Journal of Orthopaedic & Sports Physical Therapy

Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association

Rehabilitative Ultrasound Imaging Symposium: Overview

Rehabilitative Ultrasound Imaging

Symposium
San Antonio, TX
May 8-10, 2006
Guest Editor
Deydre Teyhen, PT, PhD, OCS 1

As physical therapists, we routinely evaluate and treat motor control impairments associated
with neuromusculoskeletal disorders. Over the last decade, researchers have found that deep
muscle activation patterns are different in those with lumbopelvic dysfunction compared to
those without.1,2,5-8,12 Additionally, when exercises are prescribed that target motor control
impairments, favorable effects on pain, disability, and recurrence are observed.3,4,9,11 However,
it has proved more difficult to establish reliable and valid noninvasive clinical measurement
tools to evaluate muscle and related soft tissue morphology and function during physical tasks
to improve the design of therapeutic interventions.
One tool that has potential to assist with improving physical therapists’ ability to evaluate and
treat motor control impairments is the use of rehabilitative ultrasound imaging (RUSI) based
on its ability to provide real-time visual feedback of the underlying muscular morphology and
function to both the patient and the physical therapist. Although ultrasound imaging (USI)
has been used for medical purposes since the 1950s, its application for rehabilitative sciences
only started in the 1980s with the work of Dr Archie Young, a physician at the University of
Oxford whose research team included physiotherapists.10 Although the research and clinical
applications of this emerging technology has steadily grown, there has not previously been an
international meeting to organize a research agenda that could ultimately guide its role in
clinical practice.

1
Assistant Professor and Symposium Chairperson, US Army-Baylor University Doctoral Program in Physical Therapy, San Antonio,
TX.
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the
views of the US Departments of the Army or Defense.

Journal of Orthopaedic & Sports Physical Therapy A-1

Rehabilitative Ultrasound Imaging Symposium: Overview

The US Army-Baylor University Doctoral Program in Physical Therapy hosted a RUSI

Symposium in May 2006 in San Antonio, TX. The purpose of this meeting was to develop best
practice guidelines for the use of RUSI for the abdominal, pelvic, and posterior spine muscles
and develop an international and collaborative research agenda related to the use of USI.
Participants included leading international experts from around the world in the field of
RUSI and clinical research. The objectives of the symposium were to:
1. Contribute to the development of an international set of RUSI measurement standards in
the assessment of muscle function
2. Identify and synchronize current and future international efforts to promote the use of
RUSI in clinical practice, research, and education
3. Initiate the development of an international and collaborative research agenda
4. Develop models for the implementation of RUSI to clinical practice within the Military
Healthcare System
5. Explore future applications
Delegates represented 6 countries (Australia, Canada, England, Ireland, Norway, and the
United States of America) and 13 universities (Curtin University of Technology, The
Norwegian University of Science and Technology, Marquette University, Regis University,
Trinity College Dublin, US Army-Baylor University, The University of Bergen, The University
of Evansville, The University of Kentucky, The University of Southhampton, The University of
Queensland, The University of Utah, The University of Vermont) around the world. Among
the delegates, Dr Guy Simoneau, Editor-in-Chief of the Journal of Orthopaedic & Sports Physical
Therapy, and Dr Tim Flynn, President of the American Academy of Orthopaedic and Manual
Physical Therapists, were in attendance. The list of delegates and presenters included: Dr
John Childs, Mr Jim Elliott, Dr Timothy Flynn, Dr Julie Fritz, Dr Norman Gill, Ms Haldis
Haug Dahl, Dr Sharon Henry, Mr Kyle Kiesel, Dr Julie Hides, Dr Paul Hodges, Dr Helene
Langevin, Dr Guy Simoneau, Dr Maria Stokes, Dr Deydre Teyhen, Ms Judith Thompson, Dr
Julie Whitman, and Ms Jackie Whittaker. The symposium organizers were Dr Deydre Teyhen,
Mr Kyle Kiesel, Ms Jackie Whittaker, and Dr Norman Gill.
Topics discussed at the symposium included:
• Role of USI in rehabilitation
• Professional, political, ethical, and legal issues
• Clinical applications
• RUSI of the pelvic floor muscles
• RUSI of the lateral abdominal muscles
• RUSI of the posterior paraspinal muscles
• RUSI of other muscles
• Technology and techniques
Abstracts from the presenters are provided. Additionally, for each of the main topics,
committees were established to develop synopsis statements addressing what is known, what
remains unknown, what are the future directions and research priorities, and what are the
best clinical applications of this technology.
One of the outcomes of the symposium was that the delegates unanimously agreed to a
‘‘Rehabilitative Ultrasound Imaging International Consensus Statement’’ to help define this
emerging tool in the field of physical therapy. In addition, a diagram was developed to
present a visual representation of how the practice of RUSI fits into the larger field of USI
(Figure). The consensus statement follows:
RUSI is a procedure used by physical therapists to evaluate muscle and related soft tissue
morphology and function during exercise and physical tasks. RUSI is used to assist in the
application of therapeutic interventions aimed at improving neuromuscular function. This

A-2 J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006

 Rehabilitative Ultrasound Imaging Symposium: Overview
includes providing feedback to the patient and physical therapist to improve clinical
outcomes. Additionally, RUSI is used in basic, applied, and clinical rehabilitative research to
inform clinical practice. Currently, the international community is developing education and
safety guidelines in accordance with World Federation for Ultrasound in Medicine and
Biology (WFUMB). Dated: 10 May, 2006.
Synopsis statements in the format of clinical commentaries are being developed by these
working groups and our goal is to have them ready for publication in 2007. Additionally, it is
the intention of the group to hold future international meetings, particularly for enhancing
collaborative research and steering the international physical therapy community in regards to
the implementation of RUSI.

J OrthopSports Phys Ther 2006;36(8):A1-A17. doi:10.2519/jospt.2006.0301

References
1. Cowan SM, Schache AG, Brukner P, et al. Delayed onset of transversus abdominus in long-standing
groin pain. Med Sci Sports Exerc. 2004;36:2040-2045.
2. Ferreira PH, Ferreira ML, Hodges PW. Changes in recruitment of the abdominal muscles in people
with low back pain: ultrasound measurement of muscle activity. Spine. 2004;29:2560-2566.
3. Goldby LJ, Moore AP, Doust J, Trew ME. A randomized controlled trial investigating the efficiency of
musculoskeletal physiotherapy on chronic low back disorder. Spine. 2006;31:1083-1093.
4. Hides JA, Jull GA, Richardson CA. Long-term effects of specific stabilizing exercises for first-episode
low back pain. Spine. 2001;26:E243-248.
5. Hodges PW, Moseley GL, Gabrielsson A, Gandevia SC. Experimental muscle pain changes
feedforward postural responses of the trunk muscles. Exp Brain Res. 2003;151:262-271.
6. Hodges PW, Richardson CA. Altered trunk muscle recruitment in people with low back pain with
upper limb movement at different speeds. Arch Phys Med Rehabil. 1999;80:1005-1012.
7. Hodges PW, Richardson CA. Delayed postural contraction of transversus abdominis in low back pain
associated with movement of the lower limb. J Spinal Disord. 1998;11:46-56.
8. O’Sullivan PB, Beales DJ, Beetham JA, et al. Altered motor control strategies in subjects with
sacroiliac joint pain during the active straight-leg-raise test. Spine. 2002;27:E1-8.
9. O’Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the
treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis.
Spine. 1997;22:2959-2967.
10. Stokes M, Young A. Measurement of quadriceps cross-sectional area by ultrasonography: a
description of the technique and its applications in physiotherapy. Physiother Pract. 1986;2:31-36.
11. Stuge B, Veierod MB, Laerum E, Vollestad N. The efficacy of a treatment program focusing on
specific stabilizing exercises for pelvic girdle pain after pregnancy: a two-year follow-up of a
randomized clinical trial. Spine. 2004;29:E197-203.
12. Thompson JA, O’Sullivan PB, Briffa NK, Neumann P. Altered muscle activation patterns in
symptomatic women during pelvic floor muscle contraction and Valsalva manouevre. Neurourol
Urodyn. 2006;25:268-276.

J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006 A-3

 Rehabilitative Ultrasound Imaging Symposium

Topics and Speakers

May 8-10, 2006

MAY 8, 2006 (MONDAY) Measuring Morphology (CSA-Individual Differences and Pathologi-

cal State, Parasagittal View)
SYMPOSIUM OVERVIEW Angle of Fiber Pennation
Opening Remarks Function (Biofeedback Training, Preferential Activation, and
Deydre Teyhen Thickness Change Under Load)
Role of Ultrasound Imaging (USI), Its Use to Assess Muscle, Commonalities/Differences Between Posterior Trunk and Posterior
Motor Control, and Future Directions Cervical Musculature
Paul Hodges Clinical and Research Applications
TECHNOLOGY AND TECHNIQUES Discussion and Open Lab: Measuring the Muscle at Rest, Under
Moderator: Deydre Teyhen Load, and With a Preferential Activation, Clinical Applications
Elastography
OTHER MUSCLES OF INTEREST
Helene Langevin
Moderator: Jackie Whittaker
High Hertz USI to Assess Motor Control
Haldis Dahl Diaphragm
Paul Hodges
USI during Functional Testing
Discussion Rectus Abdominis
Jackie Whittaker
USI Versus Other Imaging/MRI
Jim Elliott Cervical Musculature, Upper Trapezius
All
B-Mode Versus M-Mode
Discussion Open Discussion on Other Muscles Either Supported by the
Current Evidence or Potential (Anterior Tibialis, Masseter,
Open Discussion
Gastrocnemius, Quadriceps)
All
USI AND PELVIC FLOOR CLINICAL APPLICATIONS AND ISSUES
Moderator Jackie Whittaker Moderators: John Childs, Jackie Whittaker
Evidence Overview: The Role of the Pelvic Floor in Postural Overview of Clinical Applications: The Role of USI for the
Control of the Lumbopelvic Region Clinician
Jackie Whittaker Jackie Whittaker
Evidence Overview: The Role of the Pelvic Floor With Respect Use of Clinical Prediction Rules and USI
to Continence Julie Fritz, John Childs
Judith Thompson
PROFESSIONAL, POLITICAL, ETHICAL, AND LEGAL ISSUES
Perineal Versus Transabdominal Measurement Approaches:
Moderators: John Childs, Jackie Whittaker
Validation and Reliability
Discussion leaders: Julie Hides (Australia), Jackie Whittaker (Canada),
Judith Thompson
John Childs (United States), Maria Stokes (England), and Haldis Haug
Clinical Applications Dahl (Norway)
Jackie Whittaker
Profession Limitations
Discussion and Open Lab: Transabdominal Measurement of
Bladder Motion, Clinical Applications Appropriate Training
All Knowledge of Professional Relationships
LATERAL ABDOMINAL MUSCLES Existing Practice Guidelines
Moderators: Deydre Teyhen, Norman Gill Differences Between Musculoskeletal and Muscle Imaging
Validation of USI With MRI Need for Education-Marketing the Role of Physical Therapist in
Julie Hides Muscle Imaging to Radiologist, Sonographers, and Professional
Organizations
Reliability of USI
Deydre Teyhen Medical Insurance Coverage of Muscle Ultrasound Imaging
Biofeedback Training Similarities and Differences Between Each Country’s Approaches
Sharon Henry to This Evolving Technology
Case Study: Effects of Manipulation Possible Creation of an International Group That Can Provide
Norman Gill Oversight and Assistance as This Process Continues to Move
Forward
Discussion and Open Lab: Measuring the Muscles at Rest, Under
Load, and With a Preferential Activation, Clinical Applications
All
MAY 10, 2006 (WEDNESDAY)
MAY 9, 2006 (TUESDAY) INTERNATIONAL RUSI SYNOPSIS STATEMENT DEFINED BY
POSTERIOR TRUNK MUSCLES THE DELEGATES
Moderator: Kyle Kiesel Delegates formed working groups to help establish synopsis state-
Presenters: Maria Stokes, Julie Hides, Kyle Kiesel ments regarding the main topics of the symposium.

