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APPENDIX C: Treatment of lumbopelvic dysfunction: a case presentation
CONCLUSION
171
description of this later stage of rehabilitation and the reader is
referred elsewhere (Lee 2004, Richardson et al 2004). Although
the focus of this later phase is the coordination of the deep and
superfi cial muscles into functional activities, it is important that the
subtle isolated deep muscle system contraction be continued, and
revisited at each progression. This will assist the patient to prevent
prematurely reverting to a bracing or rigidity motor control strategy
when encountering slightly higher loads. The underlying concept
is to encourage the muscles (both deep and superfi cial) to contract
at the correct time, to the appropriate magnitude and duration for
the task, and then relax to an appropriate level once the demand is
removed. Numerous techniques can be used to implement this
treatment strategy; those presented here are just one example, as it
is not the technique that is important, rather the order and specifi city with which each issue is addressed.
The appropriate use of USI can enhance the rehabilitation of
lumbopelvic dysfunction. The challenge for the clinician is to
determine when and in what form it should be integrated into
the rehabilitation process. By presenting a practical illustration of
the use of USI in the management of a specifi c patient it is hoped
that the principles outlined in Chapter 5 take on greater meaning,
and ultimately that clinicians will be encouraged to integrate USI
into their practice.
APPENDIX D
Glossary
Absorption – In the context of ultra-
sound imaging, absorption refers to the
transfer of energy from a sound wave to
the surrounding tissues.
Acoustic shadowing – Refers to the
reduction of the sound wave echo from
structures that lie behind a strongly
refl ecting or attenuating structure
(e.g. bone).
ALARA – An acronym for ‘as low as
reasonably achievable’. This is a principle governing the prudent use of
ultrasound imaging which encourages
gathering the most amount of information with the least amount of exposure.
Specifi cally, this involves reducing
exposure times, as well as lowering
power output in favour of increased
gain settings.
Anechoic – A material that does not
produce echoes (e.g. ultrasound waves
are allowed to pass through it). The
more anechoic a structure or substance
is, the darker it will appear within an
ultrasound image.
Artefact – Refers to incorrect represen-
tations of anatomy or motion (e.g.
situations that result in structures that
are not real, missing, improperly
located, or of inaccurate brightness,
shape or size). Examples include acoustic
shadowing, edge shadowing and
enhancement.
Attenuation – Defi ned as the reduction
in the intensity or amplitude of a sound
wave. Attenuation is expressed in
decibels (dB) and it is caused by
absorption, scattering and refl ection of
the sound wave as it travels. As attenuation increases, penetration decreases.
B mode – Brightness or brilliance mode.
Capnograph – An instrument that
collects and analyses the carbon dioxide
content in expired air.
Cavitation – Refers to the production
and behaviour of gas bubbles within a
liquid when exposed to a sound wave.
This behaviour can be variable (e.g.
oscillation or collapse) and depends
upon factors such as the size of the
cavity, and the nature of the immediate
environment (Nyborg 2001).
Cine-loop – sequential display of all the
ultrasound frames stored in the memory
of an ultrasound unit at a controllable
frame rate (Kremkau 2002).
Diagnostic ultrasound – Per tains to the
use of ultrasound imaging to establish
the nature of an injury or disease
172
APPENDIX D: Glossary
173
process. Diagnostic ultrasound units
produce sound waves that enter the
body and refl ect off tissue interfaces.
These refl ections are subsequently
collected and used to generate an image.
Echogenic – A structure or material that
produces echoes (e.g. refl ection of
ultrasound waves). The more echogenic
a structure or substance is, the whiter
it will appear within an ultrasound
image.
Edge shadowing – A type of artefact in
which there is a reduction in the sound
wave echo from a structure that is
located in the shadow generated when a
sound wave bends around a fl uid-fi lled
structure (e.g. bladder).
Enhancement – A type of artefact in
which there is a strengthening of a
sound wave echo distal to a weakly
attenuating structure (e.g. a fl uid-fi lled
organ such as the bladder) (Kremkau
2002).
Far-fi eld – The bottom half of the
ultrasound screen, which represents that
part of the body furthest from the
ultrasound probe.
Feedback – Information provided by the
various sensory organs (eyes, ears, nose,
mouth, proprioceptive organs, thermal
receptors etc.) before, during and after a
task (Salmoni et al 1984).
