Exploring the Potential of Ultrasound for Endometriosis

Endometriosis is a benign and chronic condition that can cause women to experience pain and fertility problems. For a long time, and to an extent still today, surgery is required to diagnose the disease. However, in the hands of an expert, a transvaginal ultrasound can accurately map deep endometriotic nodules and identify pouch of Douglas obliteration in a noninvasive fashion (Figure 1). Though this statement exhibits optimism in the effort to minimize the use of invasive surgery for diagnostic purposes, there are a few limitations with ultrasound in this scenario.

Leonardi Fig 1

Figure 1: Ultrasound depiction of bowel deep endometriosis and negative sliding sign (can only be noted with dynamic movements) (left) and laparoscopic depiction of bowel deep endometriosis and obliterated pouch of Douglas.

This blog post will attempt to highlight a few key issues with ultrasound’s potential in the realm of endometriosis. We also encourage your comments below on how you feel about ultrasound for endometriosis. Ultimately, we must all be critical of what can and cannot be achieved with ultrasound to ensure appropriate day-to-day clinical practice. This then also allows us to pursue ongoing cutting-edge research endeavors.Leonardi

Our first limitation is in the definition of the word, “expert.”  Thus far, one might attach the term “expert” to those responsible for the bulk of the literature on ultrasound for endometriosis. Certainly, in the view of these academics, ultrasound can see much more endometriosis than previously thought. The belief in the value of ultrasound and expertise in scanning/interpreting scans may trickle down the typical training ladder to fellows, residents, and sonographers. But is there any formal teaching—didactic or tactile? Is there any formal assessment of skill to suggest a minimum level of competency? Is there, at this time, even an understanding of how to evaluate a trainees’ learning curve of endometriosis ultrasound? What is to there to stop an individual from claiming competency when ultrasound for endometriosis is still in its infancy? One concern with pseudo-experts is that they may actually impede the advancement of endometriosis ultrasound integration because surgeons do not verify their findings intraoperatively, leading to skepticism.

Another big problem with the current potential for noninvasive ultrasound diagnosis of endometriosis is the inability to visualize superficial endometriosis, the mildest form of the disease. In surgery, deposits of superficial endometriosis are generally small, only a few millimeters in width and depth, and discolored (Figure 2). They sometimes cause adhesions to form between structures, such as the ovaries and the pelvic sidewall or uterosacral ligament. Thus far, no one has been able to directly identify superficial endometriosis deposits on ultrasound. However, soft markers on ultrasound, such as ovarian immobility and site-specific tenderness (ie, the ability to elicit pain with the pressure of the transvaginal probe during the scan) may hold some secrets to the diagnosis of this enigmatic form of the disease. Until further research supports the routine use of these components in ultrasound for endometriosis, the superficial disease remains a surgical, and therefore invasive, diagnosis.

Condous and Leonardi Fig 2

Figure 2: Laparoscopic depiction of small superficial endometriosis deposit.

Despite these limitations and others not highlighted here, the ability to directly visualize the more severe forms of the disease (ie, ovarian endometriomas, deep endometriosis of the bowel, and pouch of Douglas obliteration) has led to two very clear and significant benefits. One, the patient may be able to receive a diagnosis of disease in a noninvasive fashion, which may guide treatment. Second, if surgery is elected as the treatment of choice, surgeons can prepare. If severe disease is noted on a scan, surgeons can anticipate advanced level surgery, which may necessitate skill from a minimally invasive gynecologic surgeon and/or colorectal surgeon. If no disease is identified on a scan, there will be superficial endometriosis or no disease at all in surgery.

Overall, we are at a much better place right now than we have ever been when it comes to ultrasound for endometriosis. There are still limits that must be addressed, many of which are actively being investigated by dedicated teams around the world. This blog commentary does not attempt to offer solutions to the obstacles highlighted. However, please feel free to comment below if you have any thoughts on an approach to these, or other, limitations.

