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Rehabilitative Ultrasound Imaging
Los fisioterapeutas utilizan la ecografía de rehabilitación (RUSI) como una herramienta de retroalimentación para medir los cambios en la morfología muscular durante intervenciones terapéuticas como los ejercicios de control motor (MCE). Sin embargo, falta una descripción estructurada de su eficacia.
2. Study Selection
3. Methodological Quality and Risk of Bias
|Reference.||Study Type||PEDro Scale Items||Score|
|De la Fuente et al., 2020 ||RCT||+||+||−||+||−||−||+||+||+||+||+||7|
|Henry et al., 2005 ||RCT||+||+||−||+||−||−||+||+||+||+||−||6|
|Herbert et al., 2008 ||RCT||+||+||+||+||−||−||+||+||+||+||−||7|
|Lee et al., 2016 ||RCT||+||+||−||+||−||−||−||+||+||+||−||5|
|Lee et al., 2018 ||RCT||+||+||−||+||−||−||+||+||+||+||−||6|
|Lin et al., 2021 ||RCT||+||+||−||+||−||−||−||+||+||+||−||5|
|McKenna et al., 2020 ||RCT||+||+||+||+||−||−||+||+||+||+||+||8|
|Park et al., 2011 ||CT||+||−||−||+||−||−||−||+||+||+||−||4|
|Solomon et al., 2003 ||RCT||+||+||+||+||−||−||+||+||+||+||−||7|
|Teyhen et al., 2006 ||RCT||+||+||+||+||−||+||+||+||+||+||+||9|
|Van et al., 2006 ||RCT||+||+||+||+||−||−||+||+||+||+||−||7|
4. Data Analysis
|De la Fuente et al., 2020 ||n = 20 healthy participants (7M/13F)
Age: 25 ± 5 years.
Height: 166 ± 10 cm.
Weight: 64 ± 6 kg.
BMI: 22.2 ± 5.8 kg/m2
|Visual biofeedback (RUSI)
|Participants were placed in a supine position (45° of hip flexion, 90° of knee flexion, the arms close to the trunk in a comfortable position, and the forearms in pronation).
Both groups were instructed about the protocols during 5 min before the experiment, using a video.
RUSI group watched echography images and were advised to pay attention to the changes in thickness of the TrA.
Verbal biofeedback group paid attention to the perception of contraction in the muscles
|Four repetitions of the AHE (sustaining an abdominal contraction lasting 7 s after 1 cycle of full inspiration and expiration), with 2 min of rest between repetitions.
One basal measure + 3 measures with biofeedback.
|Transversus Abdominis||Normalized Thickness:
Difference between the measurement from each repetition and the basal measure, divided by the basal condition, and expressed in arbitrary units.
Difference of pressure between each repetition and the basal measure, divided by the basal condition, and in arbitrary units.
|Post hoc power = 0.804.
Group differences were found (p = 0.006) without interactions (p = 0.994) or repetition effects (p = 0.468).
RUSI feedback resulted in larger changes in thickness than the verbal feedback alone (p < 0.05).
The bias between thickness and pressure for feedback with and without ultrasonography was 0.0490 and −0.0080 respectively.
Significant correlation was not found between pressure measurement and thickness.
The lowest minimal detectable changes were achieved by using the ultrasonography feedback.
|Henry et al., 2005 ||n = 48 healthy participants (6M/42F)
Age: 21.3–23.1 years.
Height: 1.7 ± 0.1 m.
Weight: 62.5–64.0 kg.
BMI: 22.2 ± 5.8 kg/m2
|Visual Feedback (RUSI)
Minimal verbal Feedback
Common clinical feedback
(verbal descriptive feedback of any observed substitution patterns, verbal corrective feedback, and cutaneous feedback from palpation)
|Participants were placed in a supine position with hips flexed between 40° and 80° and knees flexed between 60° and 120°.
All groups received instruction in how to perform an AHE.
Feedback was given after the first trial and after every other trial thereafter. If the subject appeared to be having difficulty performing the AHE, then the verbal corrective feedback also included a rewording of the instructions to promote understanding.
|Each subject was given 2 warm-up trials of the AHE, followed by 10 trials of the AHE, which were assessed as correct or incorrect.
Subjects able to perform 3 consecutives correct AHEs on the retention test, as in the initial test, were considered to have retained the ability to perform the AHE correctly.
|Number of trials needed for an individual to consistently perform an AHE.
