Rehabilitative Ultrasound Imaging: A Musculoskeletal Perspective

Rehabilitative
Ultrasound
Imaging: a
Musculoskeletal
Perspective
Presented by: Zinat Ashnagar

Introduction
 Ultrasound imaging (USI) has been used for
medical purposes since the 1950s.
 Ultrasound imaging related to
musculoskeletal rehabilitation has been
developing rapidly since the 1980s.
2

 The first report of muscle imaging
linked to rehabilitation was in
1968, when Ikai and Fukunaga
related the size of the upper arm
muscles to strength.
4

 It was the work of Dr Archie Young and colleagues
at the University of Oxford in the 1980s that sowed
the seeds for the use of USI by physical therapists.
 A recent (1990s) resurgence in the interest of
rehabilitative applications of USI has been seen
amongst clinical therapists.
5

6
Detect atrophy of the lumbar multifidus in
individuals with acute low back pain (Hides et
al,1994) USIHides et al,1994.pdf
Recovery of this muscle was not automatic
when pain subsided (Hides, Richardson & Jull, 1996)
USIHides, Richardson et al,1996.pdf
The biofeedback provided by USI might
facilitate the relearning process.

dRehabilitative USI (RUSI)
Current applications of USI in rehabilitation
essentially fall into 2 distinct areas of
musculoskeletal imaging:
Diagnostic imaging
7

Rehabilitative USI (RUSI)
1. evaluation of muscle structure (morphology)
and behavior
2. the use of USI as a biofeedback mechanism
9

• the measurement of morphological
features (morphometry), such as:
• muscle length
• depth
• diameter
• cross-sectional area
• volume
• pennation angles
10

 changes in these features and the impact on
associated structures (fascia and organs such as
the bladder) with contraction
 tissue movement and deformation (eg, high-
frame-rate USI and elastography)
qualitative evaluation of muscle tissue density.
11

• In May 2006, the first international meeting
on RUSI was hosted by the US Army-Baylor
University Doctoral Program in Physical
Therapy in San Antonio, TX.
• USIUSI.SYMPOSIUM.pdf
12

• The purpose of the symposium was to develop
best practice guidelines for the use of USI
for the abdominal, pelvic, and paraspinal
muscles, and to develop an international and
collaborative research agenda related to the
use of USI by physical therapists.
• At that symposium the participants agreed on
the use of the term RUSI.
13

“RUSI is a procedure used by physical
therapists to evaluate muscle and related
soft tissue morphology and function
during exercise and physical tasks.
 RUSI is used to assist in the application
of therapeutic interventions aimed at
improving neuromuscular function.
14

This includes providing feedback to the
patient and physical therapist to
improve clinical outcomes.
 Additionally, RUSI is used in basic,
applied, and clinical rehabilitative
research to inform clinical practice.
15

Basic Physics
• Penetration
– Intensity
– Frequency
– Speed of sound wave
• Attenuation
– Reflection
– Scattering
– Refraction
– Absorption
16

17
Mechanism of RUSI
When a sound wave
encounters an
interface, the portion
that is reflected
back to its source is
referred to as
“reflection” and
serves as the basis
for image formation.

At every tissue interface, sound waves are
absorbed, reflected, and/or scattered.
When sound energy reflects back to the
ultrasound probe, the unit can determine:
1. where along the length of the
transducer it arrived,
2. how long it has taken to go out and
come back,
1. its amplitude
19

the ultrasound unit uses these 3
parameters to assign the echo from a
particular structure a pixel (picture
element).
The horizontal location of the pixel is
determined by the location to which the
echo returns along the length of the
probe face.
20

vertical placement is determined by the
amount of time the sound takes to go out
and come back.
The brightness of the pixel depends on
the strength of the returning echo;
The stronger the echo, the whiter, and
the weaker the echo, the darker it will
appear.
21

22
Illustration of how a B-mode ultrasound image is generated. (A) Sound waves
penetrate into the tissues. At each interface, a portion of the sound wave is
reflected back to the transducer. (B) The unit can determine where along the
face of the transducer the echo returned, the amount of time it was away, and
its amplitude. It uses these 3 parameters to determine the vertical (time) and
horizontal (transducer) location of a pixel representing the echo from a particular
structure, and the amplitude to determine the brightness. (C) This process is
repeated until an ultrasound image is generated.

Terminology
 Echogenicity: Capacity of a structure in
the path of an ultrasound beam to
reflect back sound waves.
 Hyperechoic: The structure examined
in the ultrasound image shows a high
reflective pattern and appears brighter
than the surrounding tissue.
23

 Isoechoic: The structure demonstrates
the same echogenicity as the surrounding
soft tissues.
 Hypoechoic: The structure examined in
the ultrasound image shows a low
reflective pattern, manifesting as an
area where the echoes are not as bright
as the surrounding tissue.
24

 Anechoic: The image of the structure
shows no internal echoes (e.g., simple
fluid).
 Longitudinal Scan: is lengthwise and
parallel to the long axis of the
structure, organ, or body part.
 Transverse Scan: is crosswise and at
right angles to the long axis of the
structure, organ, or body part.
25

26
(A) An ultrasound image of the bladder. Note the hypoechoic nature (black) of the
urine. (B) A transverse ultrasound image of the fifth lumbar vertebrae. Note the
brightness of the muscle bone (lamina) interface (arrows). (C) An ultrasound image
of the muscle and fascia layers of the lateral abdominal wall. Note that the muscle
layers are darker (hypoechoic), while the intervening fascia is brighter
(hyperechoic). Abbreviations: EO, external oblique; IO, internal oblique; SP,
spinous process; TrA, transversus abdominis.

Frequency
The choice of frequency used for an imaging
application will be dependent upon the depth
of the region or structures of interest.
• Higher frequencies (7.5-10.0 MHz) are more
valuable for examining superficial structures
(superficial muscles, ligament, and tendons).
• Lower frequencies (3.5-5.0 MHz) for deeper
structures (deeper muscles, the bladder, and
contents of the abdominal/pelvic cavities).
35

USI devices generate images based upon
several assumptions:
sound travels in straight lines, echoes only
originate from objects located in the 2
dimensions of the sound beam
 the amplitude of an echo is directly related to
the reflecting or scattering properties of the
objects it encounters
the speed at which sound travels through all the
tissues is a constant 1540 m/s
36

Artifacts
Artifacts
Acoustic
enhancement
ReverberationReverberation
Acoustic
shadowing
37

Brightness mode & Motion mode
USI
There are several options (modes) available to
display the electrical signal representing the
ultrasound echo that returns from the tissues.
The most common modes of display employed in
rehabilitative settings are “B” (brightness,
brilliance) and “M” (motion, movement) modes.
b-mode
m-mode
42

B-Mode USI
B-mode displays the ultrasound echo as a cross-
sectional grey-scale image and is the mode of
display most typically associated with USI.
B-mode images provide information gathered from
the entire length of the transducer and consist
of visible dots or pixels of varying degrees of
brightness that represent the location and
density of structures encountered by the
ultrasound beam.
43

44
A brightness mode (b-mode) image of the lateral abdominal
wall. Abbreviations: EO, external oblique; IO, internal oblique;
TrA, transversus abdominis.

M-Mode
M-mode displays information collected from
the midpoint of the transducer as a continuous
image over time.
 With time on the x-axis, and the depth of the
underlying anatomical structure on the y-axis,
the m-mode image represents changes in
thickness, or depth of a structure, over time
and is, therefore, referred to as “time-motion”
mode.
45

46
A split-screen image with b-mode on the left and motion mode (m-mode) on the
right. The m-mode image represents the information from the dotted line on the
b-mode image displayed over time (x-axis). Static structures produce straight
interfaces while structures that change in thickness or depth (in this case the
TrA) create curved interfaces. The increase in depth of the TrA correlates to a
contraction.

High-Frame-Rate USI
Conventional m-mode ultrasound images are
constructed from data updated approximately
25 to 50 times per second.
Although these frame rates are capable of
detecting deformation (thickness) and changes in
the depth of a muscle, they are not high enough
to provide information related to the normal
anticipatory response demonstrated by certain
muscles and the loss of this response with
dysfunction.
47

In fact, to be able to record anticipatory
muscle response (defined as a contraction
occurring from 100 milliseconds before
and up to 50 milliseconds after activation
of a prime mover ) frame rates need to
be on the order of 500 frames per
second.
48

Although intramuscular EMG is considered
the gold standard for evaluating onset of
muscle activity, high-frame-rate m-mode
USI is a promising noninvasive alternative,
as it allows for the visualization of the
onset of deformation of muscle as it
starts to contract.
49

Elastography
It is possible to post process the electrical signal
produced from the echo returning from the
tissues to the transducer in such a way as to
quantify tissue movement and deformation in
response to internal or external mechanical
forces.
Elastography is a process of estimating the
biomechanical properties (elasticity) of tissues
through imaging techniques.
50

Tissue hardness can be determined by applying a
known pressure on the tissue under study.
 Because pathologic tissues distinctively have
different biomechanical properties from normal
tissues, elastography can help monitor
pathologic conditions.
Therefore, the elastic properties of tissues can
be helpful in making a diagnosis of pathology.
51

The principles of elastography are as
follows:
 First, tissue compression produces strain and
displacement within the tissue.
 Second, the strain is smaller in harder tissue
than it is in softer tissue.
 Lastly, tissue hardness can be estimated by
measuring the tissue strain induced by
compression.
52

It is important to keep in mind that
elastography images do not directly
represent tissue elasticity but, rather,
tissue displacement and strain.
However, in conditions in which local
tissue stress can be calculated (or
estimated), strain and stress values can
be used to map local tissue stiffness.
53

USI versus other imaging methods
Although MRI is considered the gold
standard for musculoskeletal imaging,
emerging applications of USI and CT are
capable of providing insight into in vivo
features of the musculoskeletal system.
Each imaging method has strengths as well
as weaknesses.
54

Magnetic Resonance Imaging
MRI, unlike USI, has multiplanar and multislice
imaging capabilities.
There are 2 conventional MRI sequences:
T1 and T2 weighted.
Images from T1-weighted scans demonstrate
excellent anatomical contrast of fat and other
soft aqueous tissues (e.g, skeletal muscle).
55

T2-weighted scans provide outstanding detail
related to the features of inflammation that are
suggestive of neopathological conditions.
The drawbacks of MRI remain cost, accessibility,
constraints in the number of joints that can be
investigated per session, limited real-time
imaging capacity, and variable patient tolerance
(e.g, metallic implants, pacemaker,
and pregnancy).
56

Computerized Tomography
CT, like MRI but unlike USI, permits
multislice imaging and can offer better
scan resolution and shorter imaging times
than MRI.
It is not without the inherent risks
associated with exposing a patient to
ionizing radiation.
57

CT is useful in diagnosing traumatic
musculoskeletal injuries, such as
fractures, and has been effectively used
to evaluate and quantify cross-sectional
area of paraspinal musculature in patients
with low back pain.
While CT produces high-quality images,
they are dependent on tissue densities in
order to provide contrast.
58

When tissue densities between pathologic
and adjacent anatomy are similar, contrast
media may be required for
differentiation, rendering CT inadequate
if a patient has a history of contrast
reaction.
59

Ultrasound Imaging
USI, although less sophisticated in terms of
resolution than MRI and CT, has
advantages as a safe, cost-effective,
portable, and clinically accessible method
for gathering information about the static
characteristics of muscle, as well as muscle
behavior during dynamic events.
60

Unlike CT, USI does not expose the patient to
ionizing radiation and is well tolerated by
patients.
A feature unique to USI is its dynamic
capability of scanning in real time, which makes
it superior to MRI and CT for evaluating mobile
structures such as tendons, nerves, and
muscles, and it may become an important tool
for directing appropriate physical therapy
treatment decisions.
61

USI is not without disadvantages and is highly
operator dependent.
Perhaps the most promising feature of USI is
its accessibility and the feasibility for physical
therapists to acquire the skills needed to
incorporate its use into clinical practice.
However, evidence for its use in different
applications within rehabilitation is needed
before widespread routine clinical use can be
promoted.
62

Ultrasound Imaging & Muscle Function
What is the relationship between
the pattern and magnitude of
change in muscle size and muscle
function ?
64

One aspect of muscle function that has
been compared to change in muscle size
is muscle electrical activity.
What is the relationship between
changes in muscle size (measured with
USI) and muscle activity (measured
with EMG)?
65

 The findings are clearly inconclusive,
with correlation statistics ranging
anywhere from 0.14 to 0.93.
McMeeken et al., reported a linear
relationship between 2 measurements
(thickness and EMG signal amplitude)
for the TrA (R2 = 0.87).
67

 Hodges et al., described a nonlinear
relationship (the majority of thickness
change occurring within the first 22% of EMG
signal amplitude) for the external oblique
(EO) (r = 0.23), IO (r = 0.93),and TrA
(r = 0.90) muscles.
 Brown and McGill found no definitive
relationship for the EO (r = 0.22) and
IO (r = 0.14) during contraction.
68

There are many factors, in addition to
muscle activity, that may influence
changes in muscle thickness or size.
the resting state (activity and length)
of the muscle,
 the extensibility (compliance)
structure (parallel versus pennate
muscle fiber orientation) of a
musculotendinous unit,
the type of contraction taking place
(isometric, concentric, eccentric)
69

the presence of external forces that an
expanding muscle must compete against
(eg, increases in intra-abdominal pressure
or contraction of adjacent muscles)
out-of-plane changes
 imaging technique
70

Consideration of each of the mentioned
factors and their influence on changes in
muscle size is critical when attempting to
interpret the findings of
a dynamic imaging study.
71

72
An illustration of factors that influence the change in thickness of
a muscle. (A) An increase in thickness and decrease in length of
a normal muscle (gray, at rest, precontraction; black, active,
contracted) during a submaximal concentric contraction. (B) A
relatively smaller increase in thickness and decrease in length
then seen in a normal muscle, due to increased resting activity
(e.g, secondary to pain).

73
(C) An increase in the extensibility of the myofascial unit (e.g,
postpartum). (D) Competing forces, specifically an increase in
resistance from an adjacent muscle contracting (2-headed black
arrows), and an increase in intra-abdominal pressure
(black upward pointing arrows).

In addition to factors associated with the
myofascial unit, it is also important to
consider those associated with
interpreting 2-dimensional ultrasound
images and the imaging technique itself,
specifically, architectural changes
occurring outside of the plane of motion
being imaged.
74

75
An illustration of a multifidus contraction in the
transverse plane, resulting in an increase in
the cross-sectional area (CSA) of the muscle.

76
(B) A transverse ultrasound image of a multifidus contraction, depicting
both an increase in thickness and width associated with the overall
increase in CSA. (C) A sagittal ultrasound image of a multifidus
contraction, depicting only an increase in thickness of the multifidus, as
the increase in width cannot be viewed from this imaging plane.
Abbreviations: MF, multifidus; SP, spinous process.

Therefore, although USI may be a valid
and reliable measure of muscle size
(in healthy populations), it is not surprising
that the literature regarding the
relationship between increases in muscle
activity (EMG) and thickness change
(USI) is not conclusive, with changes in
muscle size and muscle activity not
always demonstrating a direct
relationship.
77

it is important to consider that, in addition to not
establishing a relationship between USI and
EMG measures, these studies have been
conducted on small numbers of young, healthy
participants in nonclinical environments.
Consequently, there is a lack of information
regarding this relationship in other populations
or during other dynamic maneuvers.
Therefore, the validity or ability to use USI to
quantify muscle activity is, at best, context
dependent.
78

Rehabilitative
Ultrasound
Imaging of
the
Abdominal
Muscles
79

RUSI is particularly relevant for
assessment and rehabilitation of the
abdominal muscles, as it provides one of
the only clinical methods to appraise the
morphology and behavior of the deepest
abdominal muscle, the Transversus
Abdominis (TrA), which is a common
target of rehabilitation in contemporary
exercise management of certain types of
low back and pelvic pain.
80

Anterior view of the regions
of the abdominal wall.
1.The upper region is above
the 11th costal cartilage,
2.the middle region is
between the 11th costal
cartilage and the iliac crest;
3.the lower region is below
the level of the iliac crest.
81

Ultrasound image of the left lateral abdominal wall, in
which normal resting activity is assumed.
In the region between the inferior aspect of the rib cage
and the superior aspect of the iliac crest, the OI muscle
is the thickest, followed by OE, and then TrA muscles.
82