A-4 Journal of Orthopaedic & Sports Physical Therapy

 Rehabilitative Ultrasound Imaging Symposium
Abstracts
May 8-10, 2006
IMAGING IN REHABILITATION
P Hodges
Division of Physiotherapy, The University of Queensland, Brisbane,
Australia
Rehabilitative ultrasound imaging (RUSI) has the potential to
make major contribution to evaluation and training in disorders
associated with changes in muscle morphology and behavior, from
musculoskeletal pain syndromes to stress urinary incontinence.
RUSI provides an opportunity to measure both static and dynamic
parameters of muscle. Static measures of muscle morphology
include evaluation of muscle size, shape, and structure. For
instance, biomechanical properties of muscle can be estimated
from the organization of the muscle fascicles and atrophy can be
characterized by changes in density. Dynamic measures of behavior,
measured with real-time techniques including brightness mode
(b-mode), motion-mode (m-mode), and tissue velocity imaging,
can elucidate changes in muscle fascicle length, pennation angle,
and muscle shape (eg, thickness and length) to provide an
indication of muscle activity and the behavior of the contraction
(eg, muscle lengthening or shortening). Although many of these
measures have been validated against other tools, it is important to
recognize that changes morphology are complex and, in addition
to muscle activity, these measures are dependent on factors
including the type of contraction (isometric, concentric, eccentric),
the extensibility of the tendon, activity of adjacent muscles, other
muscle forces (eg, intra-abdominal pressure), and organization of
the muscle fascicles. For instance in isometric contractions there is
a nonlinear relationship between muscle activity and changes in
morphology measured with RUSI. This is because any morphologi-
cal change is dependent on the extensibility of the tendon, which
plateaus after a small degree of stretch. Despite these complexities
RUSI provides a unique method to evaluate muscle morphology
and behavior with a clarity that was until recently dependent on
expensive and invasive techniques. The validity of RUSI measures is
increasingly supported by research that shows that measures of
muscle morphology and behavior discriminate between healthy
individuals and people with a range of conditions such as acute
and chronic back pain, stress urinary incontinence, and disorders
of diaphragm function. However, the ideal measures are still
debated. In clinical practice RUSI can be used for evaluation of
morphology and behavior or feedback of muscle contraction. RUSI
is not a treatment but a tool to aid motor learning. There are a
number of key issues that must be investigated. If RUSI is to be
integrated into practice, it is necessary to determine whether RUSI
measures can be changed with intervention, whether RUSI mea-
sures contribute to prediction of those who benefit from an
intervention, and whether changes in RUSI measures with inter-
vention are associated with positive clinical outcomes. An addi-
tional consideration is whether feedback provided using RUSI
improves clinical outcomes. Although a number of studies have
confirmed that treatments that include RUSI lead to better
outcomes than control interventions, these studies have not
compared the same exercise interventions with and without feed-
back from RUSI. Further, recent data support the potential for
RUSI measures to predict and direct management. The recent
surge of interest in RUSI in the assessment and rehabilitation of
Journal of Orthopaedic & Sports Physical Therapy
muscle coordination highlights the urgent need to further test and
validate this promising rehabilitation tool.
PROFESSIONAL ISSUES ASSOCIATED WITH THE USE OF
REHABILITATIVE ULTRASOUND IMAGING BY PHYSICAL
THERAPISTS
JL Whittaker, JM Whitman, M Stokes, JA Hides, JD. Childs, DS Teyhen
Whittaker Physiotherapy Consulting, White Rock, British Columbia,
Canada; Regis University, Denver, CO; University of Southampton, United
Kingdom; Trinity College Dublin, Ireland; The University of Queensland,
Brisbane, Australia; US Army-Baylor University Doctoral Program in
Physical Therapy, San Antonio, TX
The opinions or assertions contained here in are the private views of the
Authors and are not to be construed as official or as reflecting the views of
the Departments of the Army, Air Force, or Defense.
A variety of health care professionals utilize ultrasound imaging
(USI) in their practice. Depending on the information sought and
practice domain, the purpose for its use differs. From the physical
therapy perspective rehabilitative ultrasound imaging (RUSI) per-
mits direct visualization of muscle structure and function during
static and dynamic tasks. In the current environment of evidence
based practice and fiscal accountability it is essential that all
medical professionals, including physical therapists, have access to
tools that optimize the effectiveness of their interventions, and
allow for the implementation of the growing knowledge base. As
technology advances and new tools emerge, it is important that
practitioners understand whether these tools offer benefit to the
patient in a safe and cost effective manner. Associated with this
evolutionary process, however, is the responsibility of quality
control, as well as the development of policies and guidelines that
ensure safe and appropriate use.
The clinical application of RUSI by physical therapists is on the
cusp of exponential growth. As implementation escalates, some
geographic regions are developing the associated professional
framework faster than others. For instance the Australian Physio-
therapy Association has released a national position statement
regarding the use of USI by its members,2 and educational
programs developed in collaboration with the sonography profes-
sion are available in both Australia (University of Queensland and
the University of Sydney) and the UK (University of
Southampton).9 In North America, instruction is primarily avail-
able through private postgraduate continuing educational pro-
grams (www.rtuspt.com), although an introductory course for US
military therapists (US Army-Baylor University) has recently been
implemented. Despite these developments, the international physi-
cal therapy community has yet to define its scope with respect to
the use of RUSI, implement applicable training programs, establish
widespread practice guidelines, or formally liaise with organizations
that represent USI interests among other health care professions
(ie, World Federation for Ultrasound in Medicine and Biology).
Furthermore, despite initial evidence supporting the use of USI in
rehabilitation,4,6,7,10 ultimately more information is required to
determine its clinical and cost effectiveness, and optimal imple-
mentation into clinical practice.8
Because the regulation of the physical therapy profession is
conducted by the individual state or provincial licensing bodies
A-5
Rehabilitative Ultrasound Imaging Symposium
within each country in an autonomous manner, it would be helpful
to address these issues with a unified global voice. To do so, the
profession must come to an international consensus regarding the
use of RUSI by physical therapists (see the opening statement),
identify key issues that need to be addressed (safety, legal, political
and interprofessional), as well as recognize and prepare for
potential governmental, regulatory body, interprofessional and
intraprofessional hurdles. Furthermore, it is critical that there is
recognition and sharing of existing resources (such as current
clinical practice standards and guidelines, content of
accreditation/training programs, as well as strategies for
interprofessional relationships)5 both in regard to other profes-
sional organizations (American Institute of Ultrasound in Medi-
cine, British Medical Ultrasound Society)1,3 or in jurisdictions in
which the use of RUSI by physical therapists has been ongoing (ie,
Australia, the United Kingdom and Canada).2,9,11 Consequently,
the timing and scope of this symposium provided a forum in which
resources were identified and plans to address many of these issues
were formulated.
Much work remains to be accomplished if an international
framework for the use of USI by physical therapists is to be
established. Nevertheless, as there are indicators that this tool has
the potential to transform various aspects of the profession,4,6,7,10,12
these efforts should be seen as a valuable investment in the future
and undertaken in a timely manner.
References
1. American Institute of Ultrasound Medicine. Medical
Ultrasound Safety: Part One: Bioeffects and Biophysics; Part
Two: Prudent Use; Part Three: Implementing ALARA. 1994.
2. Australian Physiotherapy Association. APA Position Statement:
Use of Ultrasound Imaging by Physiotherapists. Available at:
apa.advsol.com.au/independent/documents/
position_statements/public/UseofUltrasoundImaging.pdf. Ac-
cessed June 5, 2006.
3. British Medical Ultrasound Society. Safety of Ultrasound:
Statement on the safe use, and potential hazards, of diagnos-
tic ultrasound. Guidelines for the safe use of diagnostic
ultrasound equipment.Available at: www.bmus.org. Accessed
4. Dietz HP, Wilson PD, Clarke B. The use of perineal
ultrasound to quantify levator activity and teach pelvic floor
muscle exercises. Int Urogynecol J Pelvic Floor Dysfunct.
2001;12:166-168; discussion 168-169.
5. Frost N, Clarke J. Ultrasound of biofeedback in physiotherapy.
Sound Effects. 2004;4:10-13.
6. Henry SM, Westervelt KC. The use of real-time ultrasound
feedback in teaching abdominal hollowing exercises to
healthy subjects. J Orthop Sports Phys Ther. 2005;35:338-345.
7. Hides J, Richardson C, Jull G. Use of real-time ultrasound
imaging for feedback in rehabilitation. Man Ther. 1998;3:125-
131.
8. Hodges PW. Ultrasound imaging in rehabilitation: just a fad?
J Orthop Sports Phys Ther. 2005;35:333-337.
9. Stokes M. Ultrasound imaging of skeletal muscle: biofeedback
and clinical assessment. An introductory manual for physical
therapists. University of Southampton; 2006.
10. Stokes M, Hides J, Nassiri DK. Musculoskeletal ultrasound
imaging: diagnostic and treatment aid in rehabilitation. Phys
Ther Rev. 1997;2:73-92.
11. Whittaker JL. Recommendations for the implementation of
real time ultrasound imaging in physical therapy practice:
The final report of a College of Physical Therapists of British
Columbia real time ultrasound imaging ad hoc committee.
2004.
12. Whittaker JL. Ultrasound Imaging for Rehabilitation of the
Lumbopelvic Region. London, UK: Churchill Livingstone; 2006.
ULTRASOUND IMAGING AND THE PELVIC FLOOR MUSCLES
JA Thompson, JL Whittaker
Curtin University of Technology, Perth, Western Australia; Whittaker
Physiotherapy Consulting, White Rock, British Columbia, Canada
A-6
What Is Known?
The pelvic floor muscles (PFM) perform multiple functions: they
are involved in the control of continence, respiration, support of
the pelvic organs, containment of intra-abdominal pressure
(IAP),5,11 and provide a local stabilizing effect for the sacroiliac
joints.8 Consequently, there is a need for tools, such as rehabilita-
tive ultrasound imaging (RUSI), that are capable of accurately
measuring the various aspects of their function (neuromuscular
control, strength, endurance, and supporting action).
RUSI permits dynamic assessment of PFM function from both
transperineal (TP) and transabdominal (TA) perspectives. Specifi-
cally, RUSI has been shown to be more accurate than intravaginal
palpation4 in providing information about the supporting function
of the PFM through the measurement of their lifting action on the
bladder neck and base during various maneuvers.2,6,12 Although a
correlation between the amount of bladder neck lift during PFM
contraction and measures of PFM strength exist, the relationship is
not absolute and the amount of movement seen with RUSI does
not always equate to the force of contraction.11,13 Consequently,
care must be taken during interpretation.
Both TP and TA methods demonstrate good reliability for
measurements during PFM contraction2,9,15; however, the TP ap-
proach appears to be more reliable than the TA (sagittal) during
maneuvers known to increase IAP.15 While the TP approach is
more precise and allows for direct assessment of the bladder neck
and proximal urethra,2 the TA method has clinical advantages as it
is entirely noninvasive. However, confounding variables such as
probe movement and laxity due to prolapse may limit the
interpretation of TA images.
What Is Unknown?
While RUSI has shed light on the structural and behavioral
characteristics of the PFM during various maneuvers, only prelimi-
nary investigation into the correlation between these characteristics
and clinical symptoms has taken place. To date, researchers have
shown that many asymptomatic as well as incontinent women have
difficulty performing elevating PFM contractions,10,14 incontinent
women and individuals with lumbopelvic pain demonstrate in-
creased bladder neck and base movement during functional
tasks6,12 and increased bladder neck descent during coughing is
associated with delayed activation of the PFM.1 Beyond not fully
understanding the clinical significance of these observations, the
use of RUSI as a clinical method of evaluating functional activation
of the PFM has not been fully investigated.
Directions for Future Research
Future research priorities include: identifying objective clinical
tests that are able to assess the functional activation of the PFM in
as close to real-life situations as possible, the reliability of TA
(transverse) USI during functional maneuvers, as well as further
research involving RUSI in combination with PFM
electromyography to determine if it is a valid tool for measurement
of PFM activation during functional tasks.
Ultimately, the use of RUSI for assessment of PFM function is in
its infancy. Beyond the suggestions employing traditional (2-D)
ultrasound imaging indicated above, future investigations utilizing
novel postprocessing techniques and 3-D ultrasound imaging3,7 are
likely to improve measurement techniques, and provide more
detailed assessment of the biomechanics and function of the PFM.
References
1. Barbic M, Kralj B, Cor A. Compliance of the bladder neck
supporting structures: importance of activity pattern of leva-
tor ani muscle and content of elastic fibers of endopelvic
fascia. Neurourol Urodyn. 2003;22:269-276.
2. Dietz HP. Ultrasound imaging of the pelvic floor. Part I:
two-dimensional aspects. Ultrasound Obstet Gynecol. 2004;23:80-
92.
3. Dietz HP. Ultrasound imaging of the pelvic floor. Part II:
three-dimensional or volume imaging. Ultrasound Obstet
Gynecol. 2004;23:615-625.
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006

