Exploring the clinical use of ultrasound imaging : A survey of physiotherapists in New Zealand

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License CC BY NC-ND 4.0 ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.Background: In New Zealand ultrasound imaging (USI) is being used increasingly by physiotherapists. To fully understand the extent to which physiotherapists in New Zealand are using USI, it is necessary to evaluate not only the context of its clinical use but also the barriers preventing its uptake. Objectives: To examine the field and scope of use of USI, the type and content of training and the barriers restricting physiotherapists from using the technique. Design: Cross-sectional observational design utilising an Internet-based electronic survey. Method: An electronic survey built on the design of previous research with guidance from an expert review panel. Participants were included if they were New Zealand registered physiotherapists. Results: Of the 465 participants who responded, 433 were eligible to complete the survey. There were 415 participants who completed the survey, 24% who said they used USI whilst 76% did not. For those using USI, the uses were varied including those within a rehabilitative paradigm (i.e. biofeedback; 52%) and also diagnostic (49%). USI training was also varied ranging from formal to informal. The main barriers preventing physiotherapists from using USI were lack of training, access to equipment, and equipment expense. Conclusions: The participants reported a variety of clinical uses of USI and levels of training. A better understanding of the clinical uses and benefits of USI would enhance both training and clinical uptake. With the identification of barriers limiting physiotherapists’ use of USI, ways to overcome these in New Zealand can now be explored further.Peer reviewedFinal Published versio

Reliability and Precision of Sonography of the Lumbar Multifidus and Transversus Abdominis During Dynamic Activities

Objective: To determine the intra-rater reliability and precision of measurement of lumbar multifidus (LM) and transversus abdominis (TrA) thickness using freehand ultrasound imaging (USI) in a range of static and dynamic conditions. Methods: Fifteen asymptomatic participants performed a range of exercises whilst USI was used to measure absolute muscle thickness and change in muscle thickness from rest. Exercise conditions included the abdominal drawing in manoeuvre (ADIM), active straight leg raise (ASLR), contralateral arm lift, both unloaded (CAL) and loaded (LCAL), treadmill walking (WALK) and using the Functional Re-adaptive Exercise Device (FRED). Intra- and inter-day reliability was assessed using intraclass correlation coefficients (ICC), and standard error of measurement was used to assess measurement precision. Results: Good to excellent reliability was achieved for TrA and LM absolute thickness in all conditions. Measurement precision for absolute LM thickness was ≤2.8mm for CAL, ≤1.8mm for LCAL, ≤3.1mm for WALK and ≤3.8mm for FRED, and for absolute TrA thickness was ≤0.6mm for ADIM, ≤0.5mm for ASLR, ≤0.7mm for WALK and ≤0.5mm for FRED. Good to excellent reliability was achieved for TrA and LM relative muscle thickness in all conditions. Measurement precision for relative LM thickness was ≤3.7% for CAL, ≤3.8% for LCAL, ≤6.3% for WALK and ≤7.6% for FRED, and for relative TrA thickness was ≤13.6% for ADIM, ≤6.9% for ASLR, ≤11.1% for WALK and ≤7.2% for FRED. Conclusions: Acceptable reliability and precision of measurement is achieved for absolute and relative measures of deep spinal muscle thickness using freehand USI in relatively static and dynamic exercises

The efficacy of functional supports in mediating the effects of exercise on shoulder joint position sense

BACKGROUND: Prolonged exercise and joint position sense are considered aetiological risk factors for shoulder injury in overhead sports. OBJECTIVE: To investigate the efficacy of a neoprene sleeve and kinesiology tape (KT) in mediating the effect of exercise on shoulder joint position sense. METHODS: 25 overhead sports participants (women – 10, men – 15) completed 30 maximal isokinetic repetitions at 120◦/s of three shoulder exercise protocols: 9090 (seated 90◦ shoulder abduction, 90◦ elbow flexion, modified neutral (seated 45◦ shoulder abduction, 90◦ elbow flexion in the scapular plane and diagonal (seated GHJ flexion, abduction, external rotation and extension, adduction and internal rotation. Absolute error in active reproduction of passive positioning was assessed pre- and post-exercise at 10◦/s. This was conducted for end range internal and external rotation, and mid-range. RESULTS: A repeated measures general linear model revealed no significant main effect for gender or exercise in any test position. A main effect for support condition was observed pre-exercise in the KT condition, with JPS significantly (p < 0.01) impaired (5.30 ± 2.16◦) relative to baseline control scores (4.11 ± 2.81◦) in end range external rotation at the 9090 position. CONCLUSION: Results indicated that neither neoprene nor kinesio-tape were more effective in limiting the effects of exercise on joint position sense (JPS). Healthy, un-injured overhead athletes may not need to consider taping or supportive device, indeed KT application was observed to impair JPS in specific movements

