Authors: Tamara Rial, PhD, CSPS, Kathleen Doyle-Elmer, PT, DPT and Rebecca Keller, PT, MSPT, PRPC
Tamara Rial, PhD, CSPS, co-founder and developer of Low Pressure Fitness will be presenting the first edition of Low Pressure Fitness and Abdominal Massage for Pelvic Floor Care Level 2 and 3 in Princeton, New Jersey in September, 2019. Rebecca Keller and Kathleen Doyle-Elmer are certified Low-Pressure Fitness specialists with training in rehabilitative ultrasound imaging. In this article, the authors discuss and explore the use of transabdominal ultrasound during Low Pressure Fitness on the abdominal and pelvic floor structures.
Real-time ultrasound imaging is a reliable and valid method to evaluate muscle structure, activity and mobility. Over the past few years, there has been increasing interest in the use of transabdominal ultrasound in the field of rehabilitation. The additional value of ultrasound imaging is that it allows for real-time analysis and visual feedback during the performance of pelvic floor and abdominal exercises (Hides et al., 1998). In the field of pelvic health, this is of notable importance when assessing proper movement of the deep abdominal and pelvic muscles during voluntary muscle actions. Transabdominal ultrasound has been found to be a safe, noninvasive, and accurate method to assess and observe muscular and fascial activity (Khorasani et al., 2012). When therapists learn how to properly use and apply ultrasound imaging, this technique can be a comprehensive tool for the clinician and a comfortable procedure for the patient. Moreover, it may be the method of choice for some patients who don’t want to have an internal pelvic examination (Van Delft, Thakar & Sultan, 2015). In this regard, a cross-sectional study found a moderate-to-strong correlation between ultrasound measurements and both digital examination and perineometry for the assessment of pelvic floor muscle actions (Volløyhaug et al., 2016).
Recently, Low Pressure Fitness has gained popularity as a pelvic floor training program aimed at reducing pressure on the pelvic structures while engaging the stabilizing muscles through postural and breathing exercises. In order to evaluate proper execution of Low-Pressure Fitness exercises as well as abdomino-pelvic muscle function during this type of training, real-time transabdominal ultrasound can be a clinically relevant tool.
The amount of movement of the bladder base on transabdominal ultrasound is considered an indicator of pelvic floor muscle mobility during pelvic floor muscle exercises (Khorasani et al., 2012). When properly executed, the Low-Pressure Fitness technique will allow the bladder to lift and the pelvic floor muscles to contract. These observed actions can be cued and progressed due to the real-time imaging biofeedback of the ultrasound. Because of the postural activation and diaphragm lift occurring during Low Pressure Fitness, the bladder fascial support system is tensioned resulting in a desirable bladder lift.
For example, we used a Pathway® Musculoskeletal Rehabilitative Ultrasound Imaging unit with a curvilinear transducer and Prometheus Pathway® rehabilitative ultrasound software utilizing the pre-set parameters (Abdominal Wall 7.5MHz and Bladder 5.0MHz) during a Low-Pressure Fitness basic supine posture. A standardized bladder filling protocol was used before imaging to ensure sufficient bladder filling to allow clear imaging of the base of the bladder and pelvic floor muscles.
For the transverse view, radiologic standards were used, and the ultrasound transducer was placed in the transverse plane suprapubically and angled in a caudal/ posterior direction to obtain a clear image of the inferior-posterior aspect of the bladder. The participant was asked to perform the Low-Pressure Fitness Demeter exercise in the supine position with a neutral pelvis and knees flexed (Figure 1).
The following video illustrates the pelvic floor/urinary bladder during: a) resting position; b) active pelvic floor contraction; c) Low Pressure Fitness Demeter exercise and; d) Low Pressure Fitness Demeter exercise combined with a voluntary pelvic floor muscle contraction. It is noticeable a greater bladder lift and pelvic floor activation with the postural and breathing cueing added to an active pelvic floor contraction than with the pelvic floor contraction alone.
The lateral abdominal muscle ultrasound assessment allows us to observe the structural changes produced in the transversal section of the abdominal muscles in the midpoint between the anterior iliac crest and the costal angle. At low levels of contraction, the extent of transverse abdominis thickening measured using ultrasound is reported to be a valid method of assessment compared with either fine wire electromyographic measures of transverse activity (McMeeken et al., 2004). It is well established in the scientific literature that the lateral abdominal muscles provide stability to the trunk in different functional activities. Therefore, the assessment of the size, thickness and sliding of the abdominal wall is important for patients who present with lumbo-pelvic and/or pelvic floor dysfunctions. In this regard, patients with low back pain show different abdominal wall muscle activation patterns (i.e. less slide of the abdominal fascia and muscle thickness) than those without low back pain (Gildea et al., 2014; Unsgaard-Tondel et al., 2012).