4. Frawley HC, Galea MP, Phillips BA, Sherburn M, Bo K. Effect
of test position on pelvic floor muscle assessment. Int
Urogynecol J Pelvic Floor Dysfunct. 2006;17:365-371.
5. Hemborg B, Moritz U, Lowing H. Intra-abdominal pressure
and trunk muscle activity during lifting. IV. The causal factors
of the intra-abdominal pressure rise. Scand J Rehabil Med.
1985;17:25-38.
6. O’Sullivan PB, Beales DJ, Beetham JA, et al. Altered motor
control strategies in subjects with sacroiliac joint pain during
the active straight-leg-raise test. Spine. 2002;27:E1-8.
7. Peng Q, Jones RC, Constantinou CE. 2D Ultrasound image
processing in identifying responses of urogenital structures to
pelvic floor muscle activity. Ann Biomed Eng. 2006;34:477-493.
8. Pool-Goudzwaard A, van Dijke GH, van Gurp M, Mulder P,
Snijders C, Stoeckart R. Contribution of pelvic floor muscles
to stiffness of the pelvic ring. Clin Biomech (Bristol, Avon).
2004;19:564-571.
9. Sherburn M, Murphy CA, Carroll S, Allen TJ, Galea MP.
Investigation of transabdominal real-time ultrasound to
visualise the muscles of the pelvic floor. Aust J Physiother.
2005;51:167-170.
10. Thompson JA, O’Sullivan P B, Briffa NK, Neumann P.
Assessment of voluntary pelvic floor muscle contraction in
continent and incontinent women using transperineal
ultrasound, manual muscle testing and vaginal squeeze pres-
sure measurements. Int Urogynecol J Pelvic Floor Dysfunct. 2006;
(In press).
11. Thompson JA, O’Sullivan PB, Briffa NK, Neumann P. Altered
muscle activation patterns in symptomatic women during
pelvic floor muscle contraction and Valsalva manouevre.
Neurourol Urodyn. 2006;25:268-276.
12. Thompson JA, O’Sullivan P B, Briffa NK, et al. Comparison of
transperineal and transabdominal ultrasound in the assess-
ment of voluntary pelvic floor muscle contractions and
functional maneuvers in continent and incontinent women.
Int Urogynecol J Pelvic Floor Dysfunct. (Under review);
13. Thompson JA, O’Sullivan PB, Briffa NK, Neumann P. Differ-
ences in muscle activation patterns during pelvic floor muscle
contraction and Valsalva maneuver. Neurourol Urodyn.
2006;25:148-155.
14. Thompson JA, O’Sullivan PB. Levator plate movement during
voluntary pelvic floor muscle contraction in subjects with
incontinence and prolapse: a cross-sectional study and review.
Int Urogynecol J Pelvic Floor Dysfunct. 2003;14:84-88.
15. Thompson JA, O’Sullivan PB, Briffa K, Neumann P, Court S.
Assessment of pelvic floor movement using transabdominal
and transperineal ultrasound. Int Urogynecol J Pelvic Floor
Dysfunct. 2005;16:285-292.
ULTRASOUND IMAGING OF THE LATERAL ABDOMINAL
MUSCLES: VALIDATION OF ULTRASOUND IMAGING BY
COMPARISON WITH MAGNETIC RESONANCE IMAGING
JA Hides
University of Queensland, Brisbane, Australia; UQ/ Mater Back Stability
Clinic, Mater Health Services, Brisbane, Australia
What Is Known?
Previous research has implicated the deep abdominal muscle,
transversus abdominis, in the support and protection of the
spine4,5 and provided evidence that training this muscle is impor-
tant in the rehabilitation of low back pain.5 One of the most
important actions of the transversus abdominis is to ‘‘draw-in’’ the
abdominal wall, and this action has been shown to stiffen the
sacroiliac joints.8 It was hypothesized in a recent study that in
response to a draw in, the transversus abdominis muscle would
form a deep musculo-fascial ‘‘corset’’6 and that MRI could be used
to view this corset and verify its mechanism of action on the
lumbopelvic region.
To investigate this hypothesis, an operator blinded dual modality
trial of measurement of the abdominal muscles during drawing in
of the abdominal wall was conducted.1 Objectives of the study were
(1) to investigate, using magnetic resonance imaging (MRI), the
function of the transversus abdominis muscle bilaterally during a
drawing in of the abdominal wall and (2) to validate the use of
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006
Rehabilitative Ultrasound Imaging Symposium
real-time ultrasound imaging (USI) as a measure of the deep
abdominal muscle during a drawing in of the abdominal wall.
Thirteen healthy asymptomatic male elite cricket players were
imaged using MRI and USI as they drew in their abdominal walls.
Measurements of the thickness of the transversus abdominis and
internal oblique muscles and the slide of the anterior abdominal
fascia were measured using both MRI and ultrasound. Measure-
ment of the whole abdominal cross-sectional area (CSA) was
conducted using MRI.
Results of the MRI demonstrated that, as a result of draw-in,
there was a significant increase in thickness of the transversus
abdominis and the internal oblique muscles. There was a signifi-
cant decrease in the CSA of the trunk. Ultrasound measurements
of muscle thickness of both transversus abdominis and the internal
oblique, as well as fascial slide were correlated with measures
obtained using MRI. The MRI results demonstrated that during a
drawing-in action, the transversus abdominis muscle contracted
bilaterally to form a musculo-fascial band that appeared to tighten
(like a corset). Real-time USI was able to measure changes in the
transversus abdominis during the draw-in maneuver.
There has been one study that has compared measurement of
anterolateral abdominal muscle contraction by USI measures and
another modality other than MRI. Hodges et al2 conducted
measures of transversus abdominis and internal oblique muscle
contraction obtained by measuring changes in muscle thicknesses
using real-time USI and measures obtained by fine-wire
electromyography (EMG). For low-level isometric contractions of
these muscles, there was a correlation between USI measures of an
increase in muscular thickness and EMG measures.2
What Is Unknown?
It is important to validate measures conducted using real-time
USI by comparison with MRI, which is the gold standard for
musculoskeletal imaging. While measurements of thickness
(transversus abdominis and internal oblique muscles) and fascial
slide (of the anterior abdominal fascia) obtained using real-time
USI were correlated with measures obtained using MRI, these
measurements were conducted in asymptomatic subjects who were
elite cricketers. Future research could include examination of a
representative population group as well as differences across
subpopulations. Future studies would, therefore, incorporate larger
subject numbers and investigate the differences in these measures
between normal subjects and those with different classifications of
low back pain.
One study has examined and compared patterns of activation of
the abdominal muscles in normal and chronic low back pain
subjects using MRI.7 Patterns of activation for subjects with chronic
LBP were significantly different from those of asymptomatic
subjects. This result shows promise for future studies that could be
conducted using USI; however, subject numbers were small. Other
issues that could be examined include effects of variables such as
age, gender, laterality, and assessment of different functions of the
abdominal muscles. These measures could also be incorporated
into biomechanical models.
What Are the Future Directions and Research Priorities?
Magnetic Resonance Imaging (MRI) is considered a ‘‘gold
standard’’ for viewing the abdominal muscles in cross-section, both
at rest and during drawing-in (muscle contraction). Given the high
ICCs and similarity in the mean scores in the study of Hides et al,1
it could be proposed that the variables measured in this investiga-
tion could be adequately performed using USI. This would be
useful where large numbers of subjects are to be investigated or
where portability is an issue. In the study of Hides et al,1 ICCs for
muscle thickness measurements were similar for both conditions
(relaxed and contracted) for the muscles measured. This result is
promising for future investigations that may wish to use USI to
measure change in muscle thickness on contraction. This would
allow establishment of databases of normative data in the future.
These databases would be useful as they would allow comparison
with data collected from subjects with LBP.
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Rehabilitative Ultrasound Imaging Symposium
References
1. Hides J, Wilson S, Stanton W, et al. An MRI investigation into
the function of the transversus abdominis muscle during
‘‘drawing-in’’ of the abdominal wall. Spine. 2006;31:E175-178.
2. Hodges PW, Pengel LH, Herbert RD, Gandevia SC. Measure-
ment of muscle contraction with ultrasound imaging. Muscle
Nerve. 2003;27:682-692.
3. Hodges PW, Richardson CA. Feedforward contraction of
transversus abdominis is not influenced by the direction of
arm movement. Exp Brain Res. 1997;114:362-370.
4. Hodges PW, Richardson CA. Inefficient muscular stabilization
of the lumbar spine associated with low back pain. A motor
control evaluation of transversus abdominis. Spine.
1996;21:2640-2650.
5. O’Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation
of specific stabilizing exercise in the treatment of chronic low
back pain with radiologic diagnosis of spondylolysis or
spondylolisthesis. Spine. 1997;22:2959-2967.
6. Richardson C, Hides J. Stiffness of the lumbo-pelvic region
for load transfer. In: Richardson C, Hodges PW, Hides J, eds.
Therapeutic Exercise for Lumbopelvic Stabilization: A Motor Control
Approach for the Treatment and Prevention of Low Back Pain.
Edinburgh, UK: Churchill Livingstone; 2004.
7. Richardson C, Hides J, Wilson S, Stanton W, Snijders CJ.
Lumbo-pelvic joint protection against antigravity forces: mo-
tor control and segmental stiffness assessed with magnetic
resonance imaging. J Gravit Physiol. 2004;11:P119-122.
8. Richardson CA, Snijders CJ, Hides JA, Damen L, Pas MS,
Storm J. The relation between the transversus abdominis
muscles, sacroiliac joint mechanics, and low back pain. Spine.
2002;27:399-405.
RELIABILITY OF ULTRASOUND IMAGING TO MEASURE
MUSCLE THICKNESS OF THE LATERAL ABDOMINAL
MUSCLES
DS Teyhen
US Army-Baylor University Doctoral Program in Physical Therapy, San
Antonio, TX
The opinions or assertions contained here in are the private views of the
Authors and are not to be construed as official or as reflecting the views of
the Departments of the Army or Defense.
What Is Known?
Reliability of ultrasound imaging (USI) to measure resting
thickness of muscle and adipose tissues has been established in
animal studies.5,20 The reliability of USI to measure the thickness
of lateral abdominal muscles at rest and during muscle activation
has recently been investigated using both brightness-mode (b-
mode) and motion-mode (m-mode) USI techniques in humans.
Intraclass correlation coefficients (ICC) have been reported ⱖ 0.88
when measuring muscle thickness at rest and during muscle
activation during supine, sitting, standing, and walking using
m-mode USI.3,4,11 Excellent test-retest reliability (an ICC value
ⱖ 0.93) has been reported for the use of b-mode USI to measure
muscle thickness at rest and during muscle activation.16,17 Addi-
tionally, it has been determined that an average of 3 measures can
decrease the standard error of the measurement (SEM) by at least
50% compared to a single measure.16
Another consideration that influences the reliability of measur-
ing the lateral abdominal muscles with USI is breathing.1,6,13
Specifically, the muscles of the lateral abdominal wall are thicker
during expiration than inspiration. It is suggested that measure-
ments are taken at the end of expiration to minimize the influence
of these changes on the reliability of the measurement tech-
nique.16,17
What Is Unknown?
The influence of gender, body mass index (BMI), posture, and
hand dominance requires further exploration.16 There appears to
be a relationship with gender and BMI; with males and those with
higher BMI having thicker lateral abdominal muscles.4,16 However,
the interaction of these variables on muscle thickness remains
unknown. Researchers4,12,18 have documented changes in muscle
A-8
thickness at rest based on posture. Therefore, assessment of change
in muscle thickness with physical activity requires measurement
techniques to account for changes in thickness based on posture.
Future research should also consider commonly observed substi-
tution patterns associated with exercises such as the abdominal
drawing-in maneuver (ADIM), in which USI is used to assess
changes in lateral abdominal muscle thickness. These include
breath holding, performance of a pelvic tilt, increased weight
bearing through the heels, excessive external oblique activity, and
fast-phasic contractions.8,9,15,19 The influence of these substitution
patterns on changes in muscle thickness of the lateral abdominal
muscles and ideal control measures to minimize their influence on
reliability remains unknown.
Additionally, researchers still need to determine the optimal
dependent measure to reflect the change in muscle thickness with
physical activity. One method has been to normalize the thickness
of the muscle with physical activity by dividing it by the resting
thickness value either from the resting position of the activity of
interest or its resting value in the supine posture.3,4,17 Another
option would be to measure the percent change in muscle
thickness from rest to the activated state. A third option would be
to represent the muscle thickness as a percentage of the total
lateral abdominal muscle thickness (transversus abdominis, internal
oblique, and external oblique muscle thickness). Future research
should inform which measure is most appropriate based on the
specific research question.
What Are the Future Directions and Research Priorities?
To obtain more precise measurements that permit researchers
and clinicians to detect changes in muscle thickness and muscle
activation over time, future research should continue to explore
measurement techniques to decrease the SEM. These may include
techniques that measure the muscle thickness at multiple locations
along the muscle belly,7 multiple measurements of muscle thick-
ness during repetitions of the activity,16 or postprocessing tech-
niques to enhance the image quality prior to measuring changes in
muscle thickness during physical activity. Additionally, researchers
should address the influence of intertrial variations that are known
to exist in maximal and submaximal contractions.2,10,14
References
1. Ainscough-Potts AM, Morrissey MC, Critchley D. The re-
sponse of the transverse abdominis and internal oblique
muscles to different postures. Man Ther. 2006;11:54-60.
2. Birmingham TB, Kramer JF. Identifying submaximal muscular
effort: reliability of difference scores calculated from isomet-
ric and isokinetic measurements. Percept Mot Skills.
1998;87:1183-1191.
3. Bunce SM, Moore AP, Hough AD. M-mode ultrasound: a reliable
measure of transversus abdominis thickness? Clin Biomech (Bristol,
Avon). 2002;17:315-317.
4. Bunce SM, Hough AD, Moore AP. Measurement of abdomi-
nal muscle thickness using M-mode ultrasound imaging dur-
ing functional activities. Man Ther. 2004;9:41-44.
5. Cisneros F, Ellis M, Miller KD, Novakofski J, Wilson ER,
McKeith FK. Comparison of transverse and longitudinal
real-time ultrasound scans for prediction of lean cut yields
and fat-free lean content in live pigs. J Anim Sci. 1996;74:2566-
2576.
6. De Troyer A, Estenne M, Ninane V, Van Gansbeke D, Gorini
M. Transversus abdominis muscle function in humans. J Appl
Physiol. 1990;68:1010-1016.
7. Ferreira PH, Ferreira ML, Hodges PW. Changes in recruit-
ment of the abdominal muscles in people with low back pain:
ultrasound measurement of muscle activity. Spine.
2004;29:2560-2566.
8. Hagins M, Adler K, Cash M, Daugherty J, Mitrani G. Effects
of practice on the ability to perform lumbar stabilization
exercises. J Orthop Sports Phys Ther. 1999;29:546-555.
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006