Have you tried ultrasound for endometriosis? What is your experience with ultrasound and endometriosis? What are your thoughts on the limitations of ultrasound for endometriosis? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

Connect

Mathew Leonardi, MD, FRCSC, is an Honorary Lecturer in the Department of Obstetrics and Gynaecology and PhD student at the Nepean Clinical School, University of Sydney, under the supervision of Associate Professor George Condous. His Twitter handle is @mathewleonardi

Clinical Tests Worldwide

“A pregnancy test and a dip urine,” Dr. St. Louis responded. “Wow!” I replied in surprise. Having completed a fellowship in global health, I had learned that testing was severely limited in resource-limited settings, particularly outside of normal business hours. This was still impressive. We had just been discussing how things were going with his new job at Princess Alice Hospital and what tests were available overnight in his workplace that is located in the eastern mountains of Grenada. During weekday daytime hours, imaging is limited to plain film x-ray. Occasionally, there is an ultrasound technician also available. If desperate, the technicians can be called in from home. All other tests: blood, urine, CSF, must be batched and sent by car via a winding, serpiginous road over a mountain to the capital. If they’re lucky, you may get the test result in about 6 hours; however, most take up to 12 hours. Most advanced imaging, CT and MRI, are only available in the private sector.

I first met Dr. Daniel St. Louis just a few weeks after beginning the Masters of Emergency Medicine program offered by the University of Guyana and started with the help of Emergency Medicine faculty and Vanderbilt University. With other emergency medicine colleagues, I had spent a lot of time helping him learn to perform, interpret, and apply point-of-care ultrasound studies during his training in the Accident and Emergency Department at Georgetown Public Hospital before he returned to his native island in the south Caribbean. Dr. St. Louis immediately saw the benefit of ultrasound during his training and requested every piece of material possible to be able to master sonography.

The care that Daniel and his colleagues provide with limited testing is really impressive. But of all tests that Dr. St. Louis could be equipped with while caring for a sick patient on an overnight shift, ultrasound is uniquely valuable. Bedside ultrasound doesn’t require a technician, it is reusable, it is versatile, it provides rapid diagnosis of many critical illnesses, and it provides the diagnosis to actionable diseases where lives hang in the balance of the minutes and hours ultrasound saves. There are more significant tests: a microscope and Giemsa stain in a malaria endemic zone or rapid HIV testing at the national public health level. But when I was standing in front of a child in shock from shrapnel wounds outside Mosul, Iraq, an ultrasound probe is what I want most.

As bedside ultrasound machines continue to become more portable and more affordable, the significance of bedside ultrasound will continue to grow. This is true in a large academic tertiary medical center, in regional access hospitals in Grenada, and in critical access health posts in the most remote regions of the globe. AIUM and its members are uniquely positioned to aid in providing equipment and, more importantly, providing education and techniques to help improve the quality of bedside ultrasound as one of the most important clinical tests worldwide. Will we be up for the challenge?

If you work in a resource-limited setting, how is ultrasound most useful for you? How have you seen ultrasound incorporated into medical care in other nations? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Jordan Rupp, MD, RDMS, is an Assistant Professor of Emergency Medicine at Vanderbilt University Medical Center and the Director for Global Sounds:  Ultrasound Development Project.  Read more about Global Sounds at www.globalsoundsproject.org or continue the conversation on Twitter:  @globalsounds_us.

Ultrasound Made Me the Doctor I Wanted to Be

I didn’t come into medicine knowing much about what doctors really did. I also didn’t graduate my emergency medicine residency really believing point-of-care ultrasound (POCUS) was all that useful. Maybe it’s just a fad, I remember thinking.Minardi, Joseph J.

There were two things I did come to enjoy about medicine: making interesting diagnoses and intervening in ways that helped patients. Those were the victories and they were always more satisfying when I got to do them as independently as possible. It was great to diagnose appendicitis with a CT scan, but I had to share at least some of the credit with the radiologist.

I remember sometimes being frustrated with the fragmentation of care in American medicine. Send the patient to another facility with these services, order this imaging study by this specialist, consult this specialist for this procedure, and so on.

A few cases early in my career really brought to light these frustrations.

One was a young woman who didn’t speak English who presented to our community hospital who appeared to have abdominal pain. It took hours after getting approval to call in a sonographer, consulting with the radiologist, and eventually calling in the gynecologist from home to take her to the operating room for her ruptured ectopic pregnancy. Hours went by while her condition worsened and I felt helpless, being uncertain about her diagnosis and relying on fragmented, incomplete information from others to make management decisions. Luckily, her youth allowed her to escape unscathed, but I was frustrated with what I didn’t know and couldn’t provide for her: a rapid, accurate diagnosis and quick definitive action.

