Why ultrasound Imaging? - cdn.ymaws.com · pain Case Example One • 75 year old female with sudden...
Transcript of Why ultrasound Imaging? - cdn.ymaws.com · pain Case Example One • 75 year old female with sudden...
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PT Implications and Practice with Diagnostic Ultrasound
Michael Bourassa PT, DPT, OCS, FAAOMPT
Ansel Clayton PT, DPT
Jennifer McGrath PT, DPT
Course Objectives
Why ultrasound Imaging?
Is ultrasound Imaging realistic for Physical Therapists?
How would I utilize ultrasound imaging?
Is ultrasound imaging support in the literature?
Why ultrasound Imaging?
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Case Example One
• 75 year old female with sudden onset of shoulder pain
• Reports pain began after lifting box overhead in the garage
• Current pain 9/10
• Examination limited due to pain
• Active passive range severely limited due to pain
Case Example One
• 75 year old female with sudden onset of shoulder pain
• Reports pain began after lifting box overhead in the garage
• Current pain 9/10
• Examination limited due to pain
• Active passive range severely limited due to pain
• US imaging reveals full Supraspinatus tear
Case Two Example
• 23 year old female with history of low back pain
• Notable core muscle weakness during the exam
• 4 weeks of physical therapy have improved pain but still has poor contraction of TrA
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Potential Benefits of US imaging
Benefit to the Patient
• Consistently, physical therapy utilization of direct access has proven successful in:
• Patient satisfaction
• Reduction of wait time for care
• Fewer surgical referrals
• Decreases in costs of care
APTA Diagnostic and Procedural Imaging In Physical Therapy 2016
Benefit to Physical Therapist
• Improved patient outcomes
• Enhancement of clinical decision making
• More specificity of interventions
• Reduces inappropriate referrals or delay in treatment
APTA Diagnostic and Procedural Imaging In Physical Therapy 2016
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Benefit to Clinic
• Enhancement of services provided
• Improved ability to perform direct access services
• Marketability
APTA Diagnostic and Procedural Imaging In Physical Therapy 2016
Benefit to the Payer
• Physical therapist in physician extender roles have shown 50% reduction in radiographic examination (James)
• US health care costs = 3 trillion in 2014
• Projected to increase 6.1% each year
• PT first contact point for MSK injuries has been shown to reduce health care costs
APTA Diagnostic and Procedural Imaging In Physical Therapy 2016
Benefit to the Payer
APTA Diagnostic and Procedural Imaging In Physical Therapy 2016
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Is ultrasound imaging realistic for Physical Therapists?
Reimbursement
Cost
Training
State regulation
Reimbursement
Ordering imaging is part of the PT evaluation and would be paid under the evaluation code
• Therapeutic Exercise
• Neuromuscular re‐education
• Biofeedback
In many cases, ultrasound imaging is an adjunct to the primary procedure
Currently Medicare, Medicaid and Tricare do not offer reimbursement for diagnostic ultrasound.
Reimbursement
• Insurance payers will pay if Physical Therapist has privileges within organization or payer.
• United States military, where since 1972, PTs have practiced as direct access providers with imaging privileges. (Benson 1995, Greathouse 1994)
• Public Health Service, Indian Health Service, the Veterans Administration Health System, and the Bureau of Prisons now have imaging privileges. (Dininny 1995)
• Kaiser‐Permanente Northern California, a large nonprofit managed care organization, has provided imaging privileges for PTs for almost two decades. (Tichenor 1997)
• The University of Wisconsin Hospital and Clinics has also extended the professional privilege of plain radiography to PTs. (Boissonnault 2010)
• Georgetown University Hospital granted imaging order privileges by PTs in January 2012. (Keil 2015)
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Math Time
Addition of Biofeedback increases reimbursement $3.73Addition of Neuromuscular re‐education increases reimbursement $1.29
Cost of US units US probe $6000 US unit $20,000‐50,000
Training
Inclusion of ultrasound training as entry level competency is
controversial.
Federation of State Boards of Physical Therapy now recognized
diagnostic imaging (including US) as entry level skill
CAPTE now requires diagnostic imaging in curriculum
•7A: The physical therapist professional curriculum includes content and learning experiences in the biological, physical, behavioral and movement sciences necessary for entry level practice. Topics covered include anatomy, physiology, genetics, exercise science, biomechanics, kinesiology, neuroscience, pathology, pharmacology, diagnostic imaging, histology, nutrition, and psychosocial aspects of health and disability.