9. Henry SM, Westervelt KC. The use of real-time ultrasound
feedback in teaching abdominal hollowing exercises to
healthy subjects. J Orthop Sports Phys Ther. 2005;35:338-345.
10. Keller A, Johansen JG, Hellesnes J, Brox JI. Predictors of
isokinetic back muscle strength in patients with low back
pain. Spine. 1999;24:275-280.
11. Kidd AW, Magee S, Richardson CA. Reliability of real-time
ultrasound for the assessment of transversus abdominis func-
tion. J Gravit Physiol. 2002;9:P131-132.
12. Masuda T, Miyamoto K, Oguri K, Matsuoka T, Shimizu K.
Relationship between the thickness and hemodynamics of the
erector spinae muscles in various lumbar curvatures. Clin
Biomech (Bristol, Avon). 2005;20:247-253.
13. Misuri G, Colagrande S, Gorini M, et al. In vivo ultrasound
assessment of respiratory function of abdominal muscles in
normal subjects. Eur Respir J. 1997;10:2861-2867.
14. Owings TM, Grabiner MD. Measuring step kinematic variability
on an instrumented treadmill: how many steps are enough?
J Biomech. 2003;36:1215-1218.
15. Richardson CA, Hodges PW, Hides J. Therapeutic Exercise
for Spinal Stabilization in Low Back Pain: Scientific Basis and
Clinical Approach. New York, NY: Churchill Livingstone;
1999.
16. Springer BA, Mielcarek BJ, Nesfield TK, Teyhen DS. Relation-
ships among lateral abdominal muscles, gender, body mass
index, and hand dominance. J Orthop Sports Phys Ther.
2006;36:289-297.
17. Teyhen DS, Miltenberger CE, Deiters HM, et al. The use of
ultrasound imaging of the abdominal drawing-in maneuver in
subjects with low back pain. J Orthop Sports Phys Ther.
2005;35:346-355.
18. Watanabe K, Miyamoto K, Masuda T, Shimizu K. Use of
ultrasonography to evaluate thickness of the erector spinae
muscle in maximum flexion and extension of the lumbar
spine. Spine. 2004;29:1472-1477.
19. Whittaker J. Abdominal ultrasound imaging of pelvic floor
muscle function in individuals with low back pain. J Man
Manip Ther. 2004;12:44-49.
20. Williams RE, Bertrand JK, Williams SE, Benyshek LL. Biceps
femoris and rump fat as additional ultrasound measurements
for predicting retail product and trimmable fat in beef
carcasses. J Anim Sci. 1997;75:7-13.
USE OF REHABILITATIVE ULTRASOUND IMAGING AS
BIOFEEDBACK TOOL TO FACILITATE PERFORMANCE OF
THE ABDOMINAL-HOLLOWING EXERCISE
SM Henry
University of Vermont, Burlington, VT
What Is Known?
Treatment of people with low back pain (LBP) often includes
the abdominal-hollowing exercise (AHE) as part of a trunk
stabilization program.14 Correct performance of the AHE includes
contraction of the deeper anterolateral abdominal muscles
(transversus abdominis [TA]14,15 and internal oblique11,12,13) with-
out contraction of the global abdominal muscles, external oblique
and rectus abdominis, or the erector spinae.1 Despite little evi-
dence, rehabilitative ultrasound imaging (RUSI) is being promoted
to provide augmented real-time visual biofeedback for patients
attempting the AHE.6,7
Feedback from RUSI has been beneficial for control subjects
learning the AHE during an initial testing session.5 The precise
visual image of the anterolateral abdominal wall produced by the
RUSI scan may be a beneficial form of feedback, given that both
visual feedback9 and precise feedback19 have been shown to
accelerate skill acquisition.
The evidence supporting RUSI for teaching the AHE to patients
with LBP is conflicting. Teyhen et al17 found no improvement in
performance of the AHE (as evidenced by increased TA muscle
thickness) when RUSI biofeedback augmented the typical clinical
instruction for patients with LBP whereas other studies have
reported various benefits.4,8,18 Goldby et al4 reported superior
dysfunction, disability, and medication outcomes for people with
chronic LBP who received exercises that focused on TA, multifidus,
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Rehabilitative Ultrasound Imaging Symposium
diaphragm, and pelvic floor muscle control; these exercises were
taught using RUSI to confirm correct performance. Feedback from
RUSI also increased the proportion of subjects with LBP who
performed 3 correct AHE sequentially in significantly fewer trials
during an initial treatment session.18
What Is Unknown?
It is unknown how the chronicity of LBP may influence how
readily patients can learn the AHE and, therefore, how beneficial
the addition of RUSI can be. This factor in addition to lack of
training stimulus may account for conflicting results about RUSI in
studies of patients with LBP and should be examined further. The
effect of pretraining as well as the timing, type, and amount of
feedback is unknown but warrants consideration as these factors
affect skill acquisition.10 Although RUSI appears to facilitate the
initial learning of the AHE, the benefit of it for improving the
retention of the AHE performance is inconclusive for both
control5 and subjects with LBP.18
Future Research Directions and Priorities
Although preliminary evidence supports RUSI for teaching the
AHE, future studies should address the optimum number of
practice trials per session as well as the optimal feedback schedule.
The degree to which providing the patient with knowledge of how
well the exercise was performed and the type and amount of
feedback also should be explored. Additional studies need to
examine the relationship between various quantifiable RUSI pa-
rameters and electromyographic recordings in different patient
populations so that RUSI can be further validated as a noninvasive
tool for quantifying muscle function. Lastly, studies must be
conducted to examine if and for which subgroups of patients with
LBP2,3,16 the AHE is beneficial in terms of patient outcomes and to
determine if the significant treatment time needed to learn the
AHE is warranted.
References
1. Bergmark A. Stability of the lumbar spine. A study in
mechanical engineering. Acta Orthop Scand Suppl. 1989;230:1-
54.
2. Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A,
Erhard RE. Identifying subgroups of patients with acute/
subacute ‘‘nonspecific’’ low back pain: results of a random-
ized clinical trial. Spine. 2006;31:623-631.
3. Delitto A, Erhard RE, Bowling RW. A treatment-based classifi-
cation approach to low back syndrome: identifying and
staging patients for conservative treatment. Phys Ther.
1995;75:470-485; discussion 485-479.
4. Goldby LJ, Moore AP, Doust J, Trew ME. A randomized
controlled trial investigating the efficiency of musculoskeletal
physiotherapy on chronic low back disorder. Spine.
2006;31:1083-1093.
5. Henry SM, Westervelt KC. The use of real-time ultrasound
feedback in teaching abdominal hollowing exercises to
healthy subjects. J Orthop Sports Phys Ther. 2005;35:338-345.
6. Hides JA, Richardson CA, Jull GA. Masterclass: use of real-
time ultrasound imaging for feedback in rehabilitation. Man
Ther. 1998;3:125-131.
7. Hides JA, Richardson CA, Jull GA, Davies S. Ultrasound
imaging in rehabilitation. Aust J Physiother. 1998;41:187-193.
8. Kermode F. Benefits of utilizing real-time ultrasound imaging
in the rehabilitation of the lumbar spine stabilizing muscles
following low back injury in the elite athlete: a single case
study. Phys Ther Sport. 2004;5:13-16.
9. Kim HJ, Kramer JF. Effectiveness of visual feedback during
isokinetic exercise. J Orthop Sports Phys Ther. 1997;26:318-323.
10. Magill R. Motor Learning: Concepts and Applications. Boston,
MA: McGraw-Hill; 1997.
11. O’Sullivan P, Twomey L, Allison G, Sinclair J, Miller K.
Altered patterns of abdominal muscle activation in patients
with chronic low back pain. Aust J Physiother. 1997;43:91-98.
12. O’Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation
of specific stabilizing exercise in the treatment of chronic low
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back pain with radiologic diagnosis of spondylolysis or
spondylolisthesis. Spine. 1997;22:2959-2967.
13. O’Sullivan PB, Twomey L, Allison GT. Altered abdominal
muscle recruitment in patients with chronic back pain follow-
ing a specific exercise intervention. J Orthop Sports Phys Ther.
1998;27:114-124.
14. Richardson CA, Hodges P, Hides JA. Therapeutic Exercise for
Spinal Segmental Stabilization in Low Back Pain: Scientific Basis
and Clinical Approach. 2nd ed. Edinburgh, UK: Churchill
Livingstone; 2004.
15. Richardson CA, Jull GA, Toppenberg R, Comerford M.
Techniques for active lumbar stabilization for spinal protec-
tion: a pilot study. Aust J Physiother. 1992;38:105-112.
16. Sarhmann S. Diagnosis and Treatment of Movement Impairment
Syndromes. St Louis, MO: Mosby; 2002.
17. Teyhen DS, Miltenberger CE, Deiters HM, et al. The use of
ultrasound imaging of the abdominal drawing-in maneuver in
subjects with low back pain. J Orthop Sports Phys Ther.
2005;35:346-355.
18. Worth SG, Henry SM, Bunn JY. Real-time ultrasound feed-
back and abdominal hollowing exercises for people with back
pain. NZ J Physiother. (In review).
19. Wright DL, Smith-Munyon VL, Sidaway B. How close is too close
for precise knowledge of results? Res Q Exerc Sport. 1997;68:172-
176.
THE USE OF REHABILITATIVE ULTRASOUND IMAGING TO
INVESTIGATE THE ABILITY TO CONTRACT THE TRANS-
VERSUS ABDOMINIS FOLLOWING SPINAL MANIPULATION:
A CASE REPORT
NW Gill, DS Teyhen
Walter Reed Army Medical Center, Washington, DC; US Army-Baylor
University Doctoral Program in Physical Therapy, San Antonio, TX
The opinions or assertions contained here in are the private views of the
Authors and are not to be construed as official or as reflecting the views of
the Departments of the Army or Defense.
Background
Spinal manipulation has many possible mechanisms of action,
one of the primary being a neurophysiologic response affecting
muscle function.1-4 Ultrasound imaging (USI) offers a noninvasive,
real-time assessment of changes in muscle function and may be a
useful modality to investigate changes in muscle response to
manipulation. This case report documents short-term
neuromuscular changes in the transversus abdominis (TrA) using
rehabilitative ultrasound imaging (RUSI) prespinal and postspinal
manipulation.
Patient Presentation
A 43-year-old male presented with a primary complaint of right
low back and posterior thigh pain for 30 days with clinical signs of
lumbar instability.5,6 Although signs of ‘‘instability’’ are generally
regarded as a relative contraindication or precaution to manipula-
tion, it is feasible that manipulation may improve spinal stability in
some patients via neurophysiologic mechanisms. Additionally, the
patient met 4 out of 5 criteria that predict short-term success with
spinal manipulation.7,8
Intervention
The patient was educated and trained in the performance of the
abdominal drawing-in maneuver (ADIM). After a plateau in
performance of the ADIM was observed using RUSI a lumbopelvic
regional manipulation was performed.7,8 Assessment of muscular
thickness at rest and during the ADIM was performed immediately
premanipulation and postmanipulation.
Results
Postmanipulation, there was both a significant decrease in the
resting thickness of the TrA (from 0.51 to 0.42 cm) and an
increase in thickness of the TrA with contraction from 0.72 to 0.80
cm (SEM, 0.03 cm; 95% CI ± 2 SEM). The difference between the
resting and contracted thickness of the TrA nearly doubled, from
0.21 cm before manipulation to 0.38 cm after manipulation.
Discussion
Thickness of the TrA increased following spinal manipulation.
This is the first case report to quantify the short-term changes in
A-10
the resting and contracted thickness of the TrA after a manipula-
tion and suggests the potential of using USI for further investiga-
tions. Although no conclusions regarding cause and effect can be
made, this case report provides further support for a neurophysi-
ologic mechanism of spinal manipulation.
What Are the Future Directions and Research Priorities?
Research priorities include corroborating this initial case report
in a larger population using a randomized control trial. Further,
investigations into the effects of spinal manipulation on other
muscles that are associated with spinal stability are indicated.
Additionally, serial measurements will help to clarify the length of
time this ‘‘window of opportunity’’ may be present. Study designs
which couple USI with electromyography measurements would
allow for more definitive conclusions about the relationship be-
tween morphological changes in the muscle and degree of
activation. Lastly, the use of high frame rate USI may offer a
noninvasive way to look at the effect of manipulation on the timing
of contractions postmanipulation as a way to identify altered motor
control strategies.
References
1. Herzog W, Conway PJ, Zhang YT, Gal J, Guimaraes AC. Reflex
responses associated with manipulative treatments on the
thoracic spine: a pilot study. J Manipulative Physiol Ther.
1995;18:233-236.
2. Herzog W, Scheele D, Conway PJ. Electromyographic re-
sponses of back and limb muscles associated with spinal
manipulative therapy. Spine. 1999;24:146-152; discussion 153.
3. Lehman GJ, Vernon H, McGill SM. Effects of a mechanical
pain stimulus on erector spinae activity before and after a
spinal manipulation in patients with back pain: a preliminary
investigation. J Manipulative Physiol Ther. 2001;24:402-406.
4. Pickar JG. Neurophysiological effects of spinal manipulation.
Spine J. 2002;2:357-371.
5. Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary
development of a clinical prediction rule for determining
which patients with low back pain will respond to a stabiliza-
tion exercise program. Arch Phys Med Rehabil. 2005;86:1753-
1762.
6. Hicks GE, Fritz JM, Delitto A, Mishock J. Interrater reliability
of clinical examination measures for identification of lumbar
segmental instability. Arch Phys Med Rehabil. 2003;84:1858-1864.
7. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule
to identify patients with low back pain most likely to benefit
from spinal manipulation: a validation study. Ann Intern Med.
2004;141:920-928.
8. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule
for classifying patients with low back pain who demonstrate
short-term improvement with spinal manipulation. Spine.
2002;27:2835-2843.
REHABILITATIVE ULTRASOUND IMAGING OF THE LUMBAR
MULTIFIDUS MUSCLE: MEASURING MORPHOLOGY
M Stokes
University of Southampton, UK; Trinity College Dublin, Ireland
What Is Known?
The lumbar multifidus muscle has been characterized using
rehabilitative ultrasound imaging (RUSI) in normal populations2,8
and people with spinal pathology.4,5,6 The reliability1,8 and validity3
of the technique have been demonstrated. Morphological features
quantified for multifidus include cross-sectional area (CSA), linear
dimensions (muscle depth/thickness and width) and shape ratios,
with normal reference ranges established.8 Multifidus shape at the
fourth lumbar vertebra (L4) is usually round or oval but a
triangular muscle may indicate hypertrophy.8 At L5 the muscle
usually appears triangular due to the shape of adjacent bony
surfaces.
Linear dimensions are predictive of CSA but the strength of this
relationship is influenced by regularity of shape8 and wasting.5 The
CSA is symmetrical (less than a 10% mean difference between
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006