In another case, a young boy was transferred to our tertiary care center for possible septic hip arthritis and waited nearly 24 hours to undergo more ED imaging, subspecialty consultation, then wait for the availability of the pediatric interventional radiologist to perform X-ray guided hip aspiration with procedural sedation. I remember again feeling helpless and seeing the hopelessness in the eyes of his parents after seeing so many doctors, spending so many hours far from home just waiting on someone to tell them what was wrong with their son and what was going to be done to help him.

After I was asked to lead POCUS education for our residency program and began to embrace it as a clinical tool, I encountered similar cases, but now with much more satisfying experiences for me as a physician, and hopefully, presumably for my patients. Now, I routinely hear stories from my residents and colleagues that go something like Hey Joe, check out this ectopic case, ED to OR in 20 minutes with bedside ultrasound. We have had cases of suspected hip arthritis where we were able to provide a diagnosis and care plan from the ED in 2–3 hours by performing bedside US-guided hip arthrocentesis. These and numerous other cases where diagnoses are made in minutes independently by the treating clinician have convinced me that POCUS can help improve healthcare. My colleagues and I have performed diagnostic and therapeutic procedures that we never would have considered attempting before we could competently use POCUS, allowing us to provide immediate care right where and when the patients needed it.

The “passing fad” of POCUS has allowed me to make medicine and being a doctor more into what I wanted it to be: seeing patients, giving them a diagnosis, decreasing the anxiety over uncertainty, and providing relief for their suffering. I trained and practiced without the advantages of ultrasound and I have seen the positive impact it can have not only on patients but also on the health care system and my job satisfaction as well. The advantages of more immediate, efficient diagnoses, better availability of advanced procedures can all be provided in a less fragmented, more cost-effective manner when treating clinicians are armed with and properly trained to use POCUS. There’s no way I would ever go back.

If you learned how to use ultrasound after you completed your original medical education, how did it affect your career? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Joseph J. Minardi, MD, is Chief of Emergency and Clinical Ultrasound, and Associate Professor of Emergency Medicine and Medical Education at the West Virginia University School of Medicine.

Ultrasound in Orthopedic Practice

Point-of-care ultrasound brings great value to patient care in orthopedic practice, especially for soft tissue problems. It offers safe, cost-effective, and real-time evaluation for soft tissue pathologies and helps narrow down the differential diagnosis.Pic1

There are a variety of soft tissue lesions in orthopedic practice with a classic clinical presentation that may not necessitate ultrasound examination for confirmation of diagnosis, for example, ganglion cyst. However, there is value in performing an ultrasound scan for these common soft tissue lesions.

Ganglion cyst on the dorsum of the wrist or radial-volar aspect of the wrist are confirmed based on clinical examination and presentation. Adding ultrasound examination can help differentiate classic ganglion cyst from some rare findings like Lipoma, anomalous muscles, or soft tissue tumors. Ultrasound examination may also be helpful in finding the source of the ganglion cyst or the stalk of the ganglion cyst. This can help pre-surgical planning if resection of the ganglion cyst is desired by the patient and recommended by the surgeon, because arthroscopic or traditional surgical approach may be needed based on the location of the stalk or neck of the cyst.

Images 1 and 2 show examples of two different patients with a similar presentation of slow-growing mass on the digit. Image 1 from patient 1 shows a solid tumor overlying the flexor tendons of the digit, where the mass was palpated. Image 2 from patient 2, shows a cystic mass overlying the tendons of the digit. In both of the cases, masses were painless and slow growing with minimal to no discomfort. Ultrasound is a great tool in differentiating solid vs cystic lesions and can help avoid attempted aspiration of a solid mass when the mass is presented in an area of classic ganglion cyst’s usual presentation.

Another soft tissue problem, where ultrasound is a superior imaging tool is tendon pathology. Ultrasound can help differentiate tendinosis, tenosynovitis, or tendon tears.

In tenosynovitis, tendon by itself shows normal echotexture and uniform appearance but the tenosynovium that surrounds the tendon gets inflamed and appears as hypoechoic halo around the tendon, for example, in image 3, tendons of the first dorsal compartment of the wrist show uniform thickness and fibrillar echotexture, however there is hypoechoic swelling around the tendons, this is an example of tenosynovitis of first dorsal compartment of the wrist.

In tendinosis, tendon loses its fibrillar pattern and appears swollen and may show vascularity on color ultrasound, which is suggestive of neoangiogenesis or angiofibroblastic proliferation. For example, in Image 4, the tendons of the first dorsal compartment of the wrist show focal enlargement, hypoechoic swelling, and loss of normal fibrillar echotexture and tendon appears disorganized with evidence of increased vascularity on color ultrasound. This is an example of tendinopathy or tendinosis.