Subjects’ ability to retain the correct performance of the AHE up to 4 days later.
|The ability to perform the AHE differed among groups (p < 0.001). During the initial session, 12.5% of subjects in verbal feedback group, 50.0% of subjects in common clinical feedback group, and 87.5% of subjects in RUSI group were able to perform 3 consecutive AHEs.
There was a difference among groups in the mean number of trials until performance criterion was reached (p = 0.0006).
No differences were noted among feedback groups with regard to the proportions of subjects able to reach the retention criterion.
|Herbert et al., 2008 ||n = 28 healthy participants (9M/19F)
Age: 28 ± 8 years.
BMI: 24.0 ± 0.7 kg/m2
|Participants were positioned prone on the treatment table with the hips in the neutral position
Real-time RUSI of the multifidus muscle at the level of S1 was recorded, transferred to the video recording system, and projected on the television monitor to provide visual feedback.
Constant feedback group received visual feedback of the real-time RUSI of successful or unsuccessful multifidus muscle activation on the monitor, but were not given verbal feedback.
Variable feedback group received delayed feedback after performing a number of repetitions of the exercise, based on a pre- determined schedule.
|Subjects attended 15-min exercise training sessions in the laboratory, twice a week, for a total of 8 training sessions.
Participants were asked to recruit the multifidus muscle without extraneous movements and to hold each contraction for 3 s. It also informed the subjects that the training session would consist of 12 repetitions of the exercise and that a successful performance outcome was visualization of muscle movement on the monitor.
|Lumbar multifidus muscle||Performance success:
Defined as isolated isometric recruitment of the first sacral level (S1) multifidus muscle without substitution of extraneous movements such as Valsalva, pelvic tilt, arching the back, lifting the upper trunk, or lifting the lower extremity.
Each subject returned after 1 and 4 weeks. Same procedures were repeated, except that no augmented feedback was provided.
|Both groups had similar performances of multifidus muscle recruitment (p = 0.26).
Constant feedback group had good success (80%) that was maintained at session 8 (84%), with no difference between sessions 1 and 8 (p = 0.19).
Variable feedback group gradually increased success between sessions 1 and 8 (p = 0.002).
Both groups sustained their session 8 success when tested for short-term retention at 1 week (Both, p > 0.36).
At the long-term retention test, the variable feedback group outperformed the constant feedback group (p = 0.04), indicating superior motor learning.
|Lee et al., 2016 ||n = 30 healthy participants
Age: 20.3–21.1 years
Height: 1.66–1.67 m
Weight: 55.3–57.0 kg
|Visual biofeedback (RUSI)
Pressure biofeedback unit
|Participants were placed in a crooked lying position with their knees flexed to 90°.
Basic training group received verbal and manual contact biofeedback.
Pressure biofeedback group were told to maintain the manometer at 10 mm Hg, starting from 40 mm Hg.
RUSI group received training with monitoring of possible contraction of their muscles in the screen.
|All of the subjects received AHE training for 15 min.
After training, the subjects were measured three times being at rest in a supine position and performing the AHE with which they were trained.
|Thickness measured with ultrasound imaging.||All the groups showed greater TrA thickness (p < 0.01) but no changes in IO nor EO (p > 0.05).
During AHE, the thickness of the musculus transversus abdominis differed significantly among the groups (p < 0.05).
No significant differences were observed between the basic training and the pressure biofeedback groups, and between the pressure biofeedback and the RUSI groups (p > 0.05). However, significant differences between basic training and RUSI were found for TrA (p < 0.05).
No significant difference was observed among the three groups regarding the thicknesses of the internal oblique abdominal and external oblique abdominal muscles during AHE (p > 0.05).
|Lee et al., 2018 ||n = 20 healthy participants
Age: 29.0 ± 3.0 years
BMI: 22.1 ± 1.7 kg/m2
Visual feedback (RUSI)
|Subjects were placed in a supine hook-lying position.
Subjects in conventional feedback group were trained AHE using verbal and tactile feedback.
Subjects in RUSI group, in addition to the initial education about the conventional feedback, were educated about visual feedback provided with real-time ultrasound imaging.
|All subjects received education session about AHE with conventional (verbal and tactile) feedback for 30 min.
After the session, the baseline assessment of the muscle activity during AHE was recorded using the surface electromyogra- phy.
Thickness measurement of the 3 muscles.
Percentages of maximal voluntary contraction were calculated by normalization with maximal voluntary contraction to evaluate how efficiently TrA-IO muscles were activated.