sides) in normal populations and marked asymmetry occurs with
acute low back pain (LBP)5 and idiopathic scoliosis.6 Recovery of
size after LBP is not automatic and requires specific rehabilitation
of multifidus.4 Size measurements and description of shape are
potentially useful for clinical evaluation, and research into the
effects of pathology and interventions.
What Is Unknown?
While data on multifidus morphology are increasing, different
normal populations need to be studied to document the effects of
factors such as ethnicity and habitual physical activity, particularly
in sporting groups.
Size is highly correlated with strength in some muscles but this
relationship is difficult to quantify in multifidus, as isolated force
cannot be measured. The relationship between changes in muscle
thickness and electrical activity is also unknown. The quality of the
image can be poor in the presence of spinal pathology and in
older people, possibly due to infiltration of fat and other
noncontractile tissue, which needs to be quantified. The mecha-
nism of wasting and whether it is a cause or effect of injury are
unknown.
What Are the Future Directions and Research Priorities?
If RUSI is to become a routine aid to physical therapy practice
and a robust research tool, standardized protocols for obtaining
measurements are needed. The validity of using linear measure-
ments to assess the CSA of irregularly shaped muscles requires
attention. Comprehensive studies of different normal populations
are needed to generate reference databases for assessing changes
due to pathology and effects of interventions. Longitudinal epide-
miological studies of multifidus are needed to determine those at
risk of developing LBP, whether wasting occurs before the onset of
injury/pain and to help elucidate the mechanisms of wasting. The
contribution of noncontractile tissue to CSA needs to be quantified
to determine true muscle size, particularly with pathology and
aging. The sonographic technique of elastography is potentially
useful for distinguishing the biomechanical behavior of these
tissues.7
References
1. Coldron Y, Stokes M, Cook K. Lumbar multifidus muscle size
does not differ whether ultrasound imaging is performed in
prone or side lying. Man Ther. 2003;8:161-165.
2. Hides JA, Cooper DH, Stokes M. Diagnostic ultrasound
imaging for measurement of the lumbar multifidus muscle in
normal young adults. Physiother Theory Pract. 1992;
3. Hides JA, Richardson CA, Jull GA. Magnetic resonance
imaging and ultrasonography of the lumbar multifidus
muscle. Comparison of two different modalities. Spine.
1995;20:54-58.
4. Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery
is not automatic after resolution of acute, first-episode low
back pain. Spine. 1996;21:2763-2769.
5. Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH. Evidence
of lumbar multifidus muscle wasting ipsilateral to symptoms
in patients with acute/subacute low back pain. Spine.
1994;19:165-172.
6. Kennelly KP, Stokes MJ. Pattern of asymmetry of paraspinal
muscle size in adolescent idiopathic scoliosis examined by
real-time ultrasound imaging. A preliminary study. Spine.
1993;18:913-917.
7. Ophir J, Cespedes I, Ponnekanti H, Yazdi Y, Li X.
Elastography: a quantitative method for imaging the elasticity
of biological tissues. Ultrason Imaging. 1991;13:111-134.
8. Stokes M, Rankin G, Newham DJ. Ultrasound imaging of
lumbar multifidus muscle: normal reference ranges for mea-
surements and practical guidance on the technique. Man
Ther. 2005;10:116-126.
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006
Rehabilitative Ultrasound Imaging Symposium
REHABILITATIVE ULTRASOUND IMAGING OF THE LUMBAR
MULTIFIDUS MUSCLE: THE PARASAGITTAL VIEW
K Kiesel, F Underwood, A Nitz
University of Evansville, Evansville, IN, University of Kentucky, Lexing-
ton, KY
What Is Known?
There is a growing body of literature describing the use of
rehabilitative ultrasound imaging (RUSI) of the lumbar multifidus
(LM) in patients with low back pain (LBP). The most common
technique described in the literature is measurement of morpho-
logical characteristics utilizing a transverse probe orientation. A
longitudinal probe orientation, less commonly described, allows for
visualization of the LM in the parasagittal plane. With the probe
just lateral to the midline, the user can identify the echogenic
facet. From this point to the superficial muscle/fascia border, the
thickness of the LM can be visualized and measured.7,8 This
technique can be used for biofeedback during rehabilitation where
visualization of muscle thickness change represents muscle activa-
tion as well as for objective measurement of thickness change from
rest to activation.
The thickness of the LM can reliably be measured utilizing the
parasagittal view during rest and muscle activation.4 To study the
relationship between LM thickness change and electromyography
(EMG) activity we utilized an automatic recruitment task (prone
upper extremity lifting with 5 increasing loads) and found a linear
relationship (r = 0.79, P⬍.001), over a narrow range of activation
levels from 19% to 34% of maximum volitional isometric contrac-
tion.4 However, the relationship between muscle thickness change
and EMG activity is generally described as curvilinear when studied
across a broad range of activation levels.1
To determine how pain affects thickness change of the LM, we
utilized the same automatic recruitment task and found that
experimentally induced pain significantly decreased thickness
change of the LM on all but the second lowest load tested.3
Preliminary results of an ongoing clinical study we are conduct-
ing suggests there is a significant difference in thickness change of
the LM between subjects with LBP and controls.2
What Is Unknown?
While prone arm lifting can be used to assess thickness change
in the LM with RUSI, other limb movements or other automatic
activation tasks may be clinically more useful. Additionally, the
diagnostic value of measuring thickness change as a clinical test
has not been established.
The LM has been shown to be structurally and functionally
different5,6 in respect to its deep and superficial fibers. We do not
know the relationship between EMG activity in the deep versus
superficial fibers and thickness change, or if RUSI can accurately
distinguish activation between the superficial and deep fibers.
What Are the Future Directions and Research Priorities?
Future research should investigate the diagnostic value of RUSI
to identify activation deficits of the LM. This should include
comparing different automatic recruitment tasks as well as deter-
mining if RUSI can discriminate between the deep and superficial
fibers. A standardized protocol for clinical measurement is needed
and a reference database of normative data should be established.
With a meaningful clinical test and a normative database, research
efforts could then focus on what types of patients with LBP have
LM thickness deficits that are relevant (classification) and ulti-
mately on what intervention has the greatest impact to reduce
disability and recurrence in patients with LBP.
References
1. Hodges PW, Pengel LH, Herbert RD, Gandevia SC. Measure-
ment of muscle contraction with ultrasound imaging. Muscle
Nerve. 2003;27:682-692.
2. Keisel KB, Underwood FB, Mattacola CG, Nitz AJ. A Compari-
son of Select Trunk Muscle Thickness Change between Subjects with
Acute Low Back Pain Classified in the Treatment-Based Classifica-
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Rehabilitative Ultrasound Imaging Symposium
tion System and Asymptomatic Matched Controls. Lexington, KY:
The University of Kentucky; 2006.
3. Kiesel KB, Underwood FB, Mattacola CG, Nitz AJ. Measure-
ment of select trunk muscle activation during induced pain
[abstract]. J Orthop Sports Phys Ther. 2006;36:A46.
4. Kiesel KB, Underwood FB, Rodd DW, Uhl TL, Nitz AJ.
measurement of lumbar multifidus muscle contraction with
ultrasound imaging. Man Ther. (In press).
5. Macintosh J, Bogduk N. The morphology of the human
lumbar multifidus. Clin Biomech. 1986;1:205-231.
6. Moseley GL, Hodges PW, Gandevia SC. Deep and superficial
fibers of the lumbar multifidus muscle are differentially active
during voluntary arm movements. Spine. 2002;27:E29-36.
7. Richardson CA, Hodges PW, Hides JA. Therapeutic Exercise for
Lumbopelvic Stabilization; A Motor Control Approach for the
Treatment and Prevention of Low Back Pain. Edinburgh, UK:
Churchill Livingstone; 2004.
8. Stokes M, Rankin G, Newham DJ. Ultrasound imaging of
lumbar multifidus muscle: normal reference ranges for mea-
surements and practical guidance on the technique. Man
Ther. 2005;10:116-126.
REHABILITATIVE ULTRASOUND IMAGING OF THE LUMBAR
MULTIFIDUS MUSCLE: BIOFEEDBACK TRAINING, CLINICAL
AND RESEARCH APPLICATIONS
JA Hides
The University of Queensland, Brisbane, Australia; UQ/ Mater Back
Stability Clinic, Mater Health Services, Brisbane, Australia
What Is Known?
Rehabilitative ultrasound imaging (RUSI) provides the opportu-
nity to provide high-quality real-time biofeedback of muscle con-
traction to patients.3 The possible benefits of visual biofeedback
while learning to contract a muscle may be explained by the
principles of motor learning. This form of biofeedback may
enhance learning effectiveness when subjects find it difficult to
‘‘get the idea’’ of the contraction required. As accurate feedback is
critical for skill learning, it has been argued on a clinical basis that
biofeedback with ultrasound imaging (USI) may increase the
quality of training.5
RUSI was used to provide biofeedback of multifidus muscle
activation in a randomized controlled trial (RCT) involving pa-
tients with acute, first episode low back pain (LBP).2 A rapid
segmental decrease in the size of the multifidus ipsilateral to
painful symptoms was reported, and subjects found it difficult to
voluntarily contract the segmental multifidus.1,2 Re-education of an
isometric low-level contraction using RUSI restored multifidus size
in the short term.2 The multifidus muscle was imaged in parasagit-
tal section, and subjects observed an increase in thickness of the
muscle as they performed an isometric contraction of the muscle.
Long-term results of this study showed that subjects that performed
the multifidus rehabilitation experienced fewer recurrences of LBP
over a 3-year period than control subjects.4 It was not possible to
accurately determine the contribution of the biofeedback provided
by RUSI, as all of the subjects in the intervention group received
biofeedback (ie, there was not a comparison group who received
rehabilitation of the multifidus without biofeedback).
A recent study7 has applied motor learning principles to the
exercise skill of performing an isometric contraction of the
multifidus muscle in an asymptomatic population. Subjects were
randomly divided into 2 groups that received different forms of
biofeedback. All subjects received clinical instruction on how to
perform an isometric contraction of the multifidus muscle prior to
testing and verbal feedback regarding the amount of multifidus
contraction which occurred during 10 repetitions. In addition, 1
group of subjects received visual biofeedback (watched the
multifidus muscle contract) using RUSI. All subjects were reas-
sessed 1 week later. Results showed that subjects from both groups
improved their voluntary contraction of the multifidus muscle in
the acquisition phase, and the ability to perform the multifidus
muscle contraction differed between groups, with subjects in the
group that received visual ultrasound biofeedback achieving
greater improvements in isometric contraction of the multifidus
muscle. Retention was also improved in the group that received
A-12
visual ultrasound biofeedback as the subjects from this group
retained their improvement in performance when retested 1 week
later. It appears that RUSI can be used to provide visual
biofeedback and improve retention in the ability to activate the
multifidus muscle.
What Is Unknown?
While the results of Hides et al2,4 and Van et al7 show promise
for physical therapy practice, research in this area is still in its
infancy. There have not been any studies that have compared
measurement of multifidus muscle contraction by USI measures
and other modalities. One such study has been performed on the
anterolateral abdominal muscles. Measures of transversus
abdominis and internal oblique muscle contraction obtained by
measuring changes in muscle thicknesses using USI correlated with
electromyography (EMG) measures obtained by fine-wire EMG for
low-level isometric contractions of these muscles.6 Another area
requiring further investigation is the reliability of these measures.
The study of Van et al7 did include investigation of interrater and
intrarater reliability of the 2 assessors involved, but the measure-
ments of the thickness of the multifidus muscle were conducted at
rest.
What Are the Future Directions and Research Priorities?
Future reliability studies should evaluate the influence of variabil-
ity known to occur due to muscle activation, as previous studies
have measured the thickness of the muscle at rest. The one study
that has investigated the effects of biofeedback has been per-
formed on a healthy subject population to avoid the confounding
influences of pain and muscle inhibition. Future studies should
address the effects of biofeedback training for the multifidus using
RUSI in a LBP population. Ideally, a study could be performed on
3 groups of subjects with LBP, including 2 rehabilitation groups
(with and without ultrasound biofeedback) as well as a control
group, to allow accurate determination of the contribution of
ultrasound biofeedback. The effects of ultrasound biofeedback
should be studied in the context of motor relearning. It will be
important to determine the appropriateness of ultrasound
biofeedback in the different stages of motor learning.
References
1. Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH. Evidence
of lumbar multifidus muscle wasting ipsilateral to symptoms
in patients with acute/subacute low back pain. Spine.
1994;19:165-172.
2. Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery
is not automatic after resolution of acute, first-episode low
back pain. Spine. 1996;21:2763-2769.
3. Hides JA, Richardson CA, Jull GA. Use of real-time ultrasound
imaging for feedback in rehabilitation. Man Ther. 1998;3:125-
131.
4. Hides JA, Jull GA, Richardson CA. Long-term effects of
specific stabilizing exercises for first-episode low back pain.
Spine. 2001;26:E243-248.
5. Hodges PW. Ultrasound imaging in rehabilitation: just a fad?
J Orthop Sports Phys Ther. 2005;35:333-337.
6. Hodges PW, Pengel LH, Herbert RD, Gandevia SC. Measure-
ment of muscle contraction with ultrasound imaging. Muscle
Nerve. 2003;27:682-692.
8. Van K, Hides JA, Richardson CA. The use of real-time
ultrasound imaging for biofeedback of multifidus muscle
contraction in healthy subjects. J Orthop Sports Phys Ther. (In
review).
THE CLINICAL APPLICATION OF REHABILITATIVE
ULTRASOUND IMAGING
JL Whittaker
Whittaker Physiotherapy Consulting, White Rock, British Columbia,
Canada
What Is Known?
In recent years there has been significant growth in the
knowledge base underlying neuromusculoskeletal rehabilitation. In
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006