Focal tendon tears appear as anechoic or hypoechoic focal defects in tendon substance. Image 5 shows a partial tear of the triceps tendon from the olecranon process. The partial tear appears as a focal hypoechoic defect in the tendon, which is confirmed in the long and short axis scan of the tendon.

In full-thickness tears, the tendon is seen retracted proximally with no fiber attachment at the tendon footprint. Image 6 shows an example of a full thickness complete tear of the supraspinatus tendon from its bony attachment at the greater tubercle. The tendon has retracted proximally and the retracted stump is not visible on ultrasound examination.

Image 6

Point-of-care ultrasound adds significant value to clinical examination in an orthopedic setting. It enhances the understanding of a patient’s problem, increases confidence in the care provided, and high patient satisfaction is reported.

In what unexpected ways do you find ultrasound to be useful? Do you have additional tips for using ultrasound in orthopedics?  Comment below or let us know on Twitter: @AIUM_Ultrasound.

Mohini Rawat, DPT, MS, ECS, OCS, RMSK, is program director of Fellowship in Musculoskeletal Ultrasonography at Hands On Diagnostics and owner of Acumen Diagnostics. She is ABPTS Board-Certified in Clinical Electrophysiology; ABPTS Board-Certified in Orthopedics; registered in Musculoskeletal Sonography, APCA; and has an added Point-of-Care MSK Soft Tissue Clinical Certificate.

Pre-eclampsia, Growth Restriction, and a Placenta Bank

Our Maternal-Fetal Medicine fellow was talking about a delivery that occurred while I was away. The fetus was growth-restricted and developed worsening indices on Doppler ultrasound of the umbilical arteries. What was initially an increased Systolic/Diastolic ratio became first absent and then reversed end-diastolic flow. As this occurred over several weeks, the patient herself had worsening blood pressures and symptoms related to her pre-eclampsia and the fetal tracing became more concerning. She was ultimately delivered and her tiny and premature baby was now in the care of the neonatologists.201500581_Hill-7

The fellow’s presentation focused on the ultrasound findings and the surveillance of pregnancies that become complicated in this way. What was known was the best current management in this case. The unknown was why this had happened in the first place. I was about to interrupt the presentation when our fellow, knowing what I was going to ask, looked over at me and said “Yes, I did collect the placenta.”

Pre-eclampsia is a common condition and growth restriction, by definition, occurs in 10% of pregnancies. The conditions are highly related. We have risk factors for both, but we seldom know the cause. Our treatments seem crude to a bench researcher; try to control the condition as long as you can, and if either patient or her fetus becomes too sick, deliver the pregnancy.

As an obstetrics and gynecology resident, I was fascinated by developmental programming in these fetuses and sent in a grant application to the American Institute of Ultrasound in Medicine requesting seed funding to look at the hormonal associations with growth restriction. Their contribution to my research was a turning point for me. I had always thought of myself as a clinical researcher and this was my first exploration of translational research. During my fellowship in Maternal-Fetal Medicine, I collected ultrasound data on growth restricted pregnancies and sampled placentas and cord blood from the pregnancies when they delivered. What I had thought would be a one-off project became a jumping off point for continued exploration into placental biology.

Five years later, I have established a placenta bank at the University of Arizona. What was a small study focusing on just one condition has inspired the creation of a bigger project. Our residents and fellows now contribute to the bank and have the ability to answer their own questions with the samples already collected. The bank is a resource to all of us and has fostered collaborations with the University of Arizona Biorepository and the department of Animal and Comparative Biomedical Sciences. My initial work focused on changes in leptin, renin, and C-reactive protein in cord blood, but as I learned more, the objective changed to include RNA analysis of the placental tissue. We noted that the structural protein expression was different in the growth-restricted pregnancies. This has led to the proposal of a whole different model regarding the causation of preeclampsia and growth restriction.

We will wait and see how this baby does in the neonatal intensive care unit. As we go about our conservative management until the risk becomes too great to continue, it is a comfort to know we are looking for reasons; if we understand possible mechanisms better, there is the potential to mitigate or reverse the development of fetal and maternal morbidities.

