ABOUT REAL TIME ULTRASOUND
SCOPE OF PRACTICE ISSUES
Scope of Practice Overview
The scope of the physiotherapy profession encompasses the ability to assess and treat the neuromusculoskeletal (muscles, ligaments, joints, fascia, and their neurological control) system in individuals that are impaired by injury or disease, for pain management and for the promotion of mobility and health. In the last decade there has been considerable growth in the knowledge base that the physiotherapy profession is based upon, and in particular our understanding of the neuromusculoskeletal system in health, as well as how it is altered in dysfunction. Specifically there is substantial evidence which supports that the primary impairment of the neuromusculoskeletal system in persons with neck, thoracic or lumbopelvic regional pain and dysfunction is not one of strength or functional capacity, rather of altered neuromuscular (motor) control of the deep and superficial muscle groups in the region. From the research several tools have emerged that aid physiotherapists in the detection and treatment of this altered motor control, specifically ultrasound imaging.
Ultrasound imaging has been established as a safe, cost effective and accessible method for visualizing and measuring the deep muscles of the trunk. The value of ultrasound imaging for physiotherapy is that it allows for dynamic study (real-time images) of deep muscle groups as they contract. Consequently the complementary use of ultrasound imaging can enhance the clinical analysis of these muscles and has been advocated by various authors. In addition to its safety and accessibility record it is imperative to note that ultrasound imaging has withstood scientific rigor and has been shown to be valid and reliable when applied in a thoughtful manner.
Ultrasound imaging must be seen only as a tool, it should be viewed in the same light as a stethoscope. A variety of health care professionals employ a stethoscope during their daily practice. Depending on the information sought, their unique area of training and level of knowledge the tool is used differently. Accordingly, it is important to define the appropriate use of ultrasound imaging by physiotherapists. It is suggested that the uses of ultrasound imaging by physiotherapists include applications that result in a physical diagnosis of the size or movement characteristics of muscles and / or nerves in relation to adjacent structures. It is not within the scope of practice of physiotherapists to make a medical diagnosis. It is imperative that all physiotherapists that are accredited to use the technology are aware of this scope and adhere to it.
In the current environment of evidence based practice and fiscal accountability it is imperative that physiotherapists be allowed the tools to optimize the effectiveness of their interventions and implement the growing knowledge base.
Although the potential for harm exists when human tissue is exposed to any energy it is important to understand that due to the extensive research and development that has gone into ultrasound technology in the last 90 years, and the level of federal regulation that the technology has undergone, it has an exemplary safety record. Consequently safety concerns are related more to the lack of standardized training rather than to inherent risks associated with the devices themselves.
It is important that professionals utilizing ultrasound are aware of the basis for potential harm and use common sense in determining the suitability of the client / patient and type of scan to perform. The safety concerns related to the use of RTUS by physiotherapists are addressed through the introduction and enforcement of clinical standards of practice, the implementation of sound accreditation processes and regular (yearly) maintenance and calibration of the imaging devices.
Clinical Standards for the Application of RTUS in Physiotherapy
Clinical practice standards reflect the minimum level of professional service provided by a physiotherapist with regard to a particular application or technique. The suggested standards of practice regarding the use of real time ultrasound imaging by physiotherapists are:
- All ultrasound imaging equipment must be CSA / USDA, approved and properly (yearly), maintained.
- Informed consent must be received and charted by the therapist in the physiotherapy file before an ultrasound imaging assessment or treatment is begun. Patients must be informed that consent can be withdrawn at anytime.
- Physