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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5830_Библиотеки_им_академика_М_И_Перельмана.pdf
APPENDIX A
Outline – lumbopelvic
USI assessment
BLADDER AND PELVIC FLOOR RESTING STATE
USI – QUALITATIVE ANALYSIS TRANSVERSE SAGITTAL
Presence of respiratory motion of bladder at rest (Y/N)
Shape and symmetry of the bladder at rest (describe)
Relationship of the bladder to the pelvic fl oor (height)
BLADDER AND PELVIC FLOOR WITH A LOADING TASK (e.g. ASLR)
USI – QUALITATIVE ANALYSIS TRANSVERSE SAGITTAL
Caudodorsal motion of bladder with task (Y/N)
Dorsal motion of bladder with task (Y/N)
Lateral shift or rotation of bladder with task (direction)
Observable PFM contraction during task (Y/N)
Decrease in shape of the bladder (Y/N)
USI – QUANTITATIVE ANALYSIS TRANSVERSE SAGITTAL
Caudodorsal distance with task
Dorsal distance with task
Angle with respect to image horizontal
Lateral distance from midline with task
151151
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APPENDIX A: Outline - lumbopelvic USI assessment
PREFERENTIAL ACTIVATION OF THE PFM
USI – QUALITATIVE ANALYSIS TRANSVERSE SAGITTAL
Caudal encroachment of bladder with contraction (Y/N)
Abdominal encroachment of bladder with contraction (Y/N)
Caudodorsal motion of bladder with contraction (Y/N)
Cranioventral motion of bladder with contraction (Y/N)
Decrease in shape of the bladder (Y/N)
Observable relaxation of the PFM after the contraction (Y/N)
USI – QUALITATIVE ANALYSIS TRANSVERSE SAGITTAL
Caudodorsal distance with task
Cranioventral distance with task
Angle with respect to image horizontal
ABDOMINAL WALL RESTING STATE
USI – QUALITATIVE ANALYSIS LEFT RIGHT
Integrity of the linea alba (quality of architectural delineation)
Resting respirator y modulation (TrA, IO or both) (a+ = >20%)
TrA resting state (normal, hypertonic)
IO resting state (normal, hypertonic)
Quality of muscle (RA, EO, IO, TrA) (hypoechoic = <50%,
hyperechoic = >50%)
Distance from the midline to the linea semilunaris
USI QUANTITATIVE ANALYSIS – INSPIRATION EXPIRATION % CHANGE
RESPIRATION
LEFT RIGHT LEFT RIGHT LEFT RIGHT
TA – depth
IO – depth
APPENDIX A: Outline - lumbopelvic USI assessment
ABDOMINAL WALL WITH A LOADING TASK, (e.g. ASLR)
Width of the linea alba (static, ↑ or ↓ in width)
TrA co-activation throughout task (Y/N)
Altered TrA co-activation (absent, irregular or excessive)
IO co-activation throughout task (Y/N)
Altered IO co-activation (absent, irregular or excessive)
TrA relaxation after task ( Y/N)
IO relaxation after task (Y/N)
USI – QUANTITATIVE RESTING CONTRACTED % CHANGE
ANALYSIS
LEFT RIGHT LEFT RIGHT LEFT RIGHT
TrA – depth
TrA – length
153
IO – depth
ABDOMINAL WALL WITH PREFERENTIAL ACTIVATION OF TrA
Effect of TrA on linea alba (static, ↑ or ↓ in width)
Lateral slide of TrA under IO (Y/N)
Lateral corset of TrA (Y/N)
Lateral corset of IO (Y/N)
↑ TrA girth with activation (Y/N)
↑ IO girth with activation (Y/N)
TrA Relaxation af ter contraction (Y/N)
IO Relaxation after contraction (Y/N)
154
APPENDIX A: Outline - lumbopelvic USI assessment
USI QUANTITATIVE ANALYSIS RESTING CONTRACTED % CHANGE
LEFT RIGHT LEFT RIGHT LEFT RIGHT
TrA – depth
TrA – length
IO – depth
Midline to linea semilunaris – width
Linea alba – width
MULTIFIDUS RESTING STATE
USI – QUALITATIVE ANALYSIS LEFT RIGHT
Resting shape – level (symmetrical, round, oval or triangular)
Resting size – level (symmetrical, asymmetrical)
Quality of muscle (MF) (hypoechoic = <50%,
hyperechoic = >50%)
MULTIFIDUS WITH A LOADING TASK (e.g. prone or lateral leg lift)
USI – QUALITATIVE ANALYSIS LEFT RIGHT
MF co-activation throughout task (Y/N)
Altered MF co-activation (absent, irregular or excessive)
MF relaxation after task (Y/N)
PREFERENTIAL ACTIVATION OF MULTIFIDUS
USI – QUALITATIVE ANALYSIS LEFT RIGHT
Observed increase in dMF depth – level (Y/N)
Observed increase in sMF depth – level (Y/N)
Anterior motion of spinal column (segmental vs. multi-segmental)
Speed of contraction (tonic vs. phasic)
MF relaxation after task (Y/N)
APPENDIX A: Outline - lumbopelvic USI assessment
USI – WIDTH DEPTH % CHANGE
QUANTITATIVE
ANALYSIS
RESTING CONTRACTION RESTING CONTRACTION WIDTH DEPTH
155
L2
L3
L4
L5
S1
L R L R L R L R L R L R
APPENDIX B
Outline of the minimum
requirements for an
ultrasound imaging
accreditation process
for rehabilitation
professionals
A primary concern regarding the use of ultrasound imaging (USI)
by physiotherapists and other rehabilitation professionals is the need
for standardized training. As the clinical use of ultrasound imaging
for the assessment and treatment of neuromuscular control is in its
infancy, it is imperative that the credentialing mechanisms that are
being considered are rigorous, and refl ect the highest standards of
quality control. As such this brief appendix is devoted to topics
related to the format, curriculum and instruction of such a
process.
The clinical application of USI involves three steps: image gen-
eration (the ability to generate a clear image of the structure(s) that
is of interest), image recognition (the ability to orientate oneself to
the two-dimensional nature of an ultrasound image), and image
interpretation (the ability to interpret both static and dynamic
images). Consequently, these three processes and the information
required for their development serve as the foundation of all training programmes. Although there is some fundamental information
that is generic (principle of ultrasound wave propagation, instrumentation, etc.), the material covered varies substantially depending
on the intent of the examiner. For example, traditional medical
imaging applications involve the generation and interpretation of a
very wide range of tissues. As such, medical sonographers and radiologists require extensive training in the recognition of the diverse
aspect of normal and abnormal anatomy. Alternatively, in the rehabilitation fi eld the interest is primarily in viewing muscle (and
156
APPENDIX B: Minimum requirements for ultrasound imaging accreditation
perhaps nerve), both in its static form and during a dynamic event
(neuromuscular control). Although rehabilitation professionals share
in their requirement for certain fundamental information, their
training presents a unique challenge. Specifi cally, there is a need
for a very diverse theoretical background (regional anatomy and
motor control), a requirement of a basic level of clinical expertise
(USI is not intended as a stand-alone assessment or treatment tool,
rather is incorporated alongside existing clinical skills), and the
challenge of delivering postgraduate education on a topic that
requires repeated practical exposure.
In 2004 an ad hoc committee was established by the College of
Physical Therapists of British Columbia, Canada to investigate and
provide recommendations regarding the implementation of USI in
physiotherapy practice. This committee addressed several issues;
however, one of its primary purposes was to address the structure
and curriculum of an accreditation process for its members. The
committee took into consideration the accreditation processes of
other health-related professional associations, as well as expert
opinion; it deliberated over various formats for delivery, ranging
from correspondence and self-study, to course study, as well as
residency. Ultimately, the recommendations for minimum requirements (which are presented here) were a process that involved both
self- and course study followed by practical evaluation.
157
SUGGESTED CURRICULUM
The format of the suggested accreditation process (self-study followed by an 18-hour practical course) is intended to provide physiotherapists with the minimum basic knowledge and skills required for
the safe integration of USI into clinical practice. As USI has the
potential to be applied to many muscle groups throughout the body,
it is accepted that the preliminary list of scans included in the course
curriculum will expand in time. Although USI of muscle groups
is generic in some regards, all scans require very specifi c anatomical
and neurophysiological knowledge. This accreditation process is
aimed at providing only the generic principles on which clinicians
can base further training.
Prerequisite reading (to be completed prior to course study)
I. Students are expected to read selected articles from peer-
reviewed journals and texts that cover topics such as the nature
and propagation of ultrasound waves and ultrasound instrumentation, as well as the technical, safety and practical aspects of
USI.
158
APPENDIX B: Minimum requirements for ultrasound imaging accreditation
II.
Students are expected to demonstrate sound knowledge of the
neuromuscular mechanisms of the lumbopelvic region with
regard to postural control of the trunk, respiration and continence, both in health and during dysfunction. It is likely that
this requirement will be fulfi lled through both preliminary
self-study and previous course work.
