Investigation of Real-Time Diagnostic Ultrasound as a Means of Biofeedback Training in Transversus Abdominus Re-Education of Patients with Non-Specific Low Back Pain: A Prospective Randomized Controlled Pilot Study.

Background: It is believed that ultrasound-guided imaging of activation/contraction of the deep abdominal muscles (such as transervsus abdominis) is useful for assisting deep muscle re-education, which is often dysfunctional in non-specific low back pain (NSLBP). Thus, this pilot study aimed to evaluate the use of real-time ultrasound (US) as a feedback device for transverse abdominis (TrA) activation/contraction during an exercise program in chronic NSLBP patients. Methods: Twenty-three chronic NSLBP patients were recruited and randomly assigned to a US-guided (n = 12, 8 women, 47.6 ± 2.55 years) or control group (n = 11, 9 women, 46.9 ± 4.29 years). The same motor control-based exercise program was applied to both groups. All patients received physiotherapy twice per week for seven weeks. Outcome measures, tested at baseline and post-intervention, included Numeric Pain Rating Scale, TrA activation level (measured through a pressure biofeedback unit-based developed protocol), seven established motor control tests, Roland-Morris Disability Questionnaire and Hospital Anxiety and Depression Scale. Results: For each group, all outcome variables yielded statistical differences post-intervention (p < 0.05), indicating significant improvements. However, there were no significant group x time interactions for any of the outcomes (p > 0.05), thus, indicating no superiority of the US-guided group over the control. Conclusions: The addition of US as a visual feedback device for TrA re-education during a motor control exercise program was not proven superior to traditional physiotherapy.

Effectiveness of lumbar stabilization exercise with real-time ultrasound imaging biofeedback on lumbar multifidus muscle cross-sectional area in individuals with non-specific chronic low back pain: a study protocol for a randomized controlled trial.

BACKGROUND: Structural impairment of the lumbar multifidus muscle, such as reduced cross-sectional area, is evident among individuals with chronic low back pain. Real-time ultrasound imaging (RUSI) biofeedback has been reported to improve preferential activation of as well as retention in the ability to activate the lumbar multifidus muscle during lumbar stabilization exercises (LSE). However, evidence of the effectiveness of this treatment approach in individuals with non-specific chronic low back pain (NCLBP) is still limited. The purpose of this study is, therefore, to determine the effectiveness of LSE with RUSI biofeedback on lumbar multifidus muscle cross-sectional area in individuals with NCLBP. METHODS/DESIGN: This study is a prospective, single-center, assessor-blind, three-arm, parallel randomized controlled trial to be conducted at National Orthopedic Hospital, Kano State, Nigeria. Ninety individuals with NCLBP will be randomized in a 1:1:1: ratio to receive LSE, LSE with RUSI biofeedback, or minimal intervention. All participants will receive treatment twice weekly for 8 weeks. The primary outcome will be the lumbar multifidus muscle cross-sectional area. The secondary outcomes will include pain (Numerical Pain Rating Scale), functional disability (Roland-Morris Disability Questionnaire), and quality of life (12-Item Short-Form Health Survey). All outcomes will be assessed at baseline, 8 weeks post-intervention,  and 3 months follow-up. DISCUSSION: To our knowledge, this study will be the first powered randomized controlled trial to compare the effectiveness of LSE training with and without RUSI biofeedback in individuals with NCLBP. The outcome of the study may provide evidence for the effectiveness of LSE with RUSI biofeedback on enhancing the recovery of the lumbar multifidus muscle in individuals with NCLBP. TRIAL REGISTRATION: Pan African Clinical Trials Registry ( PACTR201801002980602) . Registered on January 16, 2018.

The Role of Rehabilitative Ultrasound Imaging Technique in the Lumbopelvic Region as a Diagnosis and Treatment Tool in Physiotherapy: Systematic Review, Meta-Analysis and Meta-Regression.