particular, focus has been placed upon identifying the
neuromuscular mechanisms consistent with health, and the alter-
ations that underlie dysfunction such as those seen with low back
and pelvic girdle pain.6 Alongside this work, a valuable tool,
rehabilitative ultrasound imaging (RUSI), has emerged which
many believe may assist physical therapists in the detection and
management of these impairments.5,12,17
RUSI has the potential to enhance both the assessment and
treatment stages of rehabilitation as it provides access to informa-
tion concerning the structure (morphology, resting relationships,
ease of architectural demarcation, and echogenicity)13,14 and
behavior (automatic and voluntary)3,18 of the myofascial system,
(including muscles and fascia that are deep and difficult to access)
that has been previously unavailable to clinicians, while at the same
time serving as a real-time biofeedback mechanism which may
facilitate motor learning.2,4 Furthermore, RUSI provides a means
by which objective measurements that reflect changes in these
structural or behavioral characteristics may be gathered.
What Is Unknown?
Although the integration of RUSI into the rehabilitation process
holds promise it is important to acknowledge that there are unique
challenges associated with the use of RUSI to describe the behavior
of a muscle, and more specifically with its clinical integration. For
instance extrapolating that an increase in size of a muscle is
indicative of actual activity may be presumptuous as the relation-
ship between the two is complex and inconsistent.7,8 The
2-dimensional representation of what is seen on the ultrasound
screen is not always an obvious reflection of what is occurring
within the body. Consequently, it is critical that the information
gathered through RUSI is interpreted alongside that obtained from
traditional means of assessment. In addition to the challenges of
accurate interpretation there are also hurdles associated with
comparing imaging studies over time or generating reliable and
meaningful measurements in a clinical environment. Nevertheless,
if care is taken to address these issues and the imaging applications
are performed in a thoughtful manner, it appears as though
accurate analysis and measurement is possible.3,11,13,15,16
What Are the Future Directions and Research Priorities?
Current clinical applications of RUSI10,12,17 are based upon
sound evidence and there is preliminary substantiation of their
clinical utility2,4,9; however, they have yet to withstand sufficient
scrutiny in regard to their evaluative or therapeutic efficacy. As the
evidence supporting their value is lacking, these applications are
currently founded on evidence informed clinical expertise and
provide a preliminary framework that must now be subjected to
critical inquiry. As this investigation goes forward it may be
important to consider that the technology is not intended as a
stand alone evaluative or therapeutic tool,1 and that it is likely its
use is only appropriate with specific populations. Consequently,
until diligent inquiry to define its role or the population it is most
likely to benefit is undertaken, investigations into its efficacy may
be inconclusive.
References
1. Delitto A. Research in low back pain: time to stop seeking the
elusive ‘‘magic bullet’’. Phys Ther. 2005;85:206-208.
2. Dietz HP, Wilson PD, Clarke B. The use of perineal
ultrasound to quantify levator activity and teach pelvic floor
muscle exercises. Int Urogynecol J Pelvic Floor Dysfunct.
2001;12:166-168; discussion 168-169.
3. Ferreira PH, Ferreira ML, Hodges PW. Changes in recruit-
ment of the abdominal muscles in people with low back pain:
ultrasound measurement of muscle activity. Spine.
2004;29:2560-2566.
4. Henry SM, Westervelt KC. The use of real-time ultrasound
feedback in teaching abdominal hollowing exercises to
healthy subjects. J Orthop Sports Phys Ther. 2005;35:338-345.
5. Hides JA, Richardson CA, Jull GA, Davies S. Ultrasound
imaging in rehabilitation. Aust J Physiother. 1998;41:187-193.
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006
Rehabilitative Ultrasound Imaging Symposium
6. Hodges PW. Lumbopelvic stability: a functional model of the
biomechanics and motor control. In: Richardson CH, Hides
JA, eds. Therapeutic Exercise for Spinal Segmental Stabilization: A
Motor Control Approach for the Treatment and Prevention of Low
Back Pain Low Back Pain. Edinburgh, UK: Churchill
Livingston; 2004:
7. Hodges PW. Ultrasound imaging in rehabilitation: just a fad?
J Orthop Sports Phys Ther. 2005;35:333-337.
8. Hodges PW, Pengel LH, Herbert RD, Gandevia SC. Measure-
ment of muscle contraction with ultrasound imaging. Muscle
Nerve. 2003;27:682-692.
9. Kermode F. Benefits of utilizing real-time ultrasound imaging
in the rehabilitation of the lumbar spine stabilizing muscles
following low back injury in the elite athlete: a single case
study. Phys Ther Sport. 2004;5:13-16.
10. Richardson CA, Hides JA. Therapeutic Exercise for Spinal Segmen-
tal Stabilization; A Motor Control Approach for the Treatment and
Prevention of Low Back Pain. 2nd ed. Edinburgh, UK: Churchill
Livingstone; 2004.
11. Springer BA, Mielcarek BJ, Nesfield TK, Teyhen DS. Relation-
ships among lateral abdominal muscles, gender, body mass
index, and hand dominance. J Orthop Sports Phys Ther.
2006;36:289-297.
12. Stokes M, Hides J, Nassiri DK. Musculoskeletal ultrasound
imaging: diagnostic and treatment aid in rehabilitation. Phys
Ther Rev. 1997;2:73-92.
13. Stokes M, Rankin G, Newham DJ. Ultrasound imaging of
lumbar multifidus muscle: normal reference ranges for mea-
surements and practical guidance on the technique. Man
Ther. 2005;10:116-126.
14. Strobel K, Hodler J, Meyer DC, Pfirrmann CW, Pirkl C,
Zanetti M. Fatty atrophy of supraspinatus and infraspinatus
muscles: accuracy of US. Radiology. 2005;237:584-589.
15. Teyhen DS, Miltenberger CE, Deiters HM, et al. The use of
ultrasound imaging of the abdominal drawing-in maneuver in
subjects with low back pain. J Orthop Sports Phys Ther.
2005;35:346-355.
16. Thompson JA, O’Sullivan PB, Briffa NK, Neumann P. Altered
muscle activation patterns in symptomatic women during
pelvic floor muscle contraction and Valsalva manouevre.
Neurourol Urodyn. 2006;25:268-276.
17. Whittaker J. Real-time ultrasound analysis of local system
function. In: Lee DG, ed. The Pelvic Girdle: An Approach to the
Examination and Treatment of the Lumbopelvic-Hip Region. Lon-
don, UK: Churchill Livingston; 2004:
18. Whittaker J. Ultrasound imaging characteristics of individuals
with pelvic instability and concurrent respiratory dysfunction.
Man Ther. (In review).
CLINICAL PREDICTION RULES: APPLICATION TO REHABILI-
TATIVE ULTRASOUND IMAGING
JD Childs, JM Fritz, TW Flynn
US Army-Baylor University Doctoral Program in Physical Therapy, Fort
Sam Houston, TX; University of Utah and Intermountain Health Care
System, Salt Lake City, UT; Regis University, Denver, CO
The opinions or assertions contained herein are the private views of the
authors and are not to be construed as official or as reflecting the views of
the US Air Force or Department of Defense.
What Is Known?
Clinical prediction rules (CPRs) are tools designed to improve
decision making in clinical practice by assisting practitioners in
making a particular diagnosis, establishing a prognosis, or match-
ing patients to optimal interventions based on a parsimonious
subset of predictor variables from the history and physical exami-
nation.7,8 CPRs have been developed to improve decision-making
in medical practice, including the diagnosis of proximal deep vein
thrombosis (DVT),10 strep throat,2 coronary artery disease,9 pulmo-
nary embolism,3 and many other conditions. Furthermore, CPRs
have been developed that have the potential to improve decision-
making in physical therapist practice, including rules to improve
the accuracy of identifying patients with acute knee or ankle
injuries who require radiographs to rule out a fracture,11,12 and to
determine when radiographs are required for patients with neck
A-13
Rehabilitative Ultrasound Imaging Symposium
trauma.13 Other CPRs have been developed to diagnose patients
with cervical radiculopathy14 and carpal tunnel syndrome.15 In
addition to their diagnostic utility, CPRs can subgroup patients into
specific classifications that are useful in guiding management
strategies by matching patients to optimal treatment approaches
such as spinal manipulation1,4 and lumbar stabilization exercise
programs.5
What Is Unknown?
Rehabilitative ultrasound imaging (RUSI) permits direct visual-
ization of muscle function during exercise and functional tasks and
is used with increasing frequency by physical therapists. Despite
initial evidence supporting the use of RUSI,6 more information is
required to determine its clinical and cost effectiveness, and
optimal implementation into clinical practice. For example, per-
haps RUSI is useful for identifying muscle dysfunction in patients
with LBP and therefore may be useful in predicting individuals
that respond to certain interventions or who are at risk for
developing chronicity. For example, data gathered with RUSI could
be used to form part of a CPR for identifying patients likely to
benefit from trunk strengthening exercises. However, to fully
explore the usefulness of RUSI variables in a CPR, a number of
steps are necessary. First, it is necessary to standardize the testing
procedures and interpretation of key RUSI imaging variables. A
vast number of quantitative variables can potentially be measured
with RUSI. However, the measurement characteristics of these
variables in individuals with LBP need to be elucidated. Once the
key variables have been identified and their measurement charac-
teristics have been established, the clinical relevance of RUSI
measures can be further explored. These variables may then be
able to be combined with other historical and physical examination
items to determine the usefulness of these factors in making a
particular diagnosis, establishing a prognosis, or matching patients
to optimal interventions.
What Are the Future Directions and Research Priorities?
The high cost of US imaging equipment likely necessitates that
the RUSI measures have a level of predictive value and can
substantially improve clinical decision making and the cost effec-
tiveness of care before being recommended for widespread imple-
mentation into clinical practice. However, if RUSI measures have a
high accuracy in predicting the likelihood that a patient with acute
low back complaints will transition to chronic low back problems,
and are able to lead therapists to a specific treatment approach
that reduces that likelihood, justifying the cost effectiveness of
RUSI may be relatively easy and straightforward. Designing a well
thought out, collaborative research agenda across multiple clinical
research networks would be a prudent next step to answer these
important questions.
References
1. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule
to identify patients with low back pain most likely to benefit
from spinal manipulation: a validation study. Ann Intern Med.
2004;141:920-928.
2. Ebell MH, Smith MA, Barry HC, Ives K, Carey M. The
rational clinical examination. Does this patient have strep
throat? JAMA. 2000;284:2912-2918.
3. Ferreira G, Carson JL. Clinical prediction rules for the
diagnosis of pulmonary embolism. Am J Med. 2002;113:337-
338.
4. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule
for classifying patients with low back pain who demonstrate
short-term improvement with spinal manipulation. Spine.
2002;27:2835-2843.
5. Hicks GE, Fritz J, Delitto A. Predictive validity of clinical
variables used in the determination of patient prognosis
following a lumbar stabilization program. Arch Phys Med
Rehabil. (In press).
6. Hides JA, Jull GA, Richardson CA. Long-term effects of
specific stabilizing exercises for first-episode low back pain.
Spine. 2001;26:E243-248.
A-14
7. Laupacis A, Sekar N, Stiell IG. Clinical prediction rules. A
review and suggested modifications of methodological stan-
dards. JAMA. 1997;277:488-494.
8. McGinn TG, Guyatt GH, Wyer PC, Naylor CD, Stiell IG,
Richardson WS. Users’ guides to the medical literature: XXII:
how to use articles about clinical decision rules. Evidence-
Based Medicine Working Group. JAMA. 2000;284:79-84.
9. Morise AP, Haddad WJ, Beckner D. Development and valida-
tion of a clinical score to estimate the probability of coronary
artery disease in men and women presenting with suspected
coronary disease. Am J Med. 1997;102:350-356.
10. Riddle DL, Hoppener MR, Kraaijenhagen RA, Anderson J,
Wells PS. Preliminary validation of clinical assessment for
deep vein thrombosis in orthopaedic outpatients. Clin Orthop
Relat Res. 2005;252-257.
11. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I,
Worthington JR. A study to develop clinical decision rules for
the use of radiography in acute ankle injuries. Ann Emerg
Med. 1992;21:384-390.
12. Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a
decision rule for the use of radiography in acute knee
injuries. Ann Emerg Med. 1995;26:405-413.
13. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian
C-spine rule for radiography in alert and stable trauma
patients. JAMA. 2001;286:1841-1848.
14. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A,
Allison S. Reliability and diagnostic accuracy of the clinical
examination and patient self-report measures for cervical
radiculopathy. Spine. 2003;28:52-62.
15. Wainner RS, Fritz JM, Irrgang JJ, Delitto A, Allison S,
Boninger ML. Development of a clinical prediction rule for
the diagnosis of carpal tunnel syndrome. Arch Phys Med
Rehabil. 2005;86:609-618.
PRINCIPLES OF PARASPINAL MUSCULAR IMAGING IN
PHYSICAL THERAPY: MAGNETIC RESONANCE IMAGING
AND ULTRASOUND IMAGING
JM Elliott, JT Noteboom, GA Jull
The University of Queensland, Brisbane, Australia; Regis University,
Denver, CO
What Is Known?
Paraspinal muscle degeneration (atrophy and fatty infiltration) is
common in patients with low back pain2,6-9,11,13 and there are
preliminary data showing similar changes in the cervical paraspinal
musculature in patients who suffer from persistent neck
pain.1,5,10,12 Quantitative measurements of paraspinal muscle de-
generation can be obtained with both real-time ultrasound imaging
(USI) and magnetic resonance imaging (MRI).3,4,6-10,14,15 Although
MRI is considered the gold-standard in the evaluation and quantifi-
cation of paraspinal muscle degeneration, the use of USI is of
increasing interest to physical therapists both for research and
clinical purposes. Clinically, USI provides a straightforward meas-
ure to objectively assess muscle changes6,8 and for real-time visual
biofeedback during rehabilitation of muscle.7 Systematic differ-
ences between the 2 modalities are outlined in the Table.16
What Is Unknown?
While muscular imaging studies have yielded new knowledge
about in-vivo morphometrical features of the paraspinal muscula-
ture (eg, cross-sectional area and fatty infiltrate), the diagnostic
value of MRI and USI from a pathoanatomical perspective has yet
to be determined. Such knowledge is essential to be able to
recognize and interpret paraspinal muscle abnormalities in patients
suffering from musculoskeletal spinal disorders. Furthermore, it is
important to determine whether these muscular abnormalities
differ across the factors of modality, muscle, vertebral level, side,
varying diagnoses and assorted anthropometric variables before the
diagnostic and predictive values can be explored.
What Are the Future Directions and Research Priorities?
There is emerging evidence that muscular imaging might be-
come an essential component of physical therapy evaluation,
classification, and treatment of patients with low back and neck
pain. Despite the exciting advances in the field of muscular
imaging research, their application has yet to be integrated into
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006
 Rehabilitative Ultrasound Imaging Symposium