Figure 2 shows the three muscle layers of the lateral wall in the resting position. The superficial layer corresponds to the external oblique, the middle layer to the internal oblique and the deep layer to the transverse abdominal muscle.
A key breathing component of the Low-Pressure Fitness program is the abdominal vacuum which manipulates intra-abdominal, intra-thoracic and intra-pelvic pressures during the breath-holding phase. Another key aspect of Low-Pressure Fitness is the shoulder girdle activation, spine elongation and ankle-dorsiflexion (Rial & Pinsach, 2017). Of note, previous studies have demonstrated greater transverse abdominis activation when performing ankle dorsi-flexion (Chon et al., 2010). We used transabdominal ultrasound to assess the lateral abdominal wall response during ankle dorsiflexion, shoulder girdle activation and the abdominal vacuum during Low Pressure Fitness.
In the following video, a voluntary (active) abdominal contraction is performed in order to distinguish this action from the involuntary abdominal contractions during Low Pressure Fitness. Afterwards, the postural technique of ankle dorsiflexion and shoulder girdle activation are performed in the Demeter exercise with arms in middle position (Figure 1). Lastly, an abdominal vacuum maneuver is added to the postural technique. If the exercises are properly executed, the progressive sliding and thickness of the abdominal muscles throughout exercise sequence should be observable (Figure 3).
Muscle thickness of the transverse and internal oblique as well as a noticeable slide of the anterior abdominal fascia are observable during the Demeter exercise of Low-Pressure Fitness. This exercise pattern reflects an abdominal draw-in maneuver and a “corseting effect”. In this regard, notice the lateral pull or displacement of the edge of the anterior fascial insertion of the transverse the internal oblique muscle.
Navarro et al., (2017) used transabdominal ultrasound to assess the muscular responses of the pelvic floor and abdominal muscles in a group of women who underwent pelvic physiotherapy over two months. They found a significant increase in the transversal section of the transverse abdominis, external oblique, and internal oblique muscles when compared to resting in the supine position. Similar to the position assessed by Navarro et al. (2017), we also assessed the pelvic floor and abdominal muscle responses during a Low-Pressure Fitness supine exercise.
Transabdominal ultrasound can provide a noninvasive and informative visual biofeedback when training patients with Low Pressure Fitness. This ultrasound imaging can be a valuable tool to both the client and the clinician to objectify progress, assist with validating correct Low-Pressure Fitness form with positioning and vacuum/hypopressive maneuver as well as a motivational technique for the client. As demonstrated during our rehabilitative ultrasound imaging, observable bladder lift, pelvic floor activation and desirable lateral abdominal muscular corseting (slide and thicking) occurs during Low Pressure Fitness postural exercises and breathing. Since Low Pressure Fitness is a progressive exercise program, qualified instruction, technique driven progression and understanding pelvic floor health are needed to optimize patient outcomes.
Chon SC, Chang KY, You JS. Effect of the abdominal draw-in manoeuvre in combination with ankle dorsiflexion in strengthening the transverse abdominal muscle in healthy young adults: a preliminary, randomised, controlled study. Physiotherapy 96: 130-6, 2017.
Gildea JE, Hides JA, Hodges PW. Morphology of the abdominal muscles in ballet dancers with and without low back pain: a magnetic resonance imaging study. J Sci Med Sport. 17(5): 452-6, 2014.
Khorasani B, Arab AM, Sedighi Gilani MA, Samadi V, Assadi H. Transabdominal ultrasound measurement of pelvic floor muscle mobility in men with and without chronic prostatitis/chronic pelvic pain syndrome. Urology, 80: 673-7, 2012.
McMeeken JM, Beith ID, Newham DJ, Milligan P, Critchley DJ. The relationship between EMG and change in thickness of transversus abdominis. Clin Biomech 19: 337–342, 2004.
Hides JA, Richardson CA, Jull GA. Use of real-time ultrasound imaging for feedback in rehabilitation. Man Ther. 3:125-131,1998.
Navarro B, Torres M, Arranz B, Sanchez O. Muscle response during a hypopressive exercise after pelvic floor physiotherapy: Assessment with transabdominal ultrasound. Fisioterapia 39: 187-94, 2017.