The efficacy of lower limb screening tests in predicting PlayerLoad within a professional soccer academy

Context: Training exposure has been associated with injury epidemiology in elite youth soccer, where lower limb musculoskeletal screening is commonly used to highlight injury risk. However, there has been little consideration of the relationship between lower limb screening and the loading response to soccer activities. Objective: To quantify the efficacy of using screening tests to predict the loading elicited in soccer-specific activities, and to develop a hierarchical ordering of musculoskeletal screening tests to identify test redundancy and inform practice. Design: Correlational. Setting: Professional soccer club academy. Participants: 21 elite male soccer players aged 15.7 ± 0.9 years. Intervention: Players completed a battery of five screening tests (knee to wall, hip internal rotation, adductor squeeze, single leg hop, anterior reach), and a 25min standardised soccer session with a GPS unit placed at C7 to collect multi-planar PlayerLoad data. Main Outcome Measures: Baseline data on each screening test, along with uni-axial PlayerLoad in the medio-lateral, anterio-posterior and vertical planes. Results: Stepwise hierarchical modelling of the screening tests revealed that dominant leg knee to wall distance was the most prevalent and powerful predictor of multi-planar PlayerLoad, accounting for up to 42% of variation in uni-axial loading. The adductor squeeze test was the least powerful predictor of PlayerLoad. Of note, one player who incurred a knee injury within three weeks of testing had shown a 20% reduction in knee to wall distance compared with peers, and elicited 23% greater PlayerLoad, supporting the hierarchical model. Conclusions: There was some evidence of redundancy in the screening battery, with implications for clinical choice. Hierarchical ordering and a concurrent case study highlight dominant leg knee to wall distance as the primary predictor of multi-axial loading in soccer. This has implications for the design and interpretation of screening data in elite youth soccer

Proportional lumbar spine inter-vertebral motion patterns: a comparison of patients with chronic, non-specific low back pain and healthy controls

Introduction: Identifying biomechanical subgroups in chronic, non-specific low back pain (CNSLBP) populations from inter-vertebral displacements has proven elusive. Quantitative fluoroscopy (QF) has excellent repeatability and provides continuous standardised inter-vertebral kinematic data from fluoroscopic sequences allowing assessment of mid-range motion. The aim of this study was to determine whether proportional continuous IV rotational patterns were different in patients and controls. A secondary aim was to update the repeatability of QF measurement of range of motion (RoM) for inter-vertebral (IV) rotation

Attainment rate as a surrogate indicator of the intervertebral neutral zone length in lateral bending: An in vitro proof of concept study

Background Lumbar segmental instability is often considered to be a cause of chronic low back pain. However, defining its measurement has been largely limited to laboratory studies. These have characterised segmental stability as the intrinsic resistance of spine specimens to initial bending moments by quantifying the dynamic neutral zone. However these measurements have been impossible to obtain in vivo without invasive procedures, preventing the assessment of intervertebral stability in patients. Quantitative fluoroscopy (QF), measures the initial velocity of the attainment of intervertebral rotational motion in patients, which may to some extent be representative of the dynamic neutral zone. This study sought to explore the possible relationship between the dynamic neutral zone and intervertebral rotational attainment rate as measured with (QF) in an in vitro preparation. The purpose was to find out if further work into this concept is worth pursuing. Method This study used passive recumbent QF in a multi-segmental porcine model. This assessed the intrinsic intervertebral responses to a minimal coronal plane bending moment as measured with a digital force guage. Bending moments about each intervertebral joint were calculated and correlated with the rate at which global motion was attained at each intervertebral segment in the first 10° of global motion where the intervertebral joint was rotating. Results Unlike previous studies of single segment specimens, a neutral zone was found to exist during lateral bending. The initial attainment rates for left and right lateral flexion were comparable to previously published in vivo values for healthy controls. Substantial and highly significant levels of correlation between initial attainment rate and neutral zone were found for left (Rho = 0.75, P = 0.0002) and combined left-right bending (Rho = 0.72, P = 0.0001) and moderate ones for right alone (Rho = 0.55, P = 0.0012). Conclusions This study found good correlation between the initial intervertebral attainment rate and the dynamic neutral zone, thereby opening the possibility to detect segmental instability from clinical studies. However the results must be treated with caution. Further studies with multiple specimens and adding sagittal plane motion are warranted