Due to the superior clarity of the muscle
boundaries,
the ease of identification of the individual
muscles,
and the clarity of changes in muscle
thickness during activation,
the middle region of the abdominal wall
is most commonly selected for USI of the
lateral abdominal muscles.
83

Patient Position
 The lateral abdominal muscles are typically
imaged with the subject relaxed in supine with
the hips and knees flexed (hook-lying
posture).
 One of the advantages of USI is its
versatility in assessing these muscles in many
postures and during functional tasks
(quadruped, sitting, sitting on physioball,
reclined in a chair, standing, or walking).
84

A picture
demonstrating
patient positioning
for rehabilitative
ultrasound imaging
of the abdominal
wall.
85

Transducer Selection
 Ultrasound transducers ranging from 5 to 10
MHz have been used to assess the lateral
abdominal muscles .
 Although a range of transducer frequencies
permits adequate visualization of the lateral
abdominal muscles, a higher frequency
curvilinear transducer, with its diverging
field of view, is ideal, as it allows for greater
visualization of the muscle throughout its length.
86

Demonstrates the entire length of the TrA muscle.
87

 If the goal is to assess a specific
region or movement of a region, such as
the lateral slide of the anterior aspect
of the TrA muscle during an abdominal
drawing-in maneuver (ADIM) or
functional activity, a higher frequency
linear transducer may allow for
greater accuracy.
88

Thickness Measurement
 Measurement of thickness of the lateral
abdominal muscles is dependent on the location
where the measurement is obtained along the
length of the muscle and the point in the
respiratory cycle.
 Although the lateral abdominal muscles have a
relatively uniform thickness in the middle and
lower regions, this can vary and the location of
the measurement should be noted.
89

 As activity of the abdominal muscles is
modulated with respiration and the
thickness of the abdominal muscles
changes with activation, it is predictable
that the muscles would be thicker during
expiration than during inspiration.
90

The measure used for analysis will vary
depending on the intention of the
evaluation in clinical practice or research.
Absolute and relative thickness values
may be appropriate for assessment of
thickness of adjacent muscle layers.
91

Assessment of asymmetry in baseline
thickness values may be best represented
as a percent difference between the
symptomatic and nonsymptomatic side.
Statistical techniques or study designs
that address potential confounding
variables (e.g, BMI, gender) as covariates
are an option.
92

Dynamic Measurement
During dynamic tasks, performance
measures can be assessed by measuring a
change in the thickness of a muscle or a
lateral displacement (slide) of the
anterior medial edge of a muscle.
93

As the TrA muscle thickens and shortens, a
lateral slide of the anterior aspect of the TrA
muscle and its fascia can be observed on USI.
The lateral slide has been associated with
tensioning of the anterior fascias, resulting in
increased tension of the deep muscular corset,
and is considered to be an important observation
with RUSI of the lateral abdominal muscles.
94

Measurement of lateral slide is used as an
indication of tightening of the anterior
fascia associated with the TrA muscle
and an indirect measure assessing the
shortening of the TrA muscle during
activation.
95

 For example, Abdominal Drawing In
Maneuver (ADIM) can be visualized as a
shortening and thickening of each side
of the TrA muscle.
 This lateral displacement is readily
observed for the TrA muscle during the
ADIM.
96

97
Ultrasound imaging of the lateral abdominal wall muscles during the abdominal
drawing in maneuver (ADIM). Images include the transversus abdominis (TrA),
obliquus internus abdominis (OI), and obliquus externus abdominis (OE)
muscles. The white dot represents the anterior reach of the TrA muscle. (A) An
ultrasound image of the left lateral abdominal wall at rest. (B) An ultrasound
image of the left lateral abdominal wall during the ADIM.

