In the past 20 years, there are very few pieces of equipment I can say unequivocally changed how I practice as a physical therapist (PT); without question, real-time ultrasound (RTUS) is one. A sports/orthopedic colleague introduced RTUS to my practice 8 years ago. As a pelvic PT, I thought it would be a nice adjunct to my current practice with biofeedback, exercise, and manual techniques. I was wrong. It was a game changer. What initially started out as an exercise in interpreting black & white ink-blot-like images has evolved into so much more.
For those unfamiliar with pelvic floor physical therapy, typical pelvic floor assessment, without RTUS, includes an external assessment of the perineal region. Frequently, internal digital assessment is used to identify pelvic floor muscle strength, endurance, coordination, tender points, and presence of pelvic organ prolapse. Biofeedback assessment can give a general sense of local muscle activity, via either internal or external electrodes. Absent from this data collection, however, is the ability to assess function. What is the effect of pelvic floor activity on the bladder? What specific muscles in the pelvis and abdomen are activating and when? What do you do when a patient is unable to tolerate an internal assessment? RTUS addresses all of these questions. Via a transabdominal approach, I am able to assess the function of pelvic, abdominal, hip, and back musculature in the context of breath and movement. I am able to make an assessment without an internal approach, which may be threatening or uncomfortable for patients with pelvic pain. I am able to determine the function of the pelvic floor and its effect on the bladder and urethra as well.
My practice includes RTUS primarily for evaluation of movement of the pelvic floor, abdominals, hip and spine. The primary goal is to find and address neuromuscular dysfunction in the context of urinary/fecal incontinence, pelvic pain, diastasis recti, and pelvic girdle pain. Beyond helping me identify inefficient movement strategies, coordination variances, and relevant dysfunction, RTUS has been an enormous help in educating my patients about their own bodies and how they function. I never anticipated how much a little black and white image would help patients make this connection! For example, many people have no idea where their pelvic floor is, much less what its relationship is to their bladder, pelvis, or breath. With just a quick look at the screen and a little orientation, RTUS can give patients a window into the simple yet complex connections within their own bodies.
The most striking patient activity with RTUS is using imaging to show the relationship between breath and the pelvic/abdominal region. Patients who are visual learners especially find this an invaluable tool. I use focused exhalation (cued blowing through a straw), vocalization, and varying volumes and octaves to get automatic activation of transverse abdominal and pelvic floor musculature. Patients see, in real time, the effect of their breathing (or breath-holding) strategies have on activation of muscles in the pelvic region. Patients no longer have to try to cognitively process how to turn these muscles on or off (which is laborious and practically impossible to be consistent), but rely on something as simple as breath to assist in activating or relaxing their muscles.
As you can see, RTUS provides both patients and clinicians a window into the pelvic region, providing additional insight into the patient’s function and dysfunction. Having AIUM recognize physical therapists in the AIUM Practice Parameter for the Performance of Selected Ultrasound-Guided Procedures is an outstanding step toward including PTs in this area of practice. I’ve been privileged to work alongside physical therapists working in the area of RTUS education, facilitated diagnostics and real-time needle tracking within our profession. I’m excited that the area of pelvic physical therapy is being included in using RTUS in progressive physical therapy practice. I am looking forward to more integration of RTUS in physical therapy patient care as well as physical therapy education! The more physical therapists have knowledge and skill using this unique tool, the more comprehensive care and outcomes PTs can provide!
Have you included real-time ultrasound in you physical therapy practice? If so, how has it impacted your practice? Comment below or let us know on Twitter: @AIUM_Ultrasound.
Carrie Pagliano, PT, DPT, MTC, is a Board Certified Women’s Health & Orthopaedic Clinical Specialist, and is owner of Carrie Pagliano PT, LLC, in Arlington, VA.