Rial T, Pinsach P. Practical Manual Low Pressure Fitness Level 1. International Hypopressive & Physical Therapy Institute, Vigo, 2017.
Unsgaard-Tøndel M, Lund Nilsen TI, Magnussen J, Vasseljen O. Is activation of transversus abdominis and obliquus internus abdominis associated with long-term changes in chronic low back pain? A prospective study with 1-year follow-up. Br J Sports Med, 46(10): 729-34, 2012.
Van Delft K, Thakar R, Sultan AH. Pelvic floor muscle contractility: digital assessment vs transperineal ultrasound. Ultrasound Obstet Gynecol, 45: 217-22, 2015. Volløyhaug I, Mørkved S, Salvesen Ø, Salvesen KÅ. Assessment of pelvic floor muscle contraction with palpation, perineometry and transperineal ultrasound: a cross-sectional study. Ultrasound Obstet Gynecol 47: 768-73, 2016.
Several weeks ago, I evaluated a patient who was referred to me from a fellow physical therapist. The patient was suffering from sacroiliac joint and low back pain. The patient is a 34-year-old nulliparous woman who is physically fit and participates in several outdoor activities. The therapist had fully evaluated the patient and did not find any articular issues within her spine or pelvis. What she did find was weakness in her local stabilizing muscles and tightness in her global stabilizing muscles. The therapist has an ample amount of clinical experience at treating low back and pelvic pain issues. She is adept at using different verbal cues, positions, and tactile cueing in order to help encourage proper activation of the local core muscles. However, the therapist knew the patient was not getting her local core muscles to fire properly. She didn’t know what else to do with this patient in order to get her to properly activate these muscles. She had tried numerous positions, verbal and tactile cueing without success.
Do you ever have patients where you feel stuck, who are not progressing as you would like them to in treatment? We all do! It is frustrating, isn’t it? The physical therapist called me and asked me to evaluate the patient using real-time ultrasound imaging. The therapist said “If the patient can just see what she is doing, she will then be able to learn how to work the muscles correctly.” She referred the patient to me so I could use ultrasound imaging within the treatment to better assess her activation strategies and use the imaging for biofeedback for with the patient. The patient was amazed with the ability to see what the different layers of muscles were doing. We found she was contracting her TA but only on her left side, and her deep multifidus was not firing at all. Using the ultrasound images, the patient was able to learn the proper way to activate her muscles. She is now working on a strengthening program for her local core muscles including her TA, pelvic floor, and multifidus. Within two treatments, the patient was able to fire her muscles in a different way and reports her back has felt better than it has in years!
The Pathway Ultrasound Imaging System, available from The Prometheus Group, is a portable ultrasound solution for pelvic rehab
I cannot emphasize enough how using ultrasound might change your practice! It not only can help you when you are stuck with a patient’s progress, but it can attract more patients to your practice. There are a lot of visual learners out there and access to visual images in therapy can influence progress and the results that are achieved. You not only can use the ultrasound to retrain the local core muscles for back and pelvic instability patients, but you can use it for incontinence patients, prolapse patients, and post prostatectomy patients as well. You can strengthen the pelvic floor without having to disrobe the patient each visit. How many men and women would appreciate that?
If you are interested in learning more about how you can use ultrasound in your practice, join me in August in New Jersey, or in November in California for Rehabilitative Ultrasound Imaging - Women's Health and Orthopedic Topics! See you there!
A couple of years ago, I wrote a blog about an interesting article by Hides and Stanton that related size and strength of the multifidus to the risk for lower extremity injury in Australian professional football players.
Now some of the same researchers are looking above. A prospective cohort study has recently been published that examined factors and their effects on concussions. Physical measurements of risk factors were taken in pre-season among Australian football players. These measurements included balance, vestibular function, and spinal control. To measure these outcomes the following tests were included: for balance the amount of sway across six test conditions were performed; vestibular function was tested with assessments of ocular-motor and vestibular ocular reflex; and for spinal control cervical joint position error, multifidus size, and contraction ability was tested. The objective measure was concussion injury obtained during the season diagnosed by the medical staff.
The findings were so interesting! Age, height, weight, and number of years playing football were not associated with concussion. Cross-sectional area of the multifidus at L5 was 10% smaller in players who went on to sustain a concussion compared to players that did not receive a concussion. There were no significant differences observed between the players that received concussion and those who did not with respect to the other physical measures that were obtained.