Force closure – Refers to compression
produced by the coordinated efforts of
muscle, ligament, and fascia to augment
the structure, orientation, and shape of a
joint so that optimal load transfer can
occur (Vleeming et al 1997, Lee 2004).
Form closure – Refers to how a joint’s
structure, orientation and shape contribute to load transfer (Vleeming et al
1997).
Frequency – The number of oscillations
a molecule or a sound wave undergoes
in one second. Frequency is expressed
in units called hertz (Hz). 1 Hz = 1
cycle per second, 1 kHz = 10 00 c ycles
per second, and 1 MHz = 1,000,000
cycles per second.
Gain – In the context of ultrasound
imaging, gain refers to the amount of
amplifi cation (expressed in decibels, dB)
imparted to the electrical signal (which
represents the echo from the tissues)
coming from the transducer. The degree
of amplifi cation can be manipulated by
the operator.
Global system – An anatomical term
used to group muscles that are superfi cially placed. In the lumbopelvic region
these muscles are torque producing and
are responsible for controlling spinal
orientation, as well as actively transferring load between the thoracic cage and
pelvis (Bergmark 1989).
Hyperechoic – A structure or substance
that is more echogenic, therefore whiter
and brighter on the ultrasound screen,
than surrounding tissue. The surface of
bone and dense fascia are examples of
hyperechoic media.
Hypocapnia – Defi ned as a reduction or
defi ciency in the arterial partial pressure
of carbon dioxide. It is a result of
behavioural, physical and/or environmental factors that lead to overbreathing, or ventilation in excess of metabolic
need. The exaggerated respiratory
response results in the elimination of
carbon dioxide in volumes greater than
it is being produced by the body and
ultimately its defi ciency. It is associated
with respiratory alkalosis and a wide
variety of symptoms, most notably
paresthesia, increased resting muscle
tone, dizziness, fatigue and chest pain
(Gardner 1996).
Hypoechoic – A structure or substance
that is less echogenic, therefore darker
on the ultrasound screen, than surrounding tissue. Fluids such as blood
and urine are examples of hypoechoic
media.
Impedance – The impedance of a
medium is equal to the density of that
174
APPENDIX D: Glossary
medium multiplied by its propagation
speed. It is measured in rayls. The
impedance of a medium increases if
either the density or the propagation
speed increase (Kremkau 2002).
Incidence angle – The angle between
the sound coming from the transducer
(incident sound) and a line perpendicular to the boundary of a medium
(Kremkau 2002).
Instrument – In the context of ultra-
sound imaging, this is an electronic
system that electrically drives a transducer, receives returning echoes, and
presents them on a visual display as an
anatomical image (Kremkau 2002).
Intensity – The rate at which energy is
delivered per unit area. The intensity of
an ultrasound wave is determined by
the total power output of the probe
(watts) divided by its area (cm
expressed in units of milliwatts per
square centimetre (mW/cm
Isoechoic – A structure or substance that
2
).
2
) and is
is just as echogenic as, and therefore
indistinguishable from, surrounding
tissue.
Knowledge of performance – Informa-
tion about the characteristics of a motor
task (e.g. the task was performed too
quickly or with too great of an effort)
(Salmoni et al 1984).
Knowledge of results – Information
provided after attempting a motor
behaviour that tells the individual of
their success in meeting a specifi c goal.
Knowledge of results is in addition to
the sources of feedback that are naturally available when an attempt at a
motor task is made and is a verbal
statement about the outcome of an
attempt (successful vs. unsuccessful) as
opposed to characteristics about the
actual task (Salmoni et al 1984).
Linea alba – An anatomical term (‘the
white line’) which refers to the vertical
tendinous medial line seen along the
anterior abdominal wall extending from
the superior aspect of the symphysis
pubis to the xyphoid. It is located
between the inner or medial borders of
the rectus abdominis muscles, and is
formed by the blending of the aponeuroses of the oblique and transversus
abdominal muscles (Williams 1995).
Linea semilunaris – An anatomical term
(‘the half curved line’) which refers to
the two vertical curved tendinous lines
seen along the lateral aspect of the
rectus abdominis muscles. Each line
extends from the ninth rib to the pubic
spine and is formed by the aponeuroses
of the internal oblique at its point of
division to enclose the rectus abdominis
muscle. This aponeuroses is reinforced
anteriorly by the fascia of the external
oblique and posteriorly by the fascia of
the transversus abdominis (Williams
1995).
