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Spinal manipulation and real time ultrasound imaging
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Spinal manipulation and real time ultrasound imaging - June 7, 2006 1:37:00 AM
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Alex Brenner PT MPT OCS
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The Army right now has an initiative where we are implementing real time diagnostic ultrasound units into all the Army physical therapy clinics. These units (similar to ones that are used in pre-natal/obstetrics clinics) are to be used in conjunction with lumbar stabilization programs to help rehab soldiers/family members with lower back pain. These machines are also helpful to evaluate transversus abdominus, multifidus and pelvic floor muscle groups. You may have seen some of this research published recently in JOSPT and in other peer reviewed journals.
I have been able to use the diagnostic US machine and have noticed some interesting changes in mulitifidus contraction following spinal manipulation. In a subject with a long history of right lower back pain and lower back stiffness around L4/5 we measured the cross section of the multifidus utilizing the real time US machine. Cross sectional measurements were taken of the bilateral multifidus with the subject lying in prone and by having the subject perform and hold a gentle “bird-dog” or "swimmer" back extension exercises. It was noted via US imaging that over the painful right side (L4/5) the subject had what appeared to be poor recruitment of the right multifidus muscle because the muscles were not symmetrical at this level as visualized with the real time US unit. The lumbosacral region manipulation was then performed aimed at the right lumbosacral region resulting in a noticeable cavitation. Cross sectional measurements were then immediately retaken with the subject again prone and performing the “bird-dog”/"swimmer" hold. Very obvious visual improvements were noted on the US screen as well as a large clinical improvement in the cross sectional measurement of the multifidus was seen immediately following the manipulation at the L4/5 level. The muscles still did not appear symmetrical but the right side appeared much improved and closer to same cross sectional size as the uninvolved side. The subject also reported immediate improvements in his AROM with forward bending and a reduction in pain.
It appears that spinal manipulation results in improvement of contraction of the multifidus musculature most likely through some neuromuscular control mechanism. Of course further research needs to be conducted in the form of a RCT but this appears to be a promising new area of research for the effects of spinal manipulation on trunk musculature. This case study is currently being written up for publication.
Any thoughts?
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Alex Brenner, PT, MPT, OCS
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Re: Spinal manipulation and real time ultrasound imaging - June 7, 2006 2:46:00 AM
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PTupdate.com
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Hey Alex,
That is very interesting. I am sure as you've scanned through articles on my site you've seen how I have lamented that I did not purchase an US machine when I had the chance.
For those who do not know the story: When we were getting the US done on our first child, around 4 years ago, they had 2 machines they wanted to ditch. Price? $500. It was just a matter of the space to shove the machine, convincing the US girl to come in some night and teach me all the basics (for a good restaurant gift certificate in exchange), etc. Needless to say, they got rid of it. It was a time when I was reviewing articles on using US for hypoechoic areas of patellar tendons, peeling back of the UCL off the bone in pitchers, thickness of biceps tendon, etc.
So, for those interested , scan eBay and call your local OB/GYN and see if they have something old sitting in a storage room. With movement into 3 & 4D images, the older B&W may be great for us.
As far as the multifidus you mention, I wonder if it's a mechanical disadvantage that is causing the poor contractility....almost like the VMO when the Q-angle gets too great, and the muscle just cannot function. Of course the next step is to follow your patients and see if natural activity causes hypertrophy to the point where symmetry is gained, and if not, what specific exercises facilitate that gain.
Cool stuff.
John Duffy, PT OCS
[URL=http://www.PTUpdate.com]www.PTUpdate.com[/URL]
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John M. Duffy, PT
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www.PTupdate.com
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Re: Spinal manipulation and real time ultrasound imaging - June 7, 2006 3:10:00 AM
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Alex Brenner PT MPT OCS
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I forgot to mention too that we retested him the next day (24 hours post manipulation) and he maintained the improved contraction of the multifidus.
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Alex Brenner, PT, MPT, OCS
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Re: Spinal manipulation and real time ultrasound imaging - June 7, 2006 3:12:00 AM
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connie.pt
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THAT is an exciting piece of news!
Alex, you may want to compare your findings to the research on quadriceps inhibition during increased knee intraarticular pressure and pain (from intraarticular swelling) in your discussion. Or joint pain & muscle inhibition.
I'll look up some articles that may apply to your case & get back to you.
Connie
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Re: Spinal manipulation and real time ultrasound imaging - June 7, 2006 3:19:00 AM
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Alex Brenner PT MPT OCS
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John, I did notice on your website the story about the US machine. The machines are very easy to use with LITTLE instruction. You could actually figure it all out with just trial and error and a good US imaging picture book that you can buy through Amazon which shows good images for all the anatomical structures.
I am not 100% sure but I think as civilian PT's you can use US imaging along with therapy sessions and it is reimbursable. Does anyone know for sure? Is it worthwhile monetarily?
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Alex Brenner, PT, MPT, OCS
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Re: Spinal manipulation and real time ultrasound imaging - June 7, 2006 3:31:00 AM
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PTupdate.com
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That was one of the company issues when I was suggesting this....I knew I could not be reimbursed, but just thought it would be a neat tool. After all, being next to 5 sport ortho surgeons, I think they would love to have an opportunity to say "Hey Duff, instead of sending this guy for MRI, can you check real quick and see if it looks like a tendon tear? But then again, we run into all those medical/legal issues. Who wants to be sued over something like a misread US?