With all the recent evidence about the harmful effects of concussions amongst our athletes, I find this information amazing and am excited to see where the researchers take this in the future. The next question for the physical therapist is how do we train the multifidus? The multifidus can be difficult to retrain in some individuals. It is a hard muscle for some patients to learn to recruit. Biofeedback using ultrasound imaging can make this daunting task easier for many patients. With the cost of ultrasound units coming down, it is also a very reasonable tool for clinics to look at investing in.
Join me to learn more about the multifidus and how to use ultrasound imaging in the retraining process. Future course offerings include August in New Jersey, and November in San Diego. I look forward to seeing you there!
Hides, Stanton. Can motor control training lower the risk of injury for professional football players? Med Sci Sports Exerc. 2014; 46(4): 762-8.
Leung, Hides, Franettovich Smith, et al. Spinal control is related to concussion in professional footballers. Brit J of Sports Med. 2017; 51(11).
In some families, puberty is not only a time to have to deal with all the physical, hormonal, and emotional changes that are occurring, but it is a time to have to worry about and check for spinal abnormalities that can run in families. Adolescent idiopathic scoliosis is an abnormal curvature of the spine that appears in late childhood or adolescence. The spine will rotate, and a curvature will develop in an “S” shape or “C” shape. Scoliosis is the most common spinal disorder in children and adolescents. It is present in 2 to 4 percent of children between the ages of 10 and 16 years of age. There is a genetic link to developing scoliosis and scientists are working to identify the gene that leads to adolescent idiopathic scoliosis. Adolescent girls are more likely to develop more severe scoliosis. The ratio of girls to boys with small curves of 10 degrees or less is equal, however the ratio of girls to boys with a curvature of 30 degrees or greater is 10:1. Additionally, the risk of curve progression is 10 times higher in girls compared to boys. Scoliosis can cause quite a bit of pain, morbidity, and if severe enough can warrant spinal surgery.
A recent article in Pediatric Physical Therapy by Zapata et al. assessed if there were asymmetries in paraspinal muscle thickness in adolescents with and without adolescent idiopathic scoliosis. They utilized ultrasound imaging to compare muscle thickness of the deep paraspinals at T8 and the multifidus at L1 and L4. They found significant differences in muscle thickness on the concave side compared to the convex side at T8 and L1 in subjects with scoliosis. They also found significantly greater muscle thickness on the concave side at T8, L1, and L4 in patients with adolescent idiopathic scoliosis compared to controls. This is very interesting to me, and exciting to think about the possibilities of how we therapists might can use this information! My first question is, is the difference in muscle thickness a cause or result of the curvature of the spine? My next question is if we trained the multifidus on the convex side, the side that is thinner, would it make a difference in supporting the spine and therefore help prevent some of the curvature? Would strengthening the multifidus in a very segmental manner comparing right versus left and targeting segments and sides that are weaker than others help prevent rotation and curvature in individuals who have a familial predisposition to developing idiopathic scoliosis? I hope so! I hope this group continues to study scoliosis and provides some evidence-based treatment that can help decrease the severity of curvature.
Assessing the multifidus thickness and strength, and differentiating it from the paraspinal muscles can be tricky. The best way to do this is the same way the authors of this article did, using ultrasound imaging. Ultrasound imaging gives unparalleled information on muscle shape, size, and activation of the muscle. Learning to use ultrasound imaging will change your practice! You will see dramatic differences in how you treat patients as well as the results you get when training the local core musculature. It also may open doors to treating different patient types than you are treating now, like adolescents with scoliosis. Join me in Spokane, WA on October 20-22 to further discuss how ultrasound can change your practice and perhaps help you reach out to a new population that you may not be treating now!
Miller NH. Cause and natural history of adolescent idiopathic scoliosis. Orthop Clin North Am. 1999;30:343–52.
Roach JW. Adolescent idiopathic scoliosis. Orthop Clin North Am. 1999;30:353–65.
Zapata KA, Wang-Price SS, Sucato DJ, Dempsey-Robertson M. Ultrasonographic measurements of parspinal muscle thickness in adolescent idiopathic scoliosis: a comparison and reliability study. Pediatr Phys Ther. 2015; 27(2): 119-25.
Have you ever tried to teach a patient how to isolate their transversus abdominis (TA) contraction or a pelvic floor muscle (PFM) contraction and the patient had difficulty or you weren’t sure how well they were isolating it? Did you ever wish you had the ability to use real-time ultrasound (US) to confirm which abdominal layers they were isolating or use it for visual feedback to assist in your patient’s learning? Could it be helpful to be able to use real-time US to identify if they were isolating the pelvic floor muscles and give your patient visual feedback? Of course!