Load transfer – Refers to the ability of
a region of the body to transfer the
loads that it is characteristically exposed
to. For example, a primar y function of
the lumbopelvic region is to transfer the
loads generated by body weight and
gravity during standing, walking and
sitting. How well the load is transferred
dictates how effi cient the region can
function (Lee 2004).
Local system – An anatomical term
used to describe a group of muscles
which have their origin or insertion at
the vertebrae (Bergmark 1989). These
muscles are both anatomically and
neurophysiologically suited to control
intervertebral and intra-pelvic segmental
mobility.
M mode – Motion mode, sometimes
referred to as time-motion (TM) mode.
Motor control – Refers to patterning of
muscle activation. Specifi cally, the
timing, magnitude, sequence and
relaxation of muscle activation.
Near-fi eld – The top half of the
ultrasound screen, which represents that
APPENDIX D: Glossary
175
part of the body closest to the ultrasound probe.
Operating frequency – The preferred
(maximum effi ciency) frequency of
operation of a transducer (Kremkau
2002). The operating frequency can also
be referred to as the resonance or main
frequency.
Penetration – In the context of ultra-
sound imaging, penetration refers to the
ability of sound to travel. Penetration is
dependent upon the strength (intensity)
and frequency of the sound wave as well
as the compressibilit y of the medium
that it travels through. For descriptive
purposes, penetration refers to image
depth.
Piezoelectric effect – Refers to a
phenomenon in which some materials
(ceramic, quartz etc.) produce a voltage
or electrical current when deformed by
an applied pressure such as sound
(Kremkau 2002).
Pixel – A contraction of ‘picture
element’. A pixel refers to the smallest
unit of a digitized, two dimensional
image. A pixel can be described by its
location (a set of x and y coordinates),
as well as its brightness.
Probe – See transducer assembly.
Real-time ultrasound imaging (RTUS) –
Refers to the rapid sequential display of
ultrasound images resulting in a moving
presentation (Kremkau 2002).
Refl ection – As a sound wave propagates
it breaks up (fractures) and loses its
energy. Refl ection is one form of
fraction which refers to the portion of
the sound wave that is refl ected back
towards the sound wave’s original
source. This refl ected energy is what is
captured and then used to generate an
ultrasound image.
Refraction – Refers to the change in
direction of a wave when it crosses a
boundary. It comes from the modifi ca-
tion of a Latin term meaning to turn
aside.
Reliability (consistency) – Refers to the
degree of stability of a measurement
when it is repeated under identical
conditions, or the degree to which a
measure is free from random error.
Inter-rater reliability refers to the degree
of agreement between identical measurements taken by different individuals,
while intra-rater reliability refers to the
agreement of identical measurements
taken by one individual at different
points in time.
Resolution – The ability of an instru-
ment to show detail.
Scan – Ultrasound lingo for a sono-
graphic examination. Confusion can
arise if used out of context as one may
wonder whether a CT scan is being
referred to as opposed to an ultrasound
examination (Kremkau 2002).
Scatter – Describes the generation of
secondary waves (fractions) in response
to the primary sound wave encountering a rough surface or heterogeneous
media. Scattering is a type of artefact
and is often referred to as diffusion.
Sonography – The term used to describe
imaging resulting from ultrasound. Latin
sonus (sound) and Greek graphien (to
write).
Sound – Mechanical energy that
propagates through air, water or any
other matter in an orderly rhythmic
fashion as determined by the molecular
make-up of the transmitting medium.
Stress incontinence – The self-report or
observation of urine leakage with
physical exertion (Hay-Smith et al
2001).
Therapeutic ultrasound – Pert ains to the
use of ultrasound for therapeutic or
healing purposes. In therapeutic applications the mechanical and thermal effects
of ultrasound on tissues are employed to
promote changes within those tissues.
176
APPENDIX D: Glossary
Unlike diagnostic applications, images of
the tissues are not generated.
Tran sd uce r – Any device that converts
one form of energy into another. The
piezoelectric crystal is a transducer that
converts electrical energy into sound
energy and vice versa.
Transducer assembly (probe) – Consists
of the transducer elements, their
associated casing and dampening
material.
Ultrasound – Sound with a frequency
greater than what can be perceived
by the human auditory system
(>20,000 Hz).