Duffy
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Spinal manipulation and real time ultrasound imaging - June 7, 2006 3:31:00 AM
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Bournephysio
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Alex, Do a pubmed search for Herzog, muscle inhibition and manipulation. He has done some work in this area but not with trunk muscles.
Doug PhD(c)
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Re: Spinal manipulation and real time ultrasound imaging - June 7, 2006 3:40:00 AM
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JLS_PT_OCS
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Alex -
Very cool. Many of us have long used manipulation to ease pain and assist with ease of stability exercises, even for patients categorized as needing stability exercises. Glad to see things are progressing re:mechanisms.
Look forward to reading it and seeing your name in a journal again!
I think the recent JOSPT about U/S imaging helps delineate our responsibilities of using the tool, ie diagnosis of pathoanatomical problems vs using as a biofeedback tool.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Spinal manipulation and real time ultrasound imaging - June 7, 2006 4:43:00 AM
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Shill
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That is cool. This may eventually be a possible way to find out more of the specific tissue effect behind treatments "working". I hadnt considered that before.
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Steve Hill PT
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Re: Spinal manipulation and real time ultrasound imaging - June 7, 2006 4:54:00 AM
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Alex Brenner PT MPT OCS
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Good point Jason. It appears from this case study that manipulation provides kind of a "window" of opportunity meaning that there may be a short time following manipulation where muscle activation is significantly improved. It would then make sense why exercise prescription immediately following manipulation would be so important to help reinforce the gains made with the manual technique.
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Alex Brenner, PT, MPT, OCS
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Re: Spinal manipulation and real time ultrasound imaging - June 7, 2006 5:26:00 AM
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Alex Brenner PT MPT OCS
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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(4):233-6.
Herzog W, Scheele D, Conway PJ. Electromyographic responses of back and limb muscles associated with spinal manipulative therapy. Spine 1999;24(2):146-53.
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Alex Brenner, PT, MPT, OCS
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Re: Spinal manipulation and real time ultrasound imaging - June 7, 2006 6:01:00 AM
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Bournephysio
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Forgot about those. He has also done the effect of manipulation on knee inhibition. Those specifically look at muscle inhibition. He also has done other work with muscle inhibition not related to manipulation.
Doug
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Re: Spinal manipulation and real time ultrasound imaging - June 7, 2006 7:52:00 AM
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PHSPT
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Interesting work.
I was under Skip's Gill (at BAMC)wing when i first heard him talking about Army pushing for this. Good to hear it took off well.
Will techs be allowed to operate these? otherwise i can see it being time consuming to do for a PT, given the tight scheduling.
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Re: Spinal manipulation and real time ultrasound imaging - June 7, 2006 1:25:00 PM
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jma
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I too like the idea Alex. Keep up the good work.
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Re: Spinal manipulation and real time ultrasound imaging - June 9, 2006 4:28:00 AM
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MPTSTUDENT
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Interesting finding. Here is an article that found an increase in lower trap strength immediately following t-spine manipulation. You probably already have it or would find it but thought I would throw it out for help.
Short term effects of thoracic spine manipulation on lower trapezius muscle strength. Journal of manual and manipulative therapy. Vol 12. 2004. 82-90. If you dont have it and would like it i can provide full text.
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Re: Spinal manipulation and real time ultrasound imaging - June 9, 2006 1:18:00 PM
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certMDT
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Alex -
I'm sure you know of the study that would refute these findings to a degree, as it was one of the most powerful arguments for specific stabilization training:
Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine. 1996;21:2763-9.
This study looked at subjects with unilateral low back pain and single-level decreased multifidus area. Although all subjects had no pain after one month, only those who had performed stabilization exercises had a return of normal multifidus size. So if manipulation and specific stabilizing exercises both increase cross-sectional area, what is the actual mechanism? One would assume from the Hides article that the muscle is inhibited by more than pain.
It would be interesting to try to correlate these changes to the other functional tests, i.e. the prone abdominal draw-in. I believe Jull reported this to be 90% accurate in detecting those with previous back pain. I wonder if performance would be changed after a manipulation.
Great job.
I would also recommend the following paper, if you can get to it. So far I think you can only get it on the Manual Therapy website.
Macdonald DA, Lorimer Moseley G, Hodges PW. The lumbar multifidus: Does the evidence support clinical beliefs? Man Ther. 2006 May 20
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Charles Sheets PT OCS Dip MDT
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Re: Spinal manipulation and real time ultrasound imaging - June 11, 2006 5:33:00 AM
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certMDT
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Here's another one, looking at the partner to multifidus in specific stabilization:
The effect of sacroiliac joint manipulation on feed-forward activation times of the deep abdominal musculature
Paul Marshall, PGDipSci,a and Bernadette Murphy, DC, PhDb
J Manipulative Physiol Ther 2006;29:196-202)
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Charles Sheets PT OCS Dip MDT
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