Real- time US has been used as an assessment and teaching tool to directly visualize abdominal and PFMs. PFM function can be assessed by observing movement at the bladder base and bladder neck. Various studies have used US on women with and without urinary incontinence (UI). These studies usually use transabdominal (TAUS) and transperineal (TPUS) ultrasound to measure if PFM isometrics or exercises are performed correctly or incorrectly, or how the muscles are functioning.
A 2015 study in the International Urogynecology Journal utilized TAUS to identify the ability to perform a correct elevating PFM contraction and assess bladder base movement during an abdominal curl up exercise. Abdominal curl ups are cited to increase intra-abdominal pressure. Activities that increase intra-abdominal pressure have been cited to provoke stress urinary incontinence (SUI). Abdominal curl ups are often completed in group exercise classes and have been found to provoke SUI in up to 16% of women.
Use of PFM exercises and of “the knack” (performing an isometric pelvic contraction before an exertional activity where intra-abdominal pressure increases, such as before lifting or coughing) has been shown to help manage stress urinary incontinence.
The theory is that elevation of the PFMs during activities that increase intraabdominal pressure (like a curl up) assist in urethral closure and counter act the downward movement, therefore stabilizing the urethra and bladder neck. When using TAUS, while performing a correct PFM contraction, one might expect to see an elevating PFM contraction. In the study, TAUS was used on 90 women participating in a variety of group exercise classes. The participants completed a survey and then three attempts of an abdominal curl up exercise in hooklying. During the curl ups, bladder base displacement was measured to determine correct or incorrect activation patterns. It was found that 25% of the women were unable to demonstrate an elevating PFM contraction, and all women displayed bladder base depression on the abdominal curl exercise. It was also found that parous women displayed more bladder base depression than nulliparous women, and overall 60% of the participants reported SUI. Lastly, this study found there was no association between SUI and the inability to perform an elevating PFM contraction or the amount of bladder base depression.
What interesting information. Using real time US in the clinic could help us identify if our patients were completing “the knack” correctly with specific activities. This study is a great example of how we can use real time US to help collect evidence to provide us with more information that can help us answer our own questions, patient questions, and improve our instructional methods to patients when teaching core or PFM exercises.
1) Barton, A., Serrao, C., Thompson, J., & Briffa, K. (2015). Transabdominal ultrasound to assess pelvic floor muscle performance during abdominal curl in exercising women. International urogynecology journal, 26(12), 1789-1795.
Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC is a published researcher and practitioner who has worked in the realms of brain injury, lymphedema, and oncology. Now she's leading the charge to encourage rehabilitation practitioners to utilize ultrasound diagnostic imaging with their patients, and you can learn these techniques in her Rehabilitative Ultrasound Imaging - Women's Health and Orthopedic Topics course taking place May 1 - 3 in Dayton, OH. We've partnered with SonoSite to make the best ultrasound equipment available for participants in this course.
Most of us are treating patients who have back pain of some nature, and we know the importance of the local stabilizing muscles including the transverse abdominis, the lumbar multifidus, and the pelvic floor muscles. These muscles work together to provide tension and create a corset of stability throughout the trunk. A common goal is to rehabilitate these muscles in order to restore motor control and strength, but the muscle depth can make them difficult to assess and palpate.
I recently read a study that is looking at the development of a test to identify lumbar multifidus function. Herbert et al. found promising results when looking at this “multifidus lift test” for inter-rater reliability and concurrent validity to identify dysfunction in the multifidus. They compared the results of this test with real-time ultrasound imaging of the lumbar multifidus. Inter-rater reliability was excellent and free from errors of bias and prevalence. Concurrent validity was demonstrated through its relationship with the reference standard results at L4-L5, but not so much for L5-S1. This preliminary research supports the reliability and validity of the multifidus lift test to assess lumbar multifidus function at some spinal levels. If this test could be further validated for other spinal levels it would be very beneficial for therapists who are using a specific stabilization program to treat patients.