Rehabilitative ultrasound imaging (RUSI) technique seems to be a valid and reliable tool for diagnosis and treatment in physiotherapy and has been widely studied in the lumbopelvic region the last three decades. The aims for this utility in clinical settings must be review through a systematic review, meta-analysis and meta-regression. A systematic review was designed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with PROSPERO registration and per review in all phases of the process using COVIDENCE, analysis of risk of bias and meta-analysis using REVMAN, and meta-regression calculation using STATA. Database screening provided 6544 references, out of which 321 reported narrative synthesis, and 21 reported quantitative synthesis, while only 7 of them provided comparable data to meta-analyze the variables pain and muscle thickness. In most cases, the forest plots showed considerable I2 heterogeneity indexes for multifidus muscle thickness (I2 = 95%), low back pain (I2 = 92%) and abdominal pain (I2 = 95%), not important for transversus abdominis muscle thickness (I2 = 22%), significant heterogenity (I2 = 69%) depending on the subgroup and not important internal oblique muscle thickness (I2 = 0%) and external oblique muscle thickness (I2 = 0%). Meta-regression did not provide significant data for the correlations between the variables analyzed and the intervention, age, and BMI (Body Mass Index). This review reveals that RUSI could contribute to a high reliability of the measurements in the lumbopelvic region with validity and reliability for the assessments, as well as showing promising results for diagnosis and intervention assessment in physiotherapy compared to the traditional model, allowing for future lines of research in this area.

Gluteus medius dysfunction in females with chronic ankle instability is consistent at different walking speeds.

BACKGROUND: Patients with chronic ankle instability often present with altered gait mechanics compared to ankle sprain copers. There is increasing evidence to suggest proximal neuromuscular alterations contribute to the injury etiology, however little is known about how these changes manifest during gait. The purpose of this study was to investigate ipsilateral gluteus maximus and medius functional activity ratios throughout treadmill walking at three speeds (preferred, 120% preferred, and 1.35 m per second) in chronic ankle instability patients compared to copers. METHODS: 28 females (14 chronic ankle instability, 14 copers) walked at the three gait speeds in randomized order. Ground reaction forces and 10-s gluteal ultrasound clips were simultaneously recorded. Clips were reduced using ground reaction forces to extract 55 measurement frames. Normalized gluteal thickness measures were used to determine functional activity ratios. 2 × 3 analyses of variance were run to assess group and speed effects on gluteal outcomes throughout walking using statistical parametric mapping. Post-hoc t-tests, mean differences, and Cohen's d effect sizes were assessed for significant findings (P ≤ .05). FINDINGS: The chronic ankle instability group had significantly decreased gluteus medius activity throughout the entire gait cycle when compared to the coper group, independent of gait speed (P < .001, mean differences: 0.10-0.18; d: 1.00-3.17). There were no significant group or speed main effects, nor an interaction for gluteus maximus activity. INTERPRETATION: Gluteal dysfunction throughout walking was identified in chronic ankle instability. The coper group remained within healthy reference muscle activity ranges, suggesting that proximal muscle activation alterations are associated chronic ankle impairments.

Ultrasound imaging of upper extremity spastic muscle post-stroke and the correlation with function: A pilot study.

BACKGROUND: With increased practice of real-time ultrasound imaging in the physical therapy profession, it is essential to evaluate the utility of its use post stroke. OBJECTIVE: Evaluate relationship of spastic brachialis muscle architectural parameters with clinical measures of upper extremity function and spasticity. METHODS: Eleven post stroke individuals with spasticity of the upper limb had their brachialis muscle pennation angle and fascicle length measured in the affected and unaffected upper arm, at rest. Involved side upper extremity Fugl-Meyer, Modified Ashworth Scale, and grip strength were collected and compared to muscle architectural parameters of affected and unaffected brachialis muscles. RESULTS: Affected side brachialis pennation angle was significantly greater than the unaffected side, and affected fascile length was significantly shorter than the unaffected side. Function levels were found to be significantly higher in those with greater fascile lengths and lower pennation angles. Higher Fugl-Meyer scores of the affected upper extremity were inversely correlated with lower Modified Ashworth Scale scores. CONCLUSIONS: An objective method of quantifying spasticity can assist in determining if functional gains made post stroke are due to compensations in movement, or due to physiological changes. Ultrasound imaging may be used as an alternative to the Modified Ashworth score to quantify muscular parameters in spastic muscles post stroke.

Using real-time ultrasound imaging as adjunct teaching tools to enhance physical therapist students' ability and confidence to perform traction of the knee joint.