An objective spinal motion imaging assessment (OSMIA): reliability, accuracy and exposure data.

BACKGROUND: Minimally-invasive measurement of continuous inter-vertebral motion in clinical settings is difficult to achieve. This paper describes the reliability, validity and radiation exposure levels in a new Objective Spinal Motion Imaging Assessment system (OSMIA) based on low-dose fluoroscopy and image processing. METHODS: Fluoroscopic sequences in coronal and sagittal planes were obtained from 2 calibration models using dry lumbar vertebrae, plus the lumbar spines of 30 asymptomatic volunteers. Calibration model 1 (mobile) was screened upright, in 7 inter-vertebral positions. The volunteers and calibration model 2 (fixed) were screened on a motorized table comprising 2 horizontal sections, one of which moved through 80 degrees. Model 2 was screened during motion 5 times and the L2-S1 levels of the volunteers twice. Images were digitised at 5fps. Inter-vertebral motion from model 1 was compared to its pre-settings to investigate accuracy. For volunteers and model 2, the first digitised image in each sequence was marked with templates. Vertebrae were tracked throughout the motion using automated frame-to-frame registration. For each frame, vertebral angles were subtracted giving inter-vertebral motion graphs. Volunteer data were acquired twice on the same day and analysed by two blinded observers. The root-mean-square (RMS) differences between paired data were used as the measure of reliability. RESULTS: RMS difference between reference and computed inter-vertebral angles in model 1 was 0.32 degrees for side-bending and 0.52 degrees for flexion-extension. For model 2, X-ray positioning contributed more to the variance of range measurement than did automated registration. For volunteer image sequences, RMS inter-observer variation in intervertebral motion range in the coronal plane was 1.86 degrees and intra-subject biological variation was between 2.75 degrees and 2.91 degrees. RMS inter-observer variation in the sagittal plane was 1.94 degrees. Radiation dosages in each view were below the levels recommended for a plain film. CONCLUSION: OSMIA can measure inter-vertebral angular motion patterns in routine clinical settings if modern image intensifier systems are used. It requires skillful radiography to achieve optimal positioning and dose limitation. Reliability in individual subjects can be judged from the variance of their averaged inter-vertebral angles and by observing automated image registration

Measurement of Intervertebral Motion Using Quantitative Fluoroscopy: Report of an International Forum and Proposal for Use in the Assessment of Degenerative Disc Disease in the Lumbar Spine

Quantitative fluoroscopy (QF) is an emerging technology for measuring intervertebral motion patterns to investigate problem back pain and degenerative disc disease. This International Forum was a networking event of three research groups (UK, US, Hong Kong), over three days in San Francisco in August 2009. Its aim was to reach a consensus on how best to record, analyse, and communicate QF information for research and clinical purposes. The Forum recommended that images should be acquired during regular trunk motion that is controlled for velocity and range, in order to minimise externally imposed variability as well as to correlate intervertebral motion with trunk motion. This should be done in both the recumbent passive and weight bearing active patient configurations. The main recommended outputs from QF were the true ranges of intervertebral rotation and translation, neutral zone laxity and the consistency of shape of the motion patterns. The main clinical research priority should initially be to investigate the possibility of mechanical subgroups of patients with chronic, nonspecific low back pain by comparing their intervertebral motion patterns with those of matched healthy controls