Until this test is further developed and validated how can therapists know for sure that their patient is truly activating their multifidus? Ultrasound imaging is the answer! Ultrasound imaging gives therapists real-time feedback for whether a patient is able to correctly activate a muscle or not. It is also a wonderful biofeedback tool for patients who are trying to rehabilitate these muscles. Getting your hands on an ultrasound machine can be tough, but therapists who work in a hospital system may have an easier time than you'd think. I have worked with many therapists to help them get access to ultrasound units through “hand me down” units from imaging or labor and delivery departments. I also have helped private practice therapists set up a working relationship with a physician who has an ultrasound in their office. Thinking outside of the box can allow clinicians to gain access to ultrasound units without having to spend a lot of money. Join me in Dayton Ohio this May to hear more about how ultrasound imaging can improve your practice and allow you to incorporate a specific stabilization program into your toolbox.
Herbert JJ, Koppenhaver SL, Teyhen DS, Walker BF, Fritz JM. The evaluation of lumbar multifidus muscle function via palpation: reliability and validity of a new clinical test. Spine J. 2015; 15(6): 1196-202.
One of the dilemmas for many clinicians new to pelvic rehab is trying to figure out which equipment to purchase, and how to convince their employer (or themselves) to purchase the equipment. A common question in relation to equipment for pelvic rehabilitation is “what do I really need?” In a perfect world, and based on both existing and emerging research as well as clinical practice recommendations, we would all have access to pressure biofeedback and real-time ultrasound to help us document and train our patients in best strategies. The truth, however, lies in the fact that when those devices are not available, clinical practice can gain meaningful information from our best tools: our eyes and our hands. Certainly when completing research about pelvic floor generated pressures we might choose pressure biofeedback, and when looking for muscle activation patterns, needle EMG is the right choice, but no one should deny patients the opportunity to learn how to increase or decrease muscle activity, focus on movement retraining, and learn strategies to decrease improve quality of life and function because the latest technology is unavailable.
Recent research published in the Brazilian Journal of Physical Therapy helps affirm the value of vaginal palpation in an article that assessed the relationship between vaginal palpation, vaginal squeeze pressure, electromyography and ultrasound. Eighty women between the ages of 18 and 35 years old, who had never given birth, and who had no known pelvic floor dysfunction were given a thorough evaluation using a multitude of evaluative methods. These methods included vaginal digital palpation (using Modified Oxford scale), vaginal squeeze pressure, electromyographic activity, diameter of the bulbocavernosus muscles as well as bladder neck movement using transperineal ultrasound. The muscles were assessed in a supine, hooklying position. A strong and positive correlation was found between pelvic floor muscle function and pelvic floor muscle contraction pressure. A less strong correlation was found between pelvic muscle function and pressure and electromyography and ultrasound.
Vaginal pelvic muscle assessment via palpation has been shown to be more accurate when assessed by more experienced therapists, and use of multiple methods may be most valuable in gaining the most accurate data. In addition to validating the usefulness of pelvic muscle palpation as an evaluative tool, the authors point out that transperineal ultrasound may also be the most appropriate tool for pediatric patients or patients who are otherwise not appropriate for internal pelvic muscle assessment.
Pereira, V. S., Hirakawa, H. S., Oliveira, A. B., & Driusso, P. (2014). Relationship among vaginal palpation, vaginal squeeze pressure, electromyographic and ultrasonographic variables of female pelvic floor muscles. Brazilian journal of physical therapy, 18(5), 428-434.
The following post comes to us from Herman & Wallace faculty member Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC. Allison authored "Use of transabdominal ultrasound imaging in retraining the pelvic-floor muscles of a woman postpartum" and is a leading expert in the use of ultrasound imaging for pelvic rehab. She is the author and instructor of the Rehabilitative Ultrasound Imaging: Women’s Health and Orthopedic Topics offered with Herman & Wallace.
In the pelvic floor series we learn how to perform examinations for cystoceles and rectoceles. It can be more difficult for therapists to examine and quantify the degree of uterine descent. In the last few years translabial ultrasound imaging has also been used to identify what is happening in the anterior compartment upon Valsalva and pelvic floor contraction, including the uterus. This is helpful when trying to determine the degree of uterine prolapse. Degree of pelvic organ descent visible on by ultrasound has been shown to have a near-linear relationship with measures on the POPQ.
Clinically we see that some patients with severe prolapses have few symptoms, while other patients with smaller prolapses will have more severe complaints of symptoms. This can be puzzling to the clinician who is trying to treat prolapse patients. Shek and Dietz performed a study to set cutoff measures of uterine descent that will predict symptoms of prolapse. Translabial ultrasound imaging was performed on 538 women with 263 women reporting prolapse symptoms. Seventy-five percent of the women presented with grade two or greater prolapse on the POPQ, with most of being cystoceles or rectoceles. The women with more complaints of symptoms of prolapse were more likely to have uterine prolapse. There was a strong association between degree of uterine descent and symptoms of prolapse. They determined that an optimal cutoff to predict symptoms of prolapse due to uterine descent is a cervix descending to 15 mm above the pubic symphysis.