Urge incontinence – The self-report or
observation of involuntary urine leakage
associated with a sudden, strong desire
to void (Hay-Smith et al 2001).
Validity – Refers to the degree to which
a test or procedure measures what it
claims to measure.
Velocity – In the context of USI,
velocity refers to the speed at which the
vibratory motion is transmitted or
propagated through a material.
Index
Page numbers marked with an asterisk* refer
to entr ies in the Glossar y. Those in bold refer
to illustrations.
A
Abdominal bulging, 86–87
Abdominal fascia, midline see Midline
abdominal fascia
Abdominal gas, 8–9
Abdominal hernia, 58
Abdominal tr igger points, 80, 95, 128
Abdominal wall, lateral see lateral abdominal
wall
Absorption, 3–4, 172*
Accreditation, 22, 25, 26, 156–161
Acoustic shadowing, 10, 11, 172*
edge shadowing, 10, 12, 173*
by ribs, 6(b)
Acoustic window, 8, 38, 117
Adams, J A, 123
Adipose tissue, 64
see also fat
ALARA (as low as reasonably achievable)
principle, 16, 25–26, 172*
American Institute of Ultrasound in Medicine
(AIUM), 23, 24
Anderson, J R, 123
Animal testing, 23
Anter ior fascial anchor, 59
Anterior medial border see linea semilunaris
Aorta, 8(b)
Artefact, 10, 172*
ASLR (active straight leg raise), 52, 64, 83,
84, 86, 125
USI of lateral abdominal wall during, 54
USI of midline abdominal fascia during, 64
USI of the bladder during, 83–87
Assessment outline, 151–155
Attenuation, 3–4, 172*
in bone, 5
thermal effects of, 23–24
B
B mode (br ightness/bri lliance mode), 18–20,
172 *
Biofeedback, 125
Bladder
artefacts produced by, 10, 12
asymmetry of, 79–83
cranioventral displacement, 88, 91, 93
effect of urine on ultrasound image, 8
image depth for, 18
measurement of bladder wall motion,
115 –118
resting state, 79–83
Bladder/pelvic fl oor imaging
defi nition of an isolated pelvic fl oor muscle
contraction, 88–91
impact of PFM contraction on bladder,
118
preferential activation of pelvic fl oor
muscles, 87–93
qualitative image interpretation, 77–93,
94
resting state of bladder, 79–83
sagitta l application, 36–39, 85, 86, 88–89,
92, 94(a)
tonic activity and positiona l bladder
stability during spinal loading, 83–87
transverse application, 39–41, 80, 81–82,
85, 88, 90, 94(b)
USI assessment outline, 151–152
Blood, 5, 7–8
Bø, K et al, 116
17717 7
178
Index
Bone
attenuation in, 5
conversion of ultrasound energy to heat by,
16, 23, 24
as hyperechoic medium, 5
shadowing effects of, 6(b), 10, 11
speed of sound through, 3
Border defi nition, 99
Brightness control, 18
C
Catheters, 116
Caudodorsal motion of the bladder, 86, 93,
94
Cavitation, 24, 172*
Chest pain, 79
Christensen, L L et al, 88, 115
Clinical cues, to elicit preferential activation of
deep muscle system, 56, 73, 88, 137
Clinical standards for application of USI in
physiotherapy, 26
College of Physical Therapists of British
Colombia accreditation
recommendations, 157–161
Contrast control, 18
Coughing, 55, 64, 83, 85–86
Coupling media, 5
see also gel
Cues, to elicit preferential activation of deep
muscle system, 56, 73, 88, 137
Cysts, 81
D
dMF (deep segmental fi bres of lumbar
multifi dus ), 70–71, 72–77, 136
co-contraction with PFM, 90–91
palpation, 76
Depth control, 17–18
adjustments, 31, 33–34, 36
Diagnostic ultrasound imaging devices, 10–14
see also imaging units
Diaphragm, 6(b)
Diastasis, 58, 66
Dietz, H P and Wilson, P D, 116
E
Echoes
impedance and the intensity of, 5
production of, 2, 4
refl ection and, 3–10
Echogenicity, 7, 64, 69, 173*
Edge shadowing, 10, 12, 173*
Enhancement, 10, 13, 173*
Environment for treatment, 129, 133–134
EO (external oblique), 30, 32, 47, 58
F
Fascia
fascial lengthening and disruption, 58–59
as hyperechoic medium, 5
midline abdominal fascia see midline
abdominal fascia
muscle and fascia layers of lateral abdominal
wall, 7
Fat
scattering effect of, 9, 64
speed of sound through, 3
Fatty atrophy, 7, 69
Feedback in modifying motor response,
125–127, 136, 137, 173*
interm ittent remova l of, 138–139
Fibroids, 81
Fitts, P M, 123
Fluid
cavitation in, 24
as hypoechoic medium, 7–8
Foam, 101
Force closure of lumbopelvic region, 58, 61,
76, 91, 93, 95, 173*
Frequency, 3, 173*
attenuation and, 4
see also operating frequency
G
Gain control, 18, 99, 100, 173*
adjustments, 31, 34, 36
Gas, abdominal, 8–9
Gaseous contrast media, 25
Gel, 5, 31, 33, 39, 41
Generation of ultrasound waves, 1–2
Goniometer s, 99, 100, 103, 107, 117
H
Haemorrhaging, ultrasonic, 24
Health and safety
clinical standards for application of USI in
physiotherapy, 26
exposure to ultrasound, 16, 22–25
safety guidelines, 25–26
Heat production, 3
thermal effects of ultrasound exposure, 16,
23–24
Hernia, 58
Hides, J A et al, 68
Hodges, P W and Richardson, 53
Hodges, P W et al, 47, 52
Index
179
Hyperechoic media, 5, 173*
Hypertonicity, 48, 49, 68, 79, 80(a), 81
as contraindication for muscle retraining,
122
reduction with use of RTUS, 127–133
sym metrical resting hypertonicity of PFM,
82(b), 91
Hypocapnia, 50, 173*
Hypoechoic media, 7–8, 173*
I
IAP (intra-abdominal pressure), 55, 64, 66, 83,
87, 91, 93
repetitive use of high IAP strategies, 63
Image generation
background to use in assessment of
myofacial system, 27–29
of bladder/pelvic fl oor (sagittal application),
36–39
of bladder/pelvic fl oor (transverse
application), 39–41
of lateral abdominal wal l musculature,
29, 30, 31
of lumbar multifi dus (sagittal application),
33, 34
of lumbar multifi dus (transverse
application), 34–36
of midline abdominal fascia, 31–33
ultrasound probe practicalities, 42–44
ultrasound unit orientation, 42, 43
Image interpretation, qualitative
of bladder/pelvic fl oor muscles, 77–93, 94
of internal oblique and transversus
abdominis, 47–63
of lumbar multifi dus, 66–74, 75, 76–77
of midline abdominal fascia, 63–66, 67
need for, 45–46
professional competency for, 96
Image interpretation, quantitative
measurement see measurement
methodological considerations, 97–101, 119
Image resolution, 4
Imaging units
construction, 10–16
depth control, 17–18
display screen controls, 18
gain control, 18, 99, 10 0, 173*
generation of pulses of ultrasound waves, 2
internal calipers used for measurement, 105,
107–108, 109, 112
modes of display, 18–20
orientation, 42, 43
power control, 16
working assumptions in design of, 9–10
Impedance, 5, 173–174*
Incontinence, 81, 88, 93, 95
Infraspinatus muscle, 69
Instrumentation
apparatus see imaging units
defi nition of instrument, 174*
for image generation of latera l abdom inal
wall musculature, 29
for image generation of midline abdominal
fascia, 31
for sagittal imaging of bladder/pelvic fl oor,
36–37
for sagittal imaging of lumbar multifi dus, 33
for transverse imaging of bladder/pelvic
fl oor, 39
for transverse imaging of lumbar multifi dus,
34
Intensity of ultrasound beam, 2, 174*
Internal oblique see IO
Intra-abdominal pressure see IAP
Inward probe pressure, 31, 33, 40– 41, 55, 99
IO (internal oblique), 30
architectural fl uctuations during resting
respiration, 50, 51
depth measurement, 102–103, 104
hyperactivity, 60
hypertonicity, 49
tonic activity with spinal loading, 52–55
TrA contraction and, 56 –58, 59, 60, 61–63
Ipsilateral sacroiliac joint, 81
K
Kinaesthetic facilitation
of abdominal wall relaxation, 130, 131
for activating and coordinating TrA, 135,
136
KP (knowledge of performance), 126, 129,
134, 136, 174*
KR (knowledge of results), 126–127, 129, 134,
136, 174*
Kremkau, F W, 10
L
Lateral abdominal wall
image generation, 29, 30, 31
image interpretation, qualitative, 47–63
measurement, 101–106
muscle and fascia layers, 7
resting state, 48, 49, 152
USI assessment outline, 152–154
scattering effects in, 9
use of RTUS to reduce hypertonicity of,
129–133
see also EO (external oblique); IO (internal
oblique); TrA (transversus abdominis)
180
Index
Lateral corseting, 48, 49, 51, 57
LBP (low-back pain), 48, 53, 68, 71
related alteration of involuntary motor
control not shown to correlate to
inability to preferentially activate
muscles, 55–56, 72, 87
Limb motion, 52–55, 70–72, 83–87
full relaxation following, 112, 115
measures to prevent movement of probe
during, 101
see also ASLR; Modifi ed active leg raise
Linea a lba, 31, 32, 58, 63– 64, 174*
gain manipulation of image, 100
of a multiparous, non-obese female, 67(b)
of a nulliparous, non-obese female, 67(a)
study of width, 66
see also midline abdominal fascia
Linea semilunaris, 29, 48, 58, 59, 62, 174*
Load transfer, 64–66, 174*
see also spinal loading
LPD (lumbopelvic dysfunction) management
see RTUS (real-time ultrasound
imaging) treatment applications
Lumbar erector spinae, 109–111, 113(a)
Lumbar multifi dus
cross-sectional area/circumference (CSA)
measurement, 112–115
depth measurement, 109–111
dMF preferential activation, 72–77
dMF tonic activity, 70–71
measurement, 108–115
qualitative image interpretation, 66–74, 75,
76–7 7
resting state, 68–69, 75(a)
sagittal application, 33, 34, 72, 74, 75
tonic activity with spinal loading, 70–72
transverse application, 34–36
USI assessment outline, 154–155
width measurement, 111–112, 113(b)
Lumbar vertebral column, 6(a)
Lumbopelvic dysfunction management see
RTUS (real-time ultrasound imaging)
treatment applications
Lumbosacral fl exion, 63
Lung tissue, 24, 25
M
M mode (motion mode), 18–20, 174*
Magnetic resonance imaging (MRI), 69, 115–116
McMeeken, J M et al, 47
Measurement
analysis and reporting, 101
of bladder wall motion, 115–118
of lateral abdominal wal l muscles, 101–106
of lumbar multifi dus, 108–115
measurement site, 98–99
methodological considerations, 97–101,
119
of midline abdominal fascia, 106–108
props, 99, 109
repeated measurement, 99–101
Midline abdominal fascia
image generation, 31–33
mea surement, 106–10 8
qualitative image interpretation, 63–64,
65, 66
response to load, 64–66
resting state, 64
see also linea alba
Modifi ed active leg raise, 52, 53, 64, 85
Modulated muscular contractions, 50
Motor control, 48, 55–56, 72–73, 174*
positional bladder stability and, 83
retraining see motor learning, use of RTUS
in
Motor learning, use of RTUS in
facilitating muscle activity, 133–140
reducing hypertonicity, 127–133
staged model framework for, 123–127
MRI (magnetic resonance imaging), 69,
115 –116
Multifi dus see lumbar multifi dus
Muscle
appearance in ultrasound image, 5–7
atrophy, 7, 69, 95
contractions and architectural change, 47
control see motor control; Motor learning,
use of RTUS in
coordinated muscle effort, 121–123 see also
motor control; Motor learning, use of
RTUS in
deep/local system, 27–28, 56, 72 see also
dMF; Pelvic fl oor; TrA
defi nition of borders, 99
echogenicity, 7, 64, 69
facilitating muscle activity with use of
RTUS, 133–140
and fascia layers of lateral abdominal wal l,
7 see also EO (external oblique); IO
(internal oblique); TrA (transversus
abdominis)
hyperactivity, 50, 55, 60, 72, 75(b), 127
hypertonicity see hypertonicity
hypoactivity, 81, 91, 133
image generation of lateral abdominal wall
musculature, 29, 30, 31
measurement see measurement
speed of sound through, 3
Myofascial suppor t loss, 81