Often, physical therapy students struggle with the skill and the confidence to perform manual techniques for musculoskeletal examination. Current teaching methods lack concurrent objective feedback. Real-time ultrasound imaging (RTUI) has the advantage of generating visualization of anatomical structures in real-time in an efficient and safe manner. We hypothesize that the use of RTUI to augment teaching with concurrent objective visual feedback will result in students' improved ability to create a change in joint space when performing a manual knee traction and higher confidence scores. Eighty-six students were randomly allocated to a control or an experimental group. All participants received baseline instructions on how to perform knee traction. The control group received standardized lab instruction (visual, video, and instructor/partner feedback). The experimental group received standardized lab instruction augmented with RTUI feedback. Pre-data and post-data collection consisted of measuring participants' ability to create changes in joint space when performing knee traction, a confidence survey evaluating perceived ability and a reflection paper. Joint space changes between groups were compared using a paired t-test. Surveys were analyzed with descriptive statistics and compared using Wilcoxon Rank Sum and for the reflection papers, themes were identified and descriptive statistics reported. Although there were no statistically significant differences between the control and the experimental group, overall scores improved. Qualitative data suggests students found the use of ultrasound imaging beneficial and would like more exposure. This novel approach to teaching knee traction with RTUI has potential and may be a basis for further studies.

Changes in deep lumbar stabilizing muscle thickness by transcutaneous neuromuscular electrical stimulation in patients with low back pain.

BACKGROUND: Transcutaneous neuromuscular electrical stimulation (NMES) is known to stimulate contraction of deep lumbar stabilizing muscles. OBJECTIVE: The purpose of this study was to investigate changes in deep lumbar stabilizing muscle thickness during transcutaneous NMES on specific abdominal wall and paraspinal regions. METHODS: Thirty patients with low back pain (LBP) were recruited. Three sessions were preformed: Session 1: NMES on abdominal wall, Session 2: NMES on lumbar paraspinal area, and Session 3: concurrent NMES on abdominal wall and lumbar paraspinal area. Real time ultrasound imaging (RUSI) of three abdominal stabilizing muscles; transverse abdominis (TrA), obliquus internus (OI), obliquus externus (OE) muscles and one posterior stabilizer, the lumbar multifidus muscles (LM) was captured. RESULTS: All studied muscles of TrA, OI, OE, and LM were found to have significant thickness increases during all three sessions compared to resting state (p < 0.05). Thicknesses changes of TrA, OI, and LM were significant during simultaneous NMES of both abdominal wall and lumbar paraspinal regions (Session 3) (p < 0.05). CONCLUSIONS: Our results indicate that concurrent NMES on abdominal wall and lumbar paraspinal area is most effective to maximally activate deep lumbar stabilizers. Rehabilitative efforts for patients with LBP may benefit from simultaneous transcutaneous NMES of abdominal and lumbar regions.

The effects of neuromuscular electrical stimulation at different frequencies on the activations of deep abdominal stabilizing muscles.

BACKGROUD: Low back pain is associated with transversus abdominis (TrA) dysfunction. Recently, it was proposed that Neuromuscular Electrical Stimulation (NMES) could be used to stimulate deep abdominal muscle contractions and improve lumbopelvic stability. OBJECTIVE: The purpose of this study was to determine the optimal stimulation frequency required during NMES for the activation of deep abdominal muscles. METHODS: Twenty healthy volunteers between the ages of 24 and 32 were included. The portable research-stimulator was applied using a 10 second contraction time, and a 10 second resting time at 20 Hz, 50 Hz, and 80 Hz. Changes in muscle thicknesses were determined for the TrA, obliquus internus (OI), and obliquus externus (OE) by real time ultrasound imaging. RESULTS: Significant thickness increases in the TrA, OI, and OE were observed during NMES versus the resting state (p < 0.05). Of the frequencies examined, 50 Hz NMES produced the greatest increase in TrA thickness (1.33 fold as compared with 1.22 fold at 20 Hz and 1.21 fold at 80 Hz) (p < 0.05). CONCLUSIONS: Our results indicate that NMES can preferentially stimulate contractions in deep abdominal stabilizing muscles. Most importantly, 50 Hz NMES produced greater muscle thickness increases than 20 or 80 Hz.

Activations of deep lumbar stabilizing muscles by transcutaneous neuromuscular electrical stimulation of lumbar paraspinal regions.

