Dynamic thinking

Amid predictions ultrasound scanners will become as commonly used by clinicians as stethoscopes, Lisa Oxlade assesses opportunities and concerns

Christine Mallion is a passionate advocate of ultrasound imaging's potential as a core part of physiotherapists' toolkit. Director of the Cheshire physiotherapy centre, Altrincham, she uses ultrasound in a variety of ways: to look at soft tissue injuries, to monitor patients' progress, and also to give guided injections, using ultrasound to assist in placing needles more accurately. As she observes, there are a number of factors contributing to the opportunities for growth: machines becoming more affordable, technology improving and last but not least, physiotherapists' enthusiasm. She says: 'It is a fantastic way to augment your physiotherapy practice: you now have the opportunity to "look inside" and see what's going on... Physiotherapists will invent ways of using it that no one has thought of before. One of the beauties of it is that it is dynamic, so you can see things move, unlike other modalities.' Physiotherapist John Leddy, clinical specialist at the Royal Berkshire hospital, is also a qualified sonographer. He uses ultrasound to review patients' rotator cuff problems. He says: 'Ultrasound is particularly suited to assessing the morphology and behaviour of muscles, tendons, fascial planes and fluids along with their interaction with neighbouring structures.' Both Mr Leddy and Mrs Mallion stress ultrasound imaging is not a diagnostic tool, rather it is used to support a physiotherapist's clinical assessment.  Mrs Mallion says: 'As a physio you approach a patient first as a clinician, and get the clinical picture. Imaging can then confirm, or not, your clinical reasoning.' Mr Leddy notes the modality can help to pinpoint the accuracy of clinical assessment and inform the treatment pathway for individual patients. He adds: 'It is invaluable in the assessment of adhesions, subluxations and effusions, and has an obvious role in monitoring the response to treatment.' REASONS TO BE CAUTIOUS While ultrasound imaging looks set to be a growth area among physiotherapists, there are issues around professional boundaries and training that need to be addressed. When Mr Leddy realised the potential ultrasound imaging had to 'revolutionise [physiotherapy] practice by allowing us to make more accurate assessments of many structures and conditions, and provide more effective treatments that could be objectively assessed', he was keen to embrace the technology. However, access to training and ultrasound equipment proved a stumbling block. Unable in 2000 to find appropriate training while practising as a physio, Mr Leddy gave up his job to spend 18 months training to be a sonographer. He says: 'At the time, there was considerable resistance to a physiotherapist using ultrasound both from radiology and from my physiotherapy colleagues. It took considerable persistence and a willingness to work and train unpaid for 18 months even to get a training place.' This situation is changing, however. As Mr Leddy observes: 'Over the past few years there has been a realisation within radiology that ultrasound is no longer its preserve, and that it is in patients' interests that clinicians use ultrasound in their practice... The radiology world has accepted ultrasound will become a clinical skill used by other professions.' As he explains: 'Ninety per cent of what physios will do [with ultrasound] would not be part of the work done by radiologists anyway.' Jane Dixon, clinical lead for woman and child health at Peterborough District Hospital, has been using real-time, or dynamic ultrasound, for about five years to assess pelvic floor dysfunction problems. She is  clear about the need for appropriate ultrasound imaging training for physiotherapists and, with John Leddy and Christine Mallion, is part of the dynamic ultrasound group (see panel: Dynamic group leading the way). It isn't a case of wanting to stop physiotherapists using ultrasound, she says, but 'it would be very naïve of physios to think they are competent to use equipment if they have only done a one-day taster study day... The recognised sonographic bodies are at pains to highlight the need for adequate training, depending on your level of use.' Her feeling is that while 'ultrasound may ultimately change the face of physiotherapy assessments and treatments...it is vitally important physios understand the safety implications and precautions before they go blindly into thinking they are competent to practise'. A REHABILITATION TOOL The type of imaging Mrs Dixon employs, rehabilitative ultrasound, focuses on evaluating muscle and related soft-tissue morphology and function during physical activity. 'Real-time ultrasound allows me to evaluate the problem [pelvic floor dysfunction] more fully because you can see the effects, or non-effects, of muscle activity,' she explains. 