Rationale, design, and protocol for the prevention of low back pain in the military (POLM) trial (NCT00373009)

<p>Abstract</p> <p>Background</p> <p>There are few effective strategies reported for the primary prevention of low back pain (LBP). Core stabilization exercises targeting the deep abdominal and trunk musculature and psychosocial education programs addressing patient beliefs and coping styles represent the current best evidence for secondary prevention of low back pain. However, these programs have not been widely tested to determine if they are effective at preventing the primary onset and/or severity of LBP. The purpose of this cluster randomized clinical trial is to determine if a combined core stabilization exercise and education program is effective in preventing the onset and/or severity of LBP. The effect of the combined program will be compared to three other standard programs.</p> <p>Methods/Design</p> <p>Consecutive Soldiers participating in advanced individual training (AIT) will be screened for eligibility requirements and consented to study participation, as appropriate. Companies of Soldiers will be randomly assigned to receive the following standard prevention programs; a core stabilization exercise program (CSEP) alone, a CSEP with a psychosocial education (PSEP), a traditional exercise (TEP), or a TEP with a PSEP. Proximal outcome measures will be assessed at the conclusion of AIT (a 12 week training period) and include imaging of deep lumbar musculature using real-time ultrasound imaging and beliefs about LBP by self-report questionnaire. We are hypothesizing that Soldiers receiving the CSEP will have improved thickness of selected deep lumbar musculature (transversus abdominus, multifidi, and erector spinae muscles). We are also hypothesizing that Soldiers receiving the PSEP will have improved beliefs about the management of LBP. After AIT, Soldiers will be followed monthly to measure the distal outcomes of LBP occurrence and severity. This information will be collected during the subsequent 2 years following completion of AIT using a web-based data entry system. Soldiers will receive a monthly email that queries whether any LBP was experienced in the previous calendar month. Soldiers reporting LBP will enter episode-specific data related to pain intensity, pain-related disability, fear-avoidance beliefs, and pain catastrophizing. We are hypothesizing that Soldiers receiving the CSEP and PSEP will report the longest duration to first episode of LBP, the lowest frequency of LBP, and the lowest severity of LBP episodes. Statistical comparisons will be made between each of the randomly assigned prevention programs to test our hypotheses related to determining which of the 4 programs is most effective.</p> <p>Discussion</p> <p>We have presented the design and protocol for the POLM trial. Completion of this trial will provide important information on how to effectively train Soldiers for the prevention of LBP.</p> <p>Trial registration</p> <p>NCT00373009</p

A Cadaveric Study Validating in vitro Monitoring Techniques to Measure the Failure Mechanism of Glenoid Implants against Clinical CT

Definite glenoid implant loosening is identifiable on radiographs, however, identifying early loosening still eludes clinicians. Methods to monitor glenoid loosening in vitro have not been validated to clinical imaging. This study investigates the correlation between in vitro measures and CT images. Ten cadaveric scapulae were implanted with a pegged glenoid implant and fatigue tested to failure. Each scapulae were cyclically loaded superiorly and CT scanned every 20,000 cycles until failure to monitor progressive radiolucent lines. The superior and inferior rim displacements were also measured. A finite element (FE) model of one scapula was used to analyse the interfacial stresses at the implant/cement and cement/bone. All ten implants failed inferiorly at the implant-cement interface, two also failed at the cement-bone interface inferiorly, and three showed superior failure. Failure occurred at of 80,966 ± 53,729 (mean ± SD) cycles. CT scans confirmed failure of the fixation, and in most cases, was observed either before or with visual failure, indicating its capacity to detect loosening earlier for earlier intervention if needed. Significant correlations were found between both increasing inferior rim displacement (ASTM standard F2028-14), increasing vertical head displacement and failure of the glenoid implant. The FE model showed peak tensile stresses inferiorly and high compressive stresses superiorly, corroborating experimental findings. Similar failure modes have been cited in clinical and in vitro studies. In vitro monitoring methods correlated to failure progression in clinical CT images. Clinical Significance: The study highlights failure at the implant-cement interface and early signs of failure are identifiable in CT images