the everyday clinical practice of orthopedic physical therapy. 15. Stokes M, Rankin G, Newham DJ. Ultrasound imaging of
Therefore, research efforts should include systematic applications lumbar multifidus muscle: normal reference ranges for mea-
of MRI and USI to the wide variety of musculoskeletal disorders surements and practical guidance on the technique. Man
commonly treated in the clinic. Furthermore, it is essential to Ther. 2005;10:116-126.
produce muscular imaging studies with longitudinal follow-up to 16. Tan AL, Wakefield RJ, Conaghan PG, Emery P, McGonagle D.
determine the diagnostic and prognostic values of both MRI and Imaging of the musculoskeletal system: magnetic resonance
USI in patients with acute spinal pain. Ultimately, this could lend imaging, ultrasonography and computed tomography. Best
to the development of appropriate evidence-based diagnostic and Pract Res Clin Rheumatol. 2003;17:513-528.
treatment strategies incorporating the use of both MRI and USI as
outcomes measures.
The exciting innovations in modern muscular imaging research TABLE. Comparisons between magnetic resonance imaging
are changing our understanding of the pathophysiology of muscle (MRI) and ultrasound imaging (USI) in the assessment of
degeneration. It is also slowly influencing clinical practice. How- musculoskeletal disorders. Adapted from Tan et al16 with per-
ever, there is a need to further international, multidisciplinary mission.
collaboration for developing more sensitive MRI and USI tech-
niques with standardized images that are cost effective, reliable, MRI USI
easily accessible, and well-tolerated by both patients and clinical
operators to ensure their appropriate use in the clinic. Cost Expensive Inexpensive
Ease of accessibility Difficult Easy
Ionizing radiation None None
Supports intervention Yes Yes
Operator dependent No Yes
References Imaging capability
1. Andary MT, Hallgren RC, Greenman PE, Rechtien JJ. Planes Multi Variable axes
Neurogenic atrophy of suboccipital muscles after a cervical to joint sur-
injury: a case study. Am J Phys Med Rehabil. 1998;77:545-549. face
2. Campbell WW, Vasconcelos O, Laine FJ. Focal atrophy of the Anatomy
multifidus muscle in lumbosacral radiculopathy. Muscle Nerve. Muscle Excellent Good
1998;21:1350-1353. Fat Excellent Fair
3. Elliott JM, Galloway GJ, Jull GA, Noteboom JT, Centeno CJ, Tendons and tendon sheaths Good Excellent
Gibbon WW. Magnetic resonance imaging analysis of the Ligaments Good Excellent
upper cer vical spine extensor musculature in an Synovial membrane Good Excellent
asymptomatic cohort: an index of fat within muscle. Clin
Bone Excellent Good
Radiol. 2005;60:355-363.
Cartilage Good Excellent
4. Elliott JM, Jull GA, Noteboom JT, Durbridge GL, Gibbon WW.
Magnetic resonance imaging study of cross-sectional area of
Inflammation Excellent Good
the cervical extensor musculature in an asymptomatic cohort. Number of joints per session Few Many
Clin Anat. 2005; Real-time scanning Cardiac only Yes
5. Hallgren RC, Greenman PE, Rechtien JJ. Atrophy of suboc- Patient tolerance Variable Good
cipital muscles in patients with chronic pain: a pilot study.
J Am Osteopath Assoc. 1994;94:1032-1038.
6. Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery
is not automatic after resolution of acute, first-episode low
HIGH-FRAME-RATE ULTRASOUND IMAGING TO ASSESS MO-
back pain. Spine. 1996;21:2763-2769. TOR CONTROL
7. Hides JA, Richardson CA, Jull GA. Use of real-time ultrasound
imaging for feedback in rehabilitation. Man Ther. 1993;3:125- HH Dahl, O Vasseljen, PJ Mork, HG Torp
131. St. Olavs Hospital, Trondheim University Hospital, Norway; Norwegian
8. Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH. Evidence University of Science and Technology, Norway
of lumbar multifidus muscle wasting ipsilateral to symptoms There is evidence of differentiated neuromuscular control of the
in patients with acute/subacute low back pain. Spine. muscles surrounding the lower spine.5-7,10 For instance, patients
1994;19:165-172. demonstrate altered control of transversus abdominis (TrA), the
9. Kader DF, Wardlaw D, Smith FW. Correlation between the deep fibres of lumbar multifidus (LM), and the pelvic floor
MRI changes in the lumbar multifidus muscles and leg pain. muscles (PF) compared to healthy individuals, due either to a
Clin Radiol. 2000;55:145-149. predisposition or as a result of pain.1,2,8 Furthermore, there is
10. Kristjansson E. Reliability of ultrasonography for the cervical growing evidence recommending exercises aimed at optimizing
multifidus muscle in asymptomatic and symptomatic subjects. motor control of these deep muscles in individuals with acute,3,4
Man Ther. 2004;9:83-88. sub-acute, and chronic11,12 low back pain (LBP), in women with
11. Laasonen EM. Atrophy of sacrospinal muscle groups in post partum pelvic pain14,15 and women with incontinence.16
patients with chronic, diffusely radiating lumbar back pain. Hence, there is a need for noninvasive reliable methods of
Neuroradiology. 1984;26:9-13. measurement aimed at evaluating the different aspects of motor
12. McPartland JM, Brodeur RR, Hallgren RC. Chronic neck function and control, including anticipatory muscular activity in
pain, standing balance, and suboccipital muscle atrophy--a these patients.
pilot study. J Manipulative Physiol Ther. 1997;20:24-29. What Is Known?
13. Parkkola R, Rytokoski U, Kormano M. Magnetic resonance Invasive electromyography (EMG) is considered to be the gold
imaging of the discs and trunk muscles in patients with standard for evaluation of muscle activity onset. However, high
chronic low back pain and healthy control subjects. Spine. frame rate motion-mode (m-mode) ultrasound imaging (USI) is a
1993;18:830-836. promising noninvasive alternative. Our group has shown that
14. Rankin G, Stokes M, Newham DJ. Size and shape of the m-mode USI with a rate of 500 frames per second has comparable
posterior neck muscles measured by ultrasound imaging: accuracy (when adjusted for a 16-millisecond delay) to intramuscu-
normal values in males and females of different ages. Man lar EMG in measuring the onset of LM activity in healthy
Ther. 2005;10:108-115. individuals.17

