Use of Real-Time Ultrasound
in the Management of Spinal Pain

Importance of Abdominal and Spinal Muscles

There is growing evidence to indicate the importance of the abdominal and spinal muscles in the management of low back and pelvic pain. Studies have shown that these muscles have a key role in supporting the spine ^1,2 and there are deficits in the size and recruitment of these muscles in people with spinal pain ^3,4. Furthermore, an exercise approach, which involves retraining these trunk muscles ⁵, has been shown in clinical trials to be effective in the management of low back pain ^6,7.

Use of Real-time Ultrasound

Real-time ultrasound (RTUS) is being used by physiotherapists in clinical practice to assist with the implementation of this exercise approach. It has been found to be a valuable tool as it allows:

• visualization of the deep abdominal and spinal muscles
  (Figure 1 & 2)
• assessment of muscle size/dimensions and recruitment
• retraining of muscles with real-time feedback to both the therapist and patient
• reassessment within and between sessions to determine progress
• imaging and assessment of pelvic floor musculature (that can assist training of trunk muscles)

How is RTUS used in clinical practice?

The assessment and management of patients with RTUS can be complex. The approach involves several key steps which begin with the patient performing various tasks/exercises to selectively activate the deep muscles while the therapist assesses the activation of these muscles on the US monitor. Assessment of the exercise is based on the (i) degree of movement and change in thickness of both the superficial and deep muscles, and (ii) the patient’s ability to hold the contraction and co-ordinate this with breathing. Once the deficits have been identified, the patient and therapist practice with the assistance of real-time feedback from the US to achieve the correct activation patterns. As improvement in muscle activation is observed, the exercises are progressed to more functional positions and dynamic activities.

What research has been published on RTUS?

Research has been published which provides valuable evidence for the use of RTUS in clinical practice to retrain the trunk muscles. Several studies indicate that changes in thickness of the trunk muscles can be reliably measured with RTUS ⁸ and that these measures are valid when compared with measurements from MRI scans ⁹ or electrical activity recorded from these muscles ^10,11. Furthermore, more recent studies highlight new findings that have important implications for the implementation of this approach. Three papers of interest include:

Paper 1:
Ferreira PH, Ferreira ML, Hodges PW 2004. Changes in recruitment of the abdominal muscles in people with low back pain: ultrasound measurement of muscle activity. Spine 29(22):2560-6

• This study measured the change in thickness of the abdominal muscles using ultrasound imaging in people with and without low back pain.
• The results show that patients with LBP have changes in recruitment of the deepest abdominal muscle (i.e. smaller increases in thickness) compared to those patients without pain.

Provides evidence for the use of RTUS to detect changes in abdominal muscle recruitment in patients with low back pain

Paper 2:
Bunce SM, Hough AD, Moore AP 2004 Measurement of abdominal muscle thickness using M-mode ultrasound imaging during functional activities. Man Ther 9(1):41-4

• This paper describes how the thickness of the abdominal muscles can be quantified with M-mode (motion mode) ultrasound.
• It also discusses the use of M-mode and a transducer holder for non-invasive measurement of abdominal muscle thickness during functional activities.

Paper 3:
Rankin G, Stokes M, Newham DJ 2005 Size and shape of the posterior neck muscles measured by ultrasound imaging: normal values in males and females of different ages. Man Ther 10(2):108-15

• This paper describes procedures for scanning and measuring the posterior neck muscles using ultrasound imaging.
• Normal data provided on size, shape and symmetry of these muscles is provided.

Summary and Future Directions

RTUS is being used in physiotherapy practice to retrain the trunk muscles in the management of low back pain.

There is a growing body of research that provides evidence for the implementation of this approach in clinical practice.

Further research is required that involves: (i) large scale studies to examine muscle size and recruitment in healthy individuals and determine whether these factors are predictive of first-episode low back pain and (ii) investigation of the use of RTUS in the assessment and management of muscle deficits of the cervical and thoracic spine regions.

References

1. Cholewicki J, Juluru K, McGill SM, 1999 Intra-abdominal pressure mechanism for stabilizing the lumbar spine. Journal of Biomechanics 32, 13–17

2. Hodges PW, Gandevia SC 2000 Changes in intra-abdominal pressure during postural and respiratory activation of the human diaphragm. Journal of Applied Physiology 89: 967–976

3. Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH 1994 Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine 15: 165-72

4. Hodges PW, Richardson CA 1996 Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis. Spine 21: 2640–2650

5. Richardson CA, Jull GA, Hodges PW et al. 1999 Therapeutic exercise for spinal segmental stabilization in low back pain: Scientific basis and clinical approach. Churchill Livingstone, London

6. Hides et al, Hides JA, Richardson CA, Jull GA 1996 Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine 21(23): 2763-69

7. O'Sullivan PB, Twomey LT, Allison GT 1997 Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 22(24): 2959-67

8. Kidd AW, Magee S, Richardson CA. (2002). Reliability of real-time ultrasound for the assessment of transversus abdominis function. Journal of Gravitational Physiology 9(1):131-2.

9. Hides JA, Richardson CA, Jull GA.Magnetic resonance imaging and ultrasonography of the lumbar multifidus muscle. Comparison of two different modalities. Spine. 1995 Jan 1;20(1):54-8.

10. Hodges PW, Pengel LH, Herbert RD, Gandevia SC (2003). Measurement of muscle contraction with ultrasound imaging. Muscle Nerve 27(6):682-92.

11. McMeeken JM, Beith ID, Newham DJ, Milligan P, Critchley DJ (2004). The relationship between EMG and change in thickness of transversus abdominis. Clinical Biomechanics 19(4): 337-42.

About the author:

Dr Donna Urquhart is an APA physiotherapist with clinical and research interests in the management of back and neck pain. Donna completed her PhD in the field of low back pain in 2003 and is continuing this research as an NHMRC Clinical Research Fellow in the Department of Epidemiology and Preventive Medicine at Monash University.

For further information about real-time ultrasound retraining visit: www.lowbackpain.com.au

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