Real-time Ultrasound in Physical Therapy

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.Lisa-Damico-Portraits-Carrie-Pagliano-0413-LOW-RES

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.

Interdisciplinary Education and Training in MSK Ultrasound

In my primary specialty of occupational medicine there is a need for practical education in musculoskeletal ultrasound for both diagnostic evaluation and therapeutic interventional guidance. Incorporation of this into education has begun recently and is continuing in the specialty. A wide variety of specialties are represented in occupational medicine, including many specialists who move into the field after a mid-career transition.

Interestingly, over the last few years clinicians have approached me and asked me to help them learn musculoskeletal ultrasound from many different disciplines outside of occupational medicine. These have included emergency medicine, orthopedics, rheumatology, sports medicine, family medicine, radiology, palliative care, and physical medicine and rehabilitation. When inquiring into why these clinicians are seeking training in this modality it seems that the consistent answer is thdr-sayeedat medical students are graduating and insisting on using ultrasound in their residency training. It would seem that many of our medical students are learning ultrasound at a rate that will outpace attending physician knowledge, exposure, and experience. Indeed, when teaching ultrasound to many of the medical students at West Virginia University as part of their medical education, I was astounded to see how proficient they were at using the machine, the transducer, and correctly identifying both normal and pathologic anatomy. It’s my understanding that many universities have included medical ultrasound into the academic curricula as a bridge to their respective gross anatomy courses and in their general clinical medical education.

Ultrasound is a modality utilized by many medical specialties for various indications. Several specialties outside of radiology, including the ones above, utilize ultrasound. Increasingly, residency programs are integrating ultrasound into their ACGME-accredited curriculum and, importantly, medical students are also learning the benefits of using the modality. It seems clear that despite the number of pitfalls, hurdles, and difficulties using ultrasound, the modality has proven to be an asset in clinical settings and has become a permanent fixture in hospital and clinical settings. The benefits of utilizing ultrasound have been well documented across many academic medical journals. I believe that medicine, as a whole, has done well to embrace the modality, however, there seems to be another vital step to take in the education arena to more fully integrate the modality into our patient’s care.

Currently, most education models for teaching ultrasound, whether it is for residents or medical students, involves grouping like kind together. Emergency residents learn it in the emergency medicine didactics. Physical medicine and rehabilitation (PM&R) residents learn it from demonstrations in their own didactics, and so on. Perhaps approaching the curriculum from a more inclusive perspective, however, would be more beneficial for residents and fellows. I, personally, had experience teaching an integrated musculoskeletal course at West Virginia University. The idea, admittedly, was born out of necessity. Physicians experienced in ultrasound from sports medicine, emergency medicine and occupational medicine created and executed a curriculum to teach musculoskeletal ultrasound and invited residents from other specialties. The interest we were able to garner quite frankly surprised me. Although the curriculum was targeted to occupational medicine residents the interest in using musculoskeletal ultrasound was widespread. Residents from specialties like emergency medicine, radiology, family medicine, internal medicine, and orthopedics attended our sessions.

While the course was a success, introducing an integrated curriculum across medical specialties posed a new set of challenges. My specialty was able to use dedicated didactic time for the education but many other specialties have disparate educational time. Many residents could not make all of the sessions and many more could not make any sessions because of fixed residency schedules. This makes coordination very difficult. As I have pondered this over the last few months I believe that educational leaders should begin to form structured educational collaborative time for activities like education in musculoskeletal ultrasound. Each discipline will be able to contribute to teaching to ensure high quality evidence-based curriculum for residents learning ultrasound. Each discipline has their individual strengths and collaboration ensures coordination and even learning amongst instructors. Integrating medicine has been a goal of thought leaders in medicine at the very highest levels and can be replicated for the instruction and training of our resident physicians.

Another option is to allow residents to attend the American Institute of Ultrasound in Medicine’s annual conference where interdisciplinary education in ultrasound occurs. This conference even has a day for collegial competition among medical students and schools. In fact, the courses are created to encourage engagement in the education and training of clinicians at all levels of training. The overall goal is to advance the education and training in this modality and hope that education leaders begin to encourage collaboration in a much larger scale thus achieving integrated medical care that provides a building block to lead to high quality evidence-based medical care for our patients, families, and communities.

What other areas of ultrasound education have room to grow? How would you recommend making changes? Do you have any stories from your own education to share? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Yusef Sayeed, MD, MPH, MEng, CPH, is a Fellow at Deuk Spine Institute, Melbourne, FL.