Maximal voluntary contraction values of TrA-IO were obtained by maximally twisting upper-body to ipsilateral side against physiatrist’s manual resistance.
|After 2 weeks of AHE training, the thicknesses of TrA, IO, and EO muscles in resting were not significantly changed in both groups.
Thicknesses of contracted TrA and IO muscles during AHE were significantly increased than those of resting state in both of real-time ultrasound imaging and conventional feedback group (p < 0.05).
The difference between resting and contraction of TrA muscle thickness in real-time ultrasound imaging feedback group was significantly higher than conventional feedback group (p < 0.05), but no for IO (p > 0.05).
Root mean squares and maximal voluntary contraction values in TrA-IO increased without statistical significance in both groups (p > 0.05).
The difference in maximal voluntary contraction value of TrA-IO was significantly higher in RUSI group than conventional feedback group (p < 0.05).
The ratio of root mean squares values of TrA-IO/EO muscles was significantly higher in RUSI group.
|Lin et al., 2021 ||n = 40 healthy participants
Age: 25.9–26.6 years
Height: 1.62–1.63 m
Weight: 55.6–56.2 kg BMI: 21.0–21.0 kg/m2
Visual feedback (RUSI)
|During contraction, subjects in the experimental group were required to watch the real-time ultrasound imaging and maintain continuous contraction with maximum effort.
Images of the right LM at rest and during maximum isometric contraction were acquired.
Images of the right TrA muscle were acquired at rest and during the ADIM maneuver.
|All participants were firstly given a verbal explanation regarding the purpose and operation procedure of the experiment and the anatomical structure and function of the muscles before the test.
Image acquisition for each condition and each time point (Trest, Tc-max, Tc-15 s, Tc-30 s) was repeated three times.
|Lumbar multifidus thickness
Three separate resting ultrasound images were collected immediately after ex- halation
ADIM was used to assess the altered muscle thickness associated with a voluntary contraction of the TrA muscle.
|No significant differences were found in the thickness of LM at rest (p > 0.999), Tc-max (p > 0.999), and T15 s (p = 0.414) between the two groups.
The ability to recruit LM muscle contraction differed between groups at T30 s (p = 0.006), with subjects in the experimental group that received visual ultrasound biofeedback maintaining a relative maximum contraction. No significant differences were found in the TrA muscle thickness at rest (p > 0.999) and Tc-max (p > 0.999) between the two groups.
Significant differences of contraction thickness were found at T15 s (p = 0.031) and T30 s (p = 0.010) between the two groups during the ADIM, with greater TrA muscle contraction thickness in the experimental group.
|McKenna et al., 2020 ||n = 27 patients with unilateral subacromial pain (15M/12F)
Age: 54.4–56.8 years
BMI: 24.6–29.5 kg/m2
NPRS score: 1.0–2.0
Manual facilitation + RUSI
|Participants performed all interventions in the supine position.
Participants received individual training in either activating the SA using RUSI feedback with manual facilitation or training with manual facilitation only at the first session.
At the second session, the participant received the intervention they did not receive on the first session.
|Five practice serratus punches were performed continuously at an approximate speed of 3 s per punch with the participant cued to “reach up”. One minute of rest was then allowed, followed by a further 10 intervention repetitions with ongoing verbal cueing and encouragement, for a total of 15 repetitions during intervention.||Serratus anterior||Electromiography
Levels of SA activation (normalized to a maximal voluntary isometric contraction).
|The predicted marginal mean difference between interventions was 55.5% (95% CI = 13.9% to 97.1%) (p = 0.009), favoring the addition of RUSI feedback.|
|Park et al., 2011 ||n = 42 healthy males
Age: 22.6–23.2 years
Height: 1.75–1.76 m
Weight: 67.8–67.9 kg
BMI: 21.8–22.2 kg/m2
|Participants were placed in 4 different positions.
The experimental group performed AHE with RUSI feedback.
The control group performed AHE with no RUSI feedback.
|All the subjects were familiarized with AHE with a 30-min training.
Measurements were conducted 3 times in each position with 2-min resting between measurements.
Thickness differences between rest and AHE were compared between the two groups.
|The difference in internal IO thickness changes between the groups were significant. The differences in EO thickness changes were only significant among the positions. A post hoc analysis of the differences in EO thickness changes among the positions found significant differences between the crook lying and four-point kneeling positions. The TrA thickness changes showed significant interaction between group and position.|
|Solomon et al., 2003 ||n = 120 patients with mild to moderate fecal incontinence with at least mild neuropathy (13M/107F)
Age: 62.0 ± 12.8 years
Exercise compliance: 83.0%
|Digital examination feedback
|All patients were lying in the left lateral position.