Training
• Continuing education courses
• Certification in MSKUSI
• Online or in class
• Credential in MSK Sonography
• The American Registry of Diagnostic Medical Sonography
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State Regulations
APTA Position (HOD P06‐12‐10‐09)
“When indicated, physical therapists order appropriate tests including but not limited to imaging and other studies, that are performed and interpreted by other health professionals. Physical therapists may also perform or interpret selected imaging or other studies”
APTA position (HOD P06‐15‐17‐09)
“The position of the American Physical Therapy Association (APTA) that physical therapists embrace and are accountable for best practice standards to provide high‐quality services that promote value, and that all individuals have access to physical therapist services.”
“The APTA supports initiatives to promote a value‐based system for physical therapist services that uses evidence, best practice, and outcomes for meeting the needs of individuals and the public.
The American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) in 2009 adopted the following statement:
“It is the Position of the AAOMPT that ultrasound imaging is within the scope of physical therapist practice.
State Reguations
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How would I utilize ultrasound imaging?
Ultrasound Defined
Diagnostic ultrasound is an imaging method that uses
high‐frequency sound waves to produce relatively precise images of structures within
your body
How it Works
Where it returns
How long it takes
How strong is the signal
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Tissues Seen on US
• No collagen = Black
• Fluid or swelling
• Bone = Bright white
• Dense collagen reflects 100%
• Begins white then dark
• Muscle = Darker
• Profused with blood
• Fascial layers = White
• Dense collagen
How Can We Use It?
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Diagnostic
Component of diagnostic process
In conjunction with patient history and physical exam findings
DOES NOT REPLACE CLINICAL EXAM
Normal Tissues
Abnormal Tissues
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Procedural
Biofeedback Neuro re‐eduReal time changes in morphology and
movement
Documenting change
Identify areas for manual
interventions and physical agents
Guided needle placement
Procedural
Biofeedback
• Knowledge of results
• Knowledge of performance
• Enables the modification of motor response
Neuro re‐edu
• Motor control recovery vs. resolution of pain
Real time changes in morphology and movement
• Morphology
• Internal structure, size, shape, position
• Ex: Decrease in thickness of lumbar multifidi in the presence of low back pain
• Movement
• Useful in detecting and txfaulty movement patterns
• Ex: Earlier glute med recruitment individuals with chronic hip pain
Procedural Imaging
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Procedural
Biofeedback Neuro re‐eduReal time changes in morphology and
movement
Documenting change
Identify areas for manual
interventions and physical agents
Guided needle placement
Procedural
Documenting change
• Tissue healing over time
• Muscle contraction
• Muscle size
Identify areas for manual interventions and physical agents
• Specific segments
• Palpation accuracy
Guided needle placement
• Correct muscle
• Improved safety and error
Procedural Imaging
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Is ultrasound imaging supported?
A case base approach to the evidence.
Case One
• 45 year old male
• Acute onset of low back pain (1 week)
• First episode
• Limited range due to pain
• Increased muscle guarding throughout spine
Case One
• What do we know about back pain?
• Muscle changes after first onset of low backpain
• Multifidus muscle recovery was not spontaneous on remission of painful symptoms
• Contraction of transversus abdominis was significantly delayed in patients with low back pain with all movement
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Case One
• What is the best way to measure these changes?
• Ultrasound imaging highly reliable
• 16 hours of training
• Approx. 20% change noted on CSA upon abdominal drawing in maneuver
Case OneTrA
Case OneMultifidus
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Real time Imaging
Medication, bed rest, resume activity as tolerated
Medical Management
Stabilization training with RUSISpecific Exercise
Teyhen, D. S., Miltenberger, C. E., Deiters, H. M., Del Toro, Y. M., Pulliam, J. N., & Childs, J. D., et al. (2005). The use of ultrasound imaging of the abdominal drawing‐in maneuver in subjects with low back pain. J Orthop Sports Phys Ther, 35(6), 346‐355. doi:10.2519/jospt.2005.35.6.346
Question: What is the most effect treatment for multifidus atrophy?
90% pain resolution in both groups after 4 weeks
Real time Imaging
Weeks 1‐4
Decrease in CSA 14‐16% difference on ipsilateral painful side
Weeks 4‐10
MM: no change in CSA
SE: Increase in CSA to 0.2‐0.7 % difference
Reoccurrence
MM: 84% 1yr/75% 3yrs
SE: 30% 1 yr/ 35% 3 yrs
Teyhen, D. S., Miltenberger, C. E., Deiters, H. M., Del Toro, Y. M., Pulliam, J. N., & Childs, J. D., et al. (2005). The use of ultrasound imaging of the abdominal drawing‐in maneuver in subjects with low back pain. J Orthop Sports Phys Ther, 35(6), 346‐355. doi:10.2519/jospt.2005.35.6.346
Question: What is the most effect treatment for multifidus atrophy?
Case Two
• 47 year old accountant with 8 months history of worsening lateral elbow pain
• Reports increasing pain throughout the work day
• Wrist extension is weak and painful
• Wrist flexion AROM is full but painful
• Current pain is 3/10, aching in nature
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Lateral Elbow Pain Differentials
• Lateral epicondylagia
• C5 and C6 pathology
• Radiohumeral joint pathology
• Radial Tunnel Syndrome
Radial Tunnel versus Lateral Epicondylagia
• Pain with middle finger extension: Both
• Deep, aching pain in lateral elbow: Both
• Pain intensified by repetitive movement of the wrist: Both
Ultrasound can assist
Healthy TissueLateral epicondylagia
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Lateral Epicondylaglia Pathophyisiology
• Chronic overuse of extensor mass
• Most commonly extensor carpi radialisbrevis
• Characterized by proliferation of fibroblasts and poorly organized collagen synthesis
Treatment
• Emphasis on eccentrics
• Look up the chain at predisposing factors
• Lower and middle trapezius strengthening
• Consider brace
• Normal movement patterns
• Look up the chain at predisposing factors
• Lower and middle trapezius strengthening
• Consider brace
Tendon Muscle
Case Three
• 33 year old male presenting to clinic with 3 week history of shoulder pain
• Has difficulty with initial portion abduction, upper trapezius compensation noted
• Abduction is weak and painful
• Current pain is 8/10, aching in nature
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Questions to Answer?
Is ultrasound imaging accurate at identifying rotator cuff tears?
• Ultrasound imaging has been showed to be as effective as MRI in identifying supraspinatus tears.
Are physical therapist capable of utilizing RUSI as well as other health care practitioners?
• Yes, physical therapists have been found to be as competent as radiologist in utilization of ultrasound imaging in dx of full thickness tears
Supraspinatus Images
Partial Thickness TearsFull Thickness Tears
Treatment Plan Supraspinatus
Full Tear
• Surgical repair
• Prehabilitation
• Education
• Scapular coordination exercises
• ROM exercises as appropriate
Partial Tear
• Conservative treatment
• Strengthening of cuff musculature
• ROM exercises as indicated
• Scapular coordination exercises
Ultrasound can delineate between full and partial thickness tears of rotator cuff musculature, which can guide treatment and expedite referral process
as appropriate.
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Case Four
• 40 year old male
• 2 year history of intermittent anterior knee pain
• Pain with running, stairs and deep squats
• Pain began after increasing training for 5k
• Since onset 2 years ago, symptoms are intermittent
Questions to Answer?
1. What structure in involved?
2. What is the status of that structure?
3. What is the most appropriate intervention strategy for this patient?
Ultrasound Image
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Variations in tendon
pathology
Most studies suggest that eccentric training may have a positive effect, but a specific protocols effects is unsubstantiated.
Ultrasound Image (3 wks)
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Case Four Outcomes after 5 visits
Functional
Able to hike several miles without pain
No pain with squat or stairs
Beginning to progress back to running program
LEFSLEFS
Case Five
• 16 year old male
• Hamstring pain/cramping
• Began during sprints at football practice
• Pain with active contraction and passive stretch of hamstring
Case Five
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Case Five
What information does ultrasound give us in this case?
1. Type of tissue
• Guides intervention
2. Timeframe for recovery
• Size and location
3. Criteria for returns to play
• Asymptomatic
• Healing tear
• Good collagen lines
Case Six
• 45 year old female
• History of pelvic floor dysfunction
• Genital hypersensitivity
• Incontinence
• Lumbar screen negative
• Exam revealed no pelvic flooractivation
• Compensation through gluts and hip add
Case Six
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Case SixDay one exercise was given to focus on pelvic floor rehab utilizing normal cueing
Case Six
• Reassessment Day two showed no change in activation with cues via RUSI
• Intervention focused on utilizing different verbal cues and tactile cues to achieve contraction
• Success was noted through contraction via ultrasound image
Questions?