'It supports palpation findings and allows the patient to see and understand their problem more fully.' More traditional methods, such as surface electromyography and manometry, will not distinguish between accurate and inaccurate muscle activity. Consequently, Mrs Dixon believes this use of ultrasound, in effect acting as a biofeedback tool, enables greater patient understanding of the situation, leading to greater treatment compliance. Maria Stokes, professor of neuromuscular rehabilitation at the University of Southampton, notes there is growing evidence that using ultrasound for biofeedback helps patients needing to exercise their back muscles, although further research is required to demonstrate the cost benefits and the impact of this on service delivery. She believes other areas of research should emerge as practical questions from clinicians using ultrasound. Prof Stokes stresses that introducing the use of dynamic ultrasound in physiotherapy practice is not only about training but also about respecting professional boundaries, working with the other professions involved, keeping them informed and ensuring training standards and practice guidelines remain appropriate. She also has advice for physios who may be thinking about using ultrasound (see panel: The considered approach). CSP professional adviser Leonie Dawson says while it is essential for physiotherapists to embrace new technology they need to 'ensure progress in application keeps step with research and does not move ahead before the evidence base is established'. She says the CSP would urge practitioners to ensure the training they receive 'is based on sound research and that they use ultrasound imaging to support clinical assessment and to provide biofeedback to aid rehabilitation'. Notwithstanding the cautions, and the planning and research that still needs to be done, Mr Leddy is delighted to be in the vanguard of what he feels is an unstoppable movement for physios to embrace the use of ultrasound. He says: 'Within as little as 10 years it is likely ultrasound scanners will be seen in the same light as a stethoscope is now – as a basic tool and skill of almost every group within medicine.' The considered approachInterested in using ultrasound? – then read on
  • think carefully about what you might want to use ultrasound  for.  If you want to use it for more than one type of assessment, go on an appropriate training course for each application
  • start with an introductory course focusing on the use of ultrasound you are interested in
  • do some research before buying an ultrasound machine to see which one best fits your needs
Ultrasound's potential Among the current and potential uses of ultrasound in physiotherapy are:
  • rehabilitation: real-time ultrasound imaging is used to evaluate and quantify muscle activity during specific exercises and functional activities, and to provide biofeedback to patients. These techniques are most often applied to the deep abdominal and lumbar musculature
  • women's health: transperineal and transabdominal dynamic assessment of pelvic floor muscles and their supporting function
  • orthopaedics/rheumatology: to assess the morphology and behaviour of muscles, tendons, fascial planes and fluids along with their interaction with neighbouring structures
  • injections: image guidance for many therapeutic soft tissue injections    •  paediatrics: for guiding Botox injections
  • in intensive therapy to assess the chest wall
  • with haemophiliacs to monitor bleeds
Dynamic group leading the waySet up by physios already involved with using or researching ultrasound, the dynamic ultrasound group's purpose is to promote the safe and effective use of ultrasound imaging in physiotherapy by providing education and guidance. Guidelines outlining scope of practice, training pathways and competencies for physiotherapists have been drafted and sent to interested parties for comment and discussion. The training pathway under proposal for physiotherapy applications is three-tiered:
  • preliminary, where physios are safe to scan after completing an appropriate one or two-day introductory course
  • basic, where appropriate images can be reliably acquired
  • advanced, which corresponds to accurate, reliable acquisition and interpretation of ultrasound images in complex clinical situations
Says chair John Leddy: 'Within DUG we have several members who are undergoing sonographer training programmes related specifically to the field in which they practise, for example, musculoskeletal and gynaecology. But for many physiotherapy applications, this level of training is not required, and we are in the consultation stage of drafting guidelines and training pathways appropriate for physiotherapists in general.' For more information on DUG visit www.dynamicultrasound.org

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