RA muscle
 Unlike the 1-dimensional measure of the lateral
abdominal muscles, the CSA, thickness, and
width of the RA muscle can be calculated using
USI.
 In addition, the distance between the right and
left RA muscle can be measured to assess those
with diastasis recti and to track changes in the
distance between the recti associated with
pregnancy.
98

Ultrasound
image of the
rectus abdominis
(RA) muscle
(cross section).
99

100
Ultrasound imaging of interrecti distance. Both the left and right rectus abdominis (RA)
muscles, as well as their intervening fascia, are observable. (A) Note the RA muscles are
adjacent in midline resulting in a small interrecti distance. (B) Note the increased in the
interrecti distance associated with diastasis recti. The interval between the plus signs
represents the interrecti distance.
(From Whitakker J. Ultrasound Imaging for Rehabilitation of the Lumbopelvic Region: A
Clinical Approach. ©2007, Elsevier)

Tissue Composition
Researchers have found that aging,
chronic musculoskeletal dysfunctions,
and/or denervation are associated with
a decrease in water content and an
increase in fatty fibrous content within
muscles.
101

102
Ultrasound imaging of the lateral abdominal wall demonstrating changes in
tissue composition. (A) Resting image of the right lateral abdominal wall at
the point where the lateral aspect of the rectus abdominis (RA) muscle
intersects with the obliquus internus abdominis (OI) muscle. Note the ease
of delineating the muscle boundaries and their similarity and echogenicity.
(B) A comparable image demonstrating a degeneration of the boundaries
and an increase in echogenicity of the RA muscle.

104
Reliability of assessment for TrA
• Population: 30 nonspecific-LBP aged 18-60
• Task: TrA- abdominal drawing-in maneuver,
active straight leg raise (20cm)
• Measurement: Thickness measurement during
2 sessions 1-3 days apart,
• Transducer:2- to 5-MHz curvilinear array
(Koppenhaver et al. 2009)

105
Intraexaminer Reliability for TrA

106
Interexaminer Reliability for TrA

SPINE Volume 31, Number 6, pp E175–E178
©2006, Lippincott Williams & Wilkins, Inc.
An MRI Investigation Into the Function of the
Transversus Abdominis Muscle During
“Drawing-In” of the Abdominal Wall
Julie Hides, PhD,* Stephen Wilson, PhD,† Warren Stanton, PhD,*
Shaun McMahon, PhD,‡ Heidi Keto, BPhty,* Katie McMahon,
PhD,§ Martina Bryant, B App Sc,§and Carolyn Richardson, PhD*
107

108
Validity of assessment for TrA
 Population: 13 Non-LBP, elite cricketers,
mean age 21.3
 Task: abdominal drawing-in maneuver
(ADIM)
 Linear transducer, 7.5 MHz
 Measurement: MRI (the golden standard)
and ultrasound imaging
 Interclass correlations: 0.78~0.95
(Hides et al. 2006)

109
Validity of assessment for
TrA at rest on MRI and RUSI
(Hides et al. 2006)

110
on ADIM on MRI and RUSI
(Hides et al. 2006)

111
Magnetic resonance imaging of the deep musculofascial “corset” of the lumbopelvic region
(cross section). Images include the transversus abdominis (TrA), obliquus internus
abdominis (OI), obliquus externus abdominis (OE), and the rectus abdominis (RA) muscles.
(A) The deep musculofascial “corset” at rest. (B) The deep musculofascial corset during the
abdominal drawing-in maneuver, depicting a bilateral concentric activation of the TrA
muscle and a decrease in cross-sectional area of the abdominal content (AC).

Measurement of thickness of the TrA, OI
& slide of TrA obtained by USI & MRI
112

113
(Hides et al. 2006)

Given the high ICCs and similarity in the mean
scores in this study, it could be proposed that
the variables measured in this investigation could
be adequately assessed using ultrasound imaging.
Ultrasound imaging, despite a limited field of
view, may be more practical and just as accurate
as MRI. This would be useful where large
numbers of subjects are to be investigated or
where portability is an issue.
114

Is Ultrasound Imaging a Fad?
The existing data suggest that ultrasound imaging
has strong potential to contribute to
rehabilitation.
Ultrasound has potential to provide informative
measures of muscle and muscle activity, and to
measure parameters that change with
rehabilitation, and has no side effects.
115
Hodges, 2005

 RUSI provides a means by which physical
therapists can see what they are feeling with
their hands.
 Researchers should address the use of RUSI as a
tool to assist physical therapists in clinical
decision making, reliably determining
impairments, improving specificity of prescribed
therapeutic exercises, and establish its influence
on outcomes.
116

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118

Hides, Julie A., Carolyn A. Richardson, and Gwendolen A. Jull. "Multifidus Muscle
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