J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006 A-15

Rehabilitative Ultrasound Imaging Symposium
High-frame-rate USI is capable of demonstrating the onset of
muscle activity because the ultrasound image is updated 500 times
per second or, every 2 milliseconds. As the images are collected
they are sequentially placed one after the other, and plotted over
time (m-mode). Subsequently, initial displacement of the muscle
under investigation indicates the initiation of a contraction. The
frame rate of m-mode USI is determined by the depth of the
structure under investigation and the capabilities of the US
scanner. Particularly, frame rate is a compromise between sector
size (width and depth) and resolution (line density).
Limitations of high-frame-rate USI vary across scanning devices.
In general, the limitations of current m-mode applications are an
inadequacy in separating the activity of different muscle layers and
an inability to detect onset variations within different regions of a
muscle after the initial starting point. Furthermore, when a muscle
contracts tissue displacement occurs in 3 dimensions; however,
m-mode is only capable of providing information about movement
of muscle tissue in 1 dimension (along the ultrasound beam).
What Is Unknown?
To date, several interventional studies have investigated the
influence of motor control training with an initial focus on the
deep trunk muscles in individuals with lumbopelvic dysfunc-
tion.3,9,11,14 The outcome variables have been related to pain,
disability, or the recurrence of pain rather than changes in
neuromuscular control and their influence on the level of impair-
ment (eg, change in anticipatory reactions or in sequence of
timing). The limited use of direct measures of change in motor
control strategies in these studies is likely related to the complexity
of invasive procedures, as well as their impracticality in larger
clinical studies. However, high-frame-rate USI has the capability of
overcoming these limitations. Consequently, our research group
has initiated an interventional study using both noninvasive high
frame rate USI and EMG analysis to evaluate the effect of motor
control exercises in patients with subacute and chronic LBP on
anticipatory control of the deep abdominal muscles.18
Future Directions/Priorities
• Compare high-frame-rate USI to invasive EMG in other muscle
groups to further investigate the reliability and validity of this novel
technique.
• Explore other applications like Tissue Velocity Imaging (TVI)
and Strain Rate (SR) to noninvasively assess regional onset varia-
tions within a muscle.13
• Use high-frame-rate USI to investigate the timing of deep
muscle activity and to identify differences between healthy subjects
and patients in an attempt to understand the effect on timing
represented by disuse and deconditioning in patients.
• Determine if the visual feedback provided to patients by
high-frame-rate USI regarding propagation of a muscle contraction
can improve outcome or impairment level in motor control
retraining.
References
1. Barbic M, Kralj B, Cor A. Compliance of the bladder neck
supporting structures: importance of activity pattern of leva-
tor ani muscle and content of elastic fibers of endopelvic
fascia. Neurourol Urodyn. 2003;22:269-276.
2. Devreese A, Staes F, De Weerdt W, et al. Clinical evaluation of
pelvic floor muscle function in continent and incontinent
women. Neurourol Urodyn. 2004;23:190-197.
3. Hides JA, Jull GA, Richardson CA. Long-term effects of
specific stabilizing exercises for first-episode low back pain.
Spine. 2001;26:E243-248.
4. Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery
is not automatic after resolution of acute, first-episode low
back pain. Spine. 1996;21:2763-2769.
5. Hodges PW, Butler JE, McKenzie DK, Gandevia SC. Contrac-
tion of the human diaphragm during rapid postural adjust-
ments. J Physiol. 1997;505 ( Pt 2):539-548.
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6. Hodges PW, Moseley GL. Pain and motor control of the
lumbopelvic region: effect and possible mechanisms.
J Electromyogr Kinesiol. 2003;13:361-370.
7. Hodges PW, Moseley GL, Gabrielsson A, Gandevia SC. Experi-
mental muscle pain changes feedforward postural responses
of the trunk muscles. Exp Brain Res. 2003;151:262-271.
8. Hodges PW, Richardson CA. Inefficient muscular stabilization
of the lumbar spine associated with low back pain. A motor
control evaluation of transversus abdominis. Spine.
1996;21:2640-2650.
9. Jull G, Trott P, Potter H, et al. A randomized controlled trial
of exercise and manipulative therapy for cervicogenic head-
ache. Spine. 2002;27:1835-1843; discussion 1843.
10. Moseley GL, Hodges PW, Gandevia SC. Deep and superficial
fibers of the lumbar multifidus muscle are differentially active
during voluntary arm movements. Spine. 2002;27:E29-36.
11. O’Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation
of specific stabilizing exercise in the treatment of chronic low
back pain with radiologic diagnosis of spondylolysis or
spondylolisthesis. Spine. 1997;22:2959-2967.
12. Rasmussen-Barr E, Nilsson-Wikmar L, Arvidsson I. Stabilizing
training compared with manual treatment in sub-acute and
chronic low-back pain. Man Ther. 2003;8:233-241.
13. Slordahl SA, Bjaerum S, Amundsen BH, et al. High frame
rate strain rate imaging of the interventricular septum in
healthy subjects. Eur J Ultrasound. 2001;14:149-155.
14. Stuge B, Laerum E, Kirkesola G, Vollestad N. The efficacy of
a treatment program focusing on specific stabilizing exercises
for pelvic girdle pain after pregnancy: a randomized con-
trolled trial. Spine. 2004;29:351-359.
15. Stuge B, Veierod MB, Laerum E, Vollestad N. The efficacy of
a treatment program focusing on specific stabilizing exercises
for pelvic girdle pain after pregnancy: a two-year follow-up of
a randomized clinical trial. Spine. 2004;29:E197-203.
16. Thompson JA, O’Sullivan P B, Briffa NK, Neumann P.
Assessment of voluntary pelvic floor muscle contraction in
continent and incontinent women using transperineal
ultrasound, manual muscle testing and vaginal squeeze pres-
sure measurements. Int Urogynecol J Pelvic Floor Dysfunct. 2006;
17. Vasseljen O, Dahl HH, Mork PJ, Torp HG. Muscle activity
onset in the lumbar multifidus muscle recorded simulta-
neously by ultrasound imaging and intramuscular
electromyography. Clin Biomech (Bristol, Avon). (In press).
18. Vasseljen O, Fladmark AM, Torp H. Anticipatory muscle
control and effect of stabilizing exercises in patients with
subacute and chronic LBP. (In progress).
ULTRASOUND ELASTOGRAPHY: MUSCULOSKELETAL CLIN-
ICAL AND RESEARCH APPLICATIONS
HM Langevin
Department of Neurology, University of Vermont, Burlington VT
A number of related ultrasound data processing techniques
(elasticity imaging, elastography, speckle tracking) have recently
been developed to quantify tissue movement and deformation
occurring in response to internal or external mechanical forces.1,8
Clinical applications of these techniques have included detection
of increased tissue stiffness associated with malignant tumors, liver
fibrosis, and deep vein thrombosis as well as quantification of
cardiac and arterial wall motion.2,3,6,9 Musculoskeletal applications
are beginning to include quantification of soft tissues displacement
and strain in response to a variety of externally applied mechanical
inputs (tension, compression, acupuncture needle manipula-
tion).4,5,7 To date, tissue elasticity imaging techniques have not
been used for rehabilitation purposes, but have potential useful-
ness for the detection of differences in muscle and muscle-
associated connective tissue biomechanical properties (eg, stiffness)
in response to physical tasks. Difficulties with applying these
techniques to rehabilitation currently include the need for obtain-
ing the raw radio frequency ultrasound signal (which is not
available on many commercially available ultrasound equipment)
and for postprocessing of ultrasound data, which precludes real-
time feedback applications. These technical issues may be solved by
newly available ultrasound equipment able to perform image
processing in real time.
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006

References
1. Chen EJ, Jenkins WK, O’Brien WD, Jr. Performance of
ultrasonic speckle tracking in various tissues. J Acoust Soc Am.
1995;98:1273-1278.
2. Garra BS, Cespedes EI, Ophir J, et al. Elastography of breast
lesions: initial clinical results. Radiology. 1997;202:79-86.
3. Geier B, Barbera L, Muth-Werthmann D, et al. Ultrasound
elastography for the age determination of venous thrombi.
Evaluation in an animal model of venous thrombosis. Thromb
Haemost. 2005;93:368-374.
4. Gennisson JL, Catheline S, Chaffai S, Fink M. Transient
elastography in anisotropic medium: application to the mea-
surement of slow and fast shear wave speeds in muscles.
J Acoust Soc Am. 2003;114:536-541.
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006
Rehabilitative Ultrasound Imaging Symposium
5. Han L, Noble JA, Burcher M. A novel ultrasound indentation
system for measuring biomechanical properties of in vivo soft
tissue. Ultrasound Med Biol. 2003;29:813-823.
6. Konofagou EE, D’Hooge J, Ophir J. Myocardial
elastography--a feasibility study in vivo. Ultrasound Med Biol.
2002;28:475-482.
7. Langevin HM, Konofagou EE, Badger GJ, et al. Tissue
displacements during acupuncture using ultrasound
elastography techniques. Ultrasound Med Biol. 2004;30:1173-
1183.
8. Ophir J, Cespedes I, Ponnekanti H, Yazdi Y, Li X.
Elastography: a quantitative method for imaging the elasticity
of biological tissues. Ultrason Imaging. 1991;13:111-134.
9. Sandrin L, Fourquet B, Hasquenoph JM, et al. Transient
elastography: a new noninvasive method for assessment of
hepatic fibrosis. Ultrasound Med Biol. 2003;29:1705-1713.
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