How has ultrasound shaped your career? Has an ultrasound study led you down an unexpected path? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Meghan Hill, MBBS, is Assistant Professor at The University of Arizona College of Medicine, Department of Obstetrics & Gynecology.

Storing Blood as a Dry Powder

Did you know that blood can only be stored for up to 6 weeks when refrigerated? Because synthetic blood is not available in the clinic, blood supplies must be continually replenished from healthy donors. Even if there is a surge in blood donations at one point in time, 6 weeks later there could be shortages if continued donations do not meet the current demand. Blood can be frozen for a decade or more but significant challenges in processing blood for frozen storage limit this option to specific situations such as for rare blood types or military use. The freezing process currently utilizes high concentrations of glycerol to protect red blood cells during frozen storage but this compound must be removed prior to transfusion, and the de-glycerolization process is very sensitive and time-consuming. Therefore, most hospitals and medical centers utilize refrigeration for blood storage.

What if, instead of refrigerating or freezing blood, there was a method to freeze-dry blood for long-term storage as a dry powder, similar to the process used for astronaut food? This could enable long-term blood storage at room temperature, and when the blood is needed for transfusion the cells could be quickly reconstituted simply by adding sterile water. Not only would this offer another option for long-term storage, it would be particularly useful in situations where refrigeration or freezing is not available, such as in some remote medical centers or for the military in far-forward settings. In addition, this method could enable stockpiles of strategic blood reserves in order to maintain an adequate blood supply during disasters such as hurricanes, which disrupt blood donations.

Blood cells dried

Electron microscopy image of red blood cells after drying/rehydration following ultrasound-mediated loading with preservative compounds.

The idea of turning blood into a dry powder and then rehydrating it for transfusion may sound like science fiction, but could it become a reality? Can nature provide clues to help us solve this problem? There are many cases in history where significant scientific breakthroughs were achieved by studying nature. For example, the Wright brothers studied the characteristics of birds’ wings during flight to discover an effective design for airplane wings. Also, Alessandro Volta invented the battery after carefully studying the electric organ in torpedo fish. In the context of cell preservation, it has been found that some organisms can survive complete desiccation for long periods of time. For example, tardigrades and brine shrimp (“water bears” and “sea monkeys”) can be dried out and remain in a state that approaches “suspended animation” for decades, but when they are rehydrated they return to normal physiological function and can even reproduce. This led us to ask the question, if these complex multicellular animals can survive desiccation, why not individual red blood cells? Scientists have found that these organisms produce protective compounds, including certain sugars and proteins, which prevent damage to their membranes during drying and rehydration.

Unfortunately, human cells do not have the transporters in their membranes that enable internalization of the protective compounds found in organisms that can survive desiccation. Therefore, an active loading method is required. We realized that the process of ultrasound-mediated drug delivery via sonoporation could potentially be applied to solve this problem and enable delivery of protective compounds into human red blood cells. In the past, most ultrasound research has either ignored red blood cells or attempted to minimize sonoporation in these cells. But what if we could intentionally sonoporate red blood cells outside of the body in order to actively load them with protective compounds so that they could be stored as a dry powder at room temperature until needed for transfusion?

Our initial efforts to load red blood cells with protective compounds for storage as a dry powder have been promising. We prepared solutions containing red blood cells, preservative compounds, and microbubbles followed by treatment with B-mode ultrasound for ~60 seconds. After ultrasound treatment, the cells were freeze-dried and stored as a dried powder at room temperature (21–23 °C) for 6 weeks or longer. Cells were rehydrated with water and we measured up to 30% recovery of viable red blood cells. In addition, we performed electron microscopy imaging of the rehydrated red blood cells and observed evidence of normal biconcave-discoid shape. Our next steps involve testing the rehydrated cells in an animal model of acute hemorrhage in order to assess the function and safety of the red blood cells in vivo after dry storage at room temperature.

Research studies are currently ongoing and much more work remains to be done before clinical translation is possible, but if it is successful this approach could have a significant impact on blood supply, particularly in locations where refrigeration and freezing are not available. In addition, this approach could potentially enable dry storage of other cell products. As I consider the possibilities of this approach, I wonder if there are other things that we can learn from nature that could also transform medical practice.

Have you learned something else from nature that has been incorporated into your medical practice? Do you have any ideas that could potentially transform medical practice? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Jonathan Kopechek is an Assistant Professor of Bioengineering at the University of Louisville. His Twitter handle is @ProfKope.

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 your 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.