This study intrigues me and makes me wonder how much we are focusing on cystoceles and rectoceles and not looking at uterine prolapses. Using translabial ultrasound imaging is a nice tool to allow the clinician to see what is going on with all of the pelvic organs. With one Valsalva maneuver you are able to assess a lot of information including support of the pelvic organs. It also gives the clinician another way to quantify the degree of prolapse. Ultrasound imaging is a wonderful tool that clinicians can use for assessment as well as a biofeedback tool. If you are interested in learning how to perform this type of assessment, I will be teaching Rehabilitative Ultrasound Imaging: Women’s Health and Orthopedic Topics May 1-3 in Dayton, OH.
Shek KL, Dietz HP. What is abnormal uterine descent on translabial ultrasound? Int. Urogynecol J. 2015; 26(12)1783-7.
What are you saying when giving directions to men during pelvic floor muscle training, and how do those instructions affect the effectiveness of a contraction? These questions are tackled in a study that is very interesting to therapists working in pelvic dysfunction. 15 healthy men ages 28-44 (with no prior training in pelvic floor training) were instructed to complete a submaximal effort pelvic muscle contraction. Tools utilized to acquire data in the study include those below:
|Transperineal ultrasound||displacement of pelvic floor landmarks|
|Surface EMG (electromyography)||abdominal, anal sphincter muscle activation|
|Nasogastric transducer||intra-abdominal pressure (IAP)|
|Fine wire electromyography (3 participants only)||puborectalis, bulbocavernosus muscles|
Participants sat upright on a plinth (backrest reclined at ~20 degrees with their knees extended). Directions for the submaximal efforts were given by telling the men to produce a level 3/10 effort with 10 being a maximal contraction. The men were instructed to hold the contraction for 3 seconds, and they were given 10 seconds rest between each of the 4 contractions using different verbal cues. (This series of 4 contractions was repeated with randomization for verbal cues, with a 2 minute rest in-between.) Verbal instructions were intended to target specific contractile tissues as described below- some of this theory could be validated via the fine wire EMG.
|"tighten around the anus"||anal sphincter|
|"elevate the bladder"||puborectalis|
|"shorten the penis"||striated urethral sphincter|
|"stop the flow of urine"||striated urethral sphincter, puborectalis|
Displacement, IAP, and abdominal/anal EMG were compared for the different verbal instructions. The greatest dorsal displacement of the mid-urethra and striated urethral sphincter activity was noted with the instruction to "shorten the penis." "Elevate the bladder" encouraged the greatest increase in abdominal EMG and IAP, while "tighten around the anus" induced the greatest anal sphincter activity. Displacement of pelvic landmarks correlated with EMG readings of the muscles thought to produce the targeted movement. The authors conclude that the therapist's choice of verbal instructions can influence the muscle activation and urethral movement in men. They suggest "shorten the penis" and "stop the flow of urine" for optimal activation of the striated urethral sphincter. They also point out the fact that by using the fine wire EMG and correlating muscle activation to observations with the transperineal ultrasound, the study validates the use of the less invasive method. If you are ready to jump into more education about male pelvic rehabilitation, join us in Denver in early August, or Seattle in November.
Today’s contribution to the Pelvic Rehab Report comes from Allison Ariail, the instructor for Herman & Wallace’s Rehabilitative Ultrasound Imaging courses. Join Allison and others this June 12-14 at Rehabilitative Ultra Sound Imaging: Women's Health and Orthopedic Topics - Baltimore, MD!
Is an Ultrasound that provides images of the pelvic floor and other deep musculature a cool gadget to have in the office or something that is truly essential? That depends on who you are asking! If you know how to use Ultrasound imaging properly and market yourself and your practice accordingly, it can become a tool that is not only fun to have and handy to use clinically, but also essential to providing your most efficient and thorough care!
