodalities.Spine 1995;20:54-58

16.BlaneyF,EnglishCS,SawyerT.Sonographicmeasurementofdiaphragmaticdisplacementduringtidalbreathingmaneu-vers:Areliabilitystudy.Aust J Physiother1999;45:41-43.

17.BunceSM,MooreAP,HoughAD.M-modeultrasound:Areliablemeasureoftransversusabdoministhickness?Clin Biomech2002;17:315-317.

18.Kremkau FW. Diagnostic Ultrasound: Principles and Instruments. 6th ed. Philadelphia, PA: WB Saunders Company,2002.

19.NyborgWL.Safetyofmedicaldiagnosticultrasound.Sem Ultrasound CT MR 2002;23:377-386.20.HodgesPW,PengelLHM,HerbertRD,GandeviaSC.Measurementofmusclecontractionwithultrasoundimaging.Muscle

Nerve2003;27:682-692.21.RankinG,StokesM,NewhamDJ.Sizeandshapeoftheposteriorneckmusclesmeasuredbyultrasoundimaging:Values

inmalesandfemalesofdifferentages. Man Ther 2005:10;108-115.22.StokesM,RankinG,NewhamDJ.Ultrasoundimagingoflumbarmultifidusmuscle:Normalreferencerangesformeasure-

mentsandpracticalguidanceonthetechnique. Man Ther 2005;10:116-126.23.KermodeF.Benefitsofutilizingreal-timeultrasoundimagingintherehabilitationofthelumbarspinestabilizingmuscles

followinglowbackinjuryintheeliteathlete:Asingecasestudy. Phys Ther Sport2004;5:13-16.24.WhittakerJL.Abdominalultrasoundimagingofpelvicfloormusclefunctioninindividualswithlowbackpain.J Manual

Manipulative Ther 2004;12:44-49.25.WhittakerJL.Real-timeultrasoundanalysisof localsystemfunction.In:LeeDG. The Pelvic Girdle: An Approach to the

Examination and Treatment of the Lumbopelvic-Hip Region.3rded. London,England:ChurchillLivingstone,2004.26.Whittaker JL. The Clinical Application of Ultrasound Imaging for Rehabilitation of the Lumbopelvic Region. London,

England:ChurchillLivingstone,(inpress). 27.HenrySM,WesterveltKC.Theuseofreal-timeultrasoundfeedbackinteachingabdominalhollowingexercisestohealthy

subjects.J Orthop Sports Phys Ther 2005;36:338-345.28.WhittakerJL.Ultrasoundimagingcharacteristicsofindividualswithpelvicinstabilityandconcurrentrespiratorydysfunc-

tion.Man Ther (submitted).29.DeTroyerA,EstenneM,NinaneVetal.Transversusabdominismusclefunctioninhumans.J Appl Physiol 1990;68:1010-

1016.30.SchaerGN,PerucchiniD,MunzE,PeschersU,KoechliOR,DelancyJOL.Sonographicevaluationofthebladderneckin

continentandstress-incontinentwomen.Obstet Gynecol1999;93:412-416.31.FerreiraPH,FerreiraML,HodgesPW.Changes in recruitmentof theabdominalmuscles inpeoplewith lowbackpain:

Ultrasoundmeasurementofmuscleactivity.Spine 2004;29:2560-2566.32.BunceSM,HoughAD,MooreAP.MeasurementofabdominalmusclethicknessusingM-modeultrasoundimagingduring

functionalactivities.Man Ther 2004;9:41-44.33.ThompsonJA,O’SullivanPB,BriffaK,NeumannP,CourtS.Assessmentofpelvicfloormovementusingtransabdominal

andtransperinealultrasound.Int Urogynecol J 2005;16:285-292.34.TeyhanD,MiltenbergerCE,DeitersHMetal.Theuseofultrasound imagingof theabdominaldrawing inmaneuver in

subjectswithlowbackpain.J Orthop Sports Phys Ther 2005;35:346-355.35.HodgesPW.Ultrasoundimaginginrehabilitation:Justafad?J Orthop Sports Phys Ther 2005;35:333-337.

TheJournalofManualandManipulativeTherapyisindexedintheCumulativeIndextoNursingandAlliedHealthLiterature(CINAHL),EBSCOdatabases,andinEMBASE,theExcerptaMedicadatabase.