In the digital examination group, patients performed a full set of supervised exercises guided by digital per anal examination of the external sphincter.
In the RUSI group, patients were taught how to contract the anal sphincters while watching the real-time ultrasound display on the monitor screen, and a full set of exercises were performed during each treatment session.
In the anal manometry group, Patients were taught how to contract and relax the anal sphincters while attending to the pressures generated in the anal canal, and a full set of exercises were performed during each treatment session.
|All participants performed a full set of exercises, consisting of ten five-second sphincter contractions, each at one-second intervals, repeated ten times (a total of 100 contractions).
All patients were urged to perform an identical set of exercises twice per day between outpatient visits and were asked to estimate the percentage of exercises they had actually completed.
|Pelvic floor||St. Mark’s Hospital fecal incontinence score
Pescatori fecal incontinence score
Patient’s self-assessment of fecal incontinence severity using a visual analog scale
Investigator’s assessment of fecal incontinence severity using a visual analog scale.
Quality-of-life measure using Direct Questioning of Objectives
Resting and maximal squeeze anal canal manometric pressures
Isotonic fatigue time
Isometric fatigue contractions
|One hundred two patients (85 percent) completed the four-month treatment program. Across all treatment allocations, patients experienced modest but highly significant improvements in all nine outcome measures during treatment, with 70 percent of all patients perceiving improvement in symptom severity and 69 percent of patients reporting improved quality of life. With the possible exception of isotonic fatigue time, there were no significant differences between the three treatment groups in compliance, physiologic sphincter strength, and clinical or quality-of-life measures. Correlations between physiologic measures and clinical outcomes were much stronger with ultrasound-based measures than with manometry.|
|Teyhen et al., 2005 ||n = 30 patients with chronic low back pain (18M/12F)
Age: 62.0 ± 12.8 years
Exercise compliance: 83.0%
|Tactile and verbal feedback
Tactile, verbal and RUSI feedback
|All patients were placed on quadruped position.
In both groups, tactile and verbal instructions were provided to all subjects in each position.
After the training in quadruped, patients were then randomly assigned to receive further instruction using traditional training (visual + tactile feedback) or traditional training with biofeedback in the ADIM.
|To determine the baseline performance of the patient’s ability to per- form the ADIM prior to training, subjects were instructed to contract their abdominals by bringing their belly button up and in towards their spine. No other instruction or tactile cues were provided.
After baseline measurements were obtained, all subjects received an education session and training in the ADIM in 3 positions: quadruped, seated and supine.
A total of 5 contraction attempts, each with a 10-s hold, were performed in each of the 3 positions.
Thickness differences between rest and ADIM. In addition, a reliability analysis was performed.
At the end of the first session, all subjects received instruction on the home exercise program and were asked to return after 4 days.
|Intrarater reliability measuring lateral abdominal muscle thickness exceeded 0.93.
On average, patients in both groups demonstrated a 2-fold increase in the thickness of the TrA during the ADIM. Performance of the ADIM did not differ between the groups.
|Van et al., 2006 ||n = 25 healthy participants (6M/19F)
Age: 19.1–19.9 years
Verbal and RUSI feedback
|Subjects were placed in a prone position.
All subjects received feedback on the number of millimeters of increase in muscle thickness that occurred with contraction of the multifidus (KR), with the aim being to increase this value.
In addition to the provision of KR, subjects in the other group received biofeedback in the form of visual observation of the ultrasound image of the muscle contraction as it occurred.
|Prior to testing in the acquisition phase, all subjects received the same initial explanation relating to the multifidus muscle.
Each subject performed a total of 10 contractions (acquisition phase) with 20 s of rest between measurements.
After completing the 10 trials in the acquisition phase, all subjects were asked to return in 1 week for follow-up assessments (retention phase).
|Lumbar multifidus||Ultrasound imaging
To assess multifidus muscle contraction, the difference between the multifidus muscle thickness at rest and during contraction was calculated.
|Subjects from both groups improved their voluntary contraction of the multifidus muscle in the acquisition phase (p < 0.001) and the ability to recruit the multifidus muscle differed between groups (p < 0.05), with subjects in the group that received visual ultrasound biofeedback achieving greater improvements. In addition, the group that received visual ultrasound biofeedback retained their improvement in performance from week 1 to week 2 (p > 0.90), whereas the performance of the other group decreased (p < 0.05).|
The entry is from 10.3390/ijerph18147554
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