OBJECTIVE: To investigate changes in lumbar multifidus (LM) and deep lumbar stabilizing abdominal muscles (transverse abdominis [TrA] and obliquus internus [OI]) during transcutaneous neuromuscular electrical stimulation (NMES) of lumbar paraspinal L4-L5 regions using real-time ultrasound imaging (RUSI). METHODS: Lumbar paraspinal regions of 20 healthy physically active male volunteers were stimulated at 20, 50, and 80 Hz. Ultrasound images of the LM, TrA, OI, and obliquus externus (OE) were captured during stimulation at each frequency. RESULTS: The thicknesses of superficial LM and deep LM as measured by RUSI were greater during NMES than at rest for all three frequencies (p<0.05). The thicknesses in TrA, OI, and OE were also significantly greater during NMES of lumbar paraspinal regions than at rest (p<0.05). CONCLUSION: The studied transcutaneous NMES of the lumbar paraspinal region significantly activated deep spinal stabilizing muscle (LM) and the abdominal lumbar stabilizing muscles TrA and OI as evidenced by RUSI. The findings of this study suggested that transcutaneous NMES might be useful for improving spinal stability and strength in patients having difficulty initiating contraction of these muscles.

Verification of an optimized stimulation point on the abdominal wall for transcutaneous neuromuscular electrical stimulation for activation of deep lumbar stabilizing muscles.

BACKGROUND CONTEXT: Transcutaneous neuromuscular electrical stimulation (NMES) can stimulate contractions in deep lumbar stabilizing muscles. An optimal protocol has not been devised for the activation of these muscles by NMES, and information is lacking regarding an optimal stimulation point on the abdominal wall. PURPOSE: The goal was to determine a single optimized stimulation point on the abdominal wall for transcutaneous NMES for the activation of deep lumbar stabilizing muscles. STUDY DESIGN: Ultrasound images of the spinal stabilizing muscles were captured during NMES at three sites on the lateral abdominal wall. After an optimal location for the placement of the electrodes was determined, changes in the thickness of the lumbar multifidus (LM) were measured during NMES. METHODS: Three stimulation points were investigated using 20 healthy physically active male volunteers. A reference point R, 1 cm superior to the iliac crest along the midaxillary line, was used. Three study points were used: stimulation point S1 was located 2 cm superior and 2 cm medial to the anterior superior iliac spine, stimulation point S3 was 2 cm below the lowest rib along the same sagittal plane as S1, and stimulation point S2 was midway between S1 and S3. Sessions were conducted stimulating at S1, S2, or S3 using R for reference. Real-time ultrasound imaging (RUSI) of the abdominal muscles was captured during each stimulation session. In addition, RUSI images were captured of the LM during stimulation at S1. RESULTS: Thickness, as measured by RUSI, of the transverse abdominis (TrA), obliquus internus, and obliquus externus was greater during NMES than at rest for all three study points (p<.05). Transverse abdominis was significantly stimulated more by NMES at S1 than at the other points (p<.05). The LM thickness was also significantly greater during NMES at S1 than at rest (p<.05). CONCLUSIONS: Neuromuscular electrical stimulation at S1 optimally activated deep spinal stabilizing muscles, TrA and LM, as evidenced by RUSI. The authors recommend this optimal stimulation point be used for NMES in the course of lumbar spine stabilization training in patients having difficulty initiating contraction of these muscles.

Activations of Deep Lumbar Stabilizing Muscles by Transcutaneous Neuromuscular Electrical Stimulation of Lumbar Paraspinal Regions

OBJECTIVE: To investigate changes in lumbar multifidus (LM) and deep lumbar stabilizing abdominal muscles (transverse abdominis [TrA] and obliquus internus [OI]) during transcutaneous neuromuscular electrical stimulation (NMES) of lumbar paraspinal L4-L5 regions using real-time ultrasound imaging (RUSI). METHODS: Lumbar paraspinal regions of 20 healthy physically active male volunteers were stimulated at 20, 50, and 80 Hz. Ultrasound images of the LM, TrA, OI, and obliquus externus (OE) were captured during stimulation at each frequency. RESULTS: The thicknesses of superficial LM and deep LM as measured by RUSI were greater during NMES than at rest for all three frequencies (p<0.05). The thicknesses in TrA, OI, and OE were also significantly greater during NMES of lumbar paraspinal regions than at rest (p<0.05). CONCLUSION: The studied transcutaneous NMES of the lumbar paraspinal region significantly activated deep spinal stabilizing muscle (LM) and the abdominal lumbar stabilizing muscles TrA and OI as evidenced by RUSI. The findings of this study suggested that transcutaneous NMES might be useful for improving spinal stability and strength in patients having difficulty initiating contraction of these muscles.