Using an ultrasound (US) machine allows you to view the deeper musculature to assess how the muscles are functioning. The most common muscles assessed with US imaging are the transverse abdominis, the multifidus, and the pelvic floor. The patient then can use what is seen on the US screen as biofeedback to retrain their strategy and timing of recruitment. The therapist can also assess the patient’s ability to activate and maintain a contraction in various positions and even during motor tasks as well. This type of biofeedback is not only useful for pelvic floor patients, but is also important for patients with back and sacroiliac joint pain. Research is showing that using this type of stabilization program is making a difference in athletes. Julie Hides has published two articles recently showing that this type of stabilization program has helped with low back pain in professional cricket players, as well as to decrease the rate of lower extremity injury in Australian professional football players. (1,2) (see my post on The Local Stabilizing Muscles and Lower Extremity Injury.
You may be saying to yourself that you can save a lot of money and just palpate the transverse abdominis (TA), and the multifidus. However I would ask you… are you really feeling a transverse abdominis contraction, or some of the internal obliques? I have had 2 patients referred to me from very capable therapists that I respect and look up to. They were referred to me due to a lack of progress in their treatment. The therapist was addressing a local stabilization program, but their back pain was not getting better. To their credit, the therapist was able to train both patients to perform a proper TA contraction in supine, however one patient was unable to hold a contraction beyond 1 second, and another one was not able to activate it in sitting, or standing. This would explain why they were not progressing with respect to their pain. After treating each patient for 1 or 2 visits using US imaging, and sending them back to their referring therapist, they made rapid progress. Both therapists were so convinced on the usefulness of US imaging that they both went out and bought a machine to use in their clinic. Additionally, you would be surprised how many physical therapists (I can’t count the number on two hands anymore) I have seen that think they are properly performing a TA contraction and want to see how they are doing on the US. However, once we used the US imaging to assess their TA contraction, they realized they were overcompensating with their internal obliques. This is with physical therapists who have more knowledge than the general public regarding the importance of these muscles and how to activate them!
If you are knowledgeable in using ultrasound imaging, you open your doors to a number of possible patients you may not be currently accessing as referrals. There are numerous women and men who would like to receive treatment for pelvic floor weakness issues, but do not want to have to disrobe each treatment. Using ultrasound imaging is a wonderful option for these patients. It also is a way to treat younger patients that you have not been able to treat in the past as well (I would recommend taking the Pediatric Incontinence and Pelvic Floor Dysfunction course prior to treating pediatric patients). By using ultrasound imaging you not only gain an edge over your competing clinics that specialize in pelvic floor therapy, but you can gain an edge for back patients and sacroiliac joint patients as well. For the reasons I stated above when discussing a stabilization program centered on the use of US imaging, you could become very busy with referrals from spine surgeons, and ortho docs. In my office we have six therapists trained in using ultrasound imaging and two ultrasound machines. One of our most limiting factors is not the lack of patients to use ultrasound on, but that we only have two US units available to use! We have several spine physicians that send all of their patients to us because they have seen the difference using ultrasound imaging and the stabilization program can make in patients’ lives. We are eagerly awaiting a third machine and know it will be immediately used and allow us to further grow our clinic.
Now you may be saying, “Yes this would be handy but the pricing makes it impossible!” I would say think outside of the box! Some machines are going down in price making them more affordable. Plus, the settings we as therapists use are pretty basic, so we do not need to purchase a unit with a lot of bells and whistles that makes it more expensive. However there are other ways to acquire a unit other than purchasing one brand new. You could look into the price of refurbished units or look to your referring physician groups that you have a good relationship with. You may be surprised to find out how much physician’s offices get for machines when they are upgrading; hardly anything! If you work for a hospital system you may be able get the old machine transferred to your department for no cost to you! Or if you work in a private practice, you could offer to match the little amount the office would get from the vendor when upgrading. I guarantee you it would not be as much as a new unit. You also might be able to share a unit with another department, office, or clinic. In the past, I have shared ultrasound units with a surgical department, and a gynecology office. I would use the ultrasound some days of the week, and they would other days of the week. It worked out well! There are a lot of possibilities of ways to acquire an ultrasound unit if you think outside of the box! It may take a little effort coordinating things in order to get an US unit, but with proper knowledge, proper marketing, and word of mouth your business will grow and you will not regret the decision to invest in your practice!
Join me to discuss more ideas of how to use US imaging to grow your practice in both clinical skill as well as business growth this June in Baltimore!
1. Hides, Stanton, Wilson et al. Retraining motor control of abdominal muscles among elite cricketers with low back pain. Scand J Med Sci Sports. 2010; 20: 834-842.
2. Hides JA, Stanton WR. Can motor control training lower the risk of injury for professional football players? Med Sci Sports Exec. 2014; 46(4): 762-8.