In an attempt to ensure that this material has been thoroughly
covered prior to entering into course work a remote closed-book,
invigilated exam could be administered.
Course outline
This suggested curriculum contains material that can be covered in
18 hours. However, it can also serve as an outline for more comprehensive instruction.
I. Introduction
a.
Outline the goals and objectives of the course.
b.
Defi ne the differences between medical musculoskeletal USI
i.
ii.
iii.
iv.
II. Physics of sound
a.
The nature of ultrasound waves, including a discussion on
b.
The nature of an ultrasound echo, including a discussion on
(diagnosis of ligament, tendon, muscle structural pathology by
radiologists and sonographers) and rehabilitative musculoskeletal USI (applications that result in a physical diagnosis of the
size or movement characteristics of muscles and/or nerves in
relation to adjacent structures, or involve the use of USI as a
biofeedback tool by physiotherapists).
History of the use of USI in physiotherapy.
Scope of practice issues, including a model for communica-
tion with other health care professionals who employ
USI.
Current clinical uses of USI in physiotherapy (see the list
of current physiotherapy USI applications below).
Limitations to the use of USI in physiotherapy.
topics such as amplitude, frequency, wavelength, intensity,
power, propagation speed, pulsed ultrasound, attenuation,
absorption, refection, scattering, resolution and penetration.
topics such as the angle of incidence, impedance, refraction and
APPENDIX B: Minimum requirements for ultrasound imaging accreditation
the difference between a refl ector or a scatterer, as well as the
effects of different tissue densities.
III. Instrumentation
a. Transducers (construction, operation, focusing, types of arrays
and their uses, resolution).
b. Imaging instruments (components and their function as well as
brightness and motion display modes).
IV. Safety and risk of harm issues
a. Thermal considerations.
b. Mechanical considerations.
c. ALAR A (as low as reasonably achievable) principle, including
a discussion on how to minimize power output in favour of
higher gain settings.
d. Identifi cation of specifi c individuals or situations at higher risk
of harm.
159
e. Discussion of a generic plan of action and model of communi-
cation for incidences in which unusual structures are identifi ed
while performing an USI assessment of motor control.
V. Understanding static ultrasound images
a. 2-D representations of 3-D anatomical structures.
b. 2-D planes of view and motion.
c. Image modulation (near, far and total gain, brightness, focal
zones).
d.
Artefact (general defi nition, as well as the basic types, their
causes and implications).
e.
Specifi c tissue identifi cation (bone, fascia, fl uid, muscle, tendon
etc.).
VI. Indications for the use of USI in physiotherapy
a. Identifi cation of individuals with neuromuscular dysfunction
(particularly in the vertebral column).
b. A review of contemporary approaches regarding neuromuscular
control of the spine.
160
APPENDIX B: Minimum requirements for ultrasound imaging accreditation
c.
A review of the literature surrounding the topic of spinal pos-
tural control, including a review of the anatomy and activation
studies of the muscles responsible for postural control, respiration and continence.
VII. USI in the lumbopelvic region – assessment
a. Overview of the functions of ultrasound instrumentation
(transducer specifi cs, probe orientation, control buttons etc.).
b. Didactic sessions:
i.
Instruction in the generation of ultrasound images of the
abdominal wall, lumbar spine and pelvic fl oor.
ii.
Presentation of various normal and abnormal images, both
as static images and real-time video clips.
iii.
Interpretation of various normal and abnormal images from
the abdominal wall, lumbar spine and pelvic fl oor.
iv.
Demonstration of the uses of USI for measuring the
architectural features of muscle (depth, width, crosssectional area).
c.
Practical sessions:
i. Demonstration of techniques to generate images of the
abdominal wall, lumbar spine, and pelvic fl oor.
ii.
Practice aimed at generating images of the abdominal wall,
lumbar spine and pelvic fl oor.
iii.
Practice aimed at interpreting muscle and fascial echo-
genicity (limitations) and architectural delineations.
iv.
Practice aimed at interpreting images of load transfer
through the lumbopelvic region, abdominal wall, lumbar
spine and pelvic fl oor in both normal and abnormal
cohorts.
v. Practice aimed at interpreting images of preferential activa-
tion of specifi c deep system muscles (e.g. transversus
abdominis, the deep segmental fi bres of lumbar multifi dus
and the pelvic fl oor muscles), as well as their infl uence on
the fascial tissue into which they attach.
vi.
Practice aimed at measuring the architectural features of
muscle.
At present, the majority of USI applications of interest to the
rehabilitation professional centre around the lumbopelvic region.
However, as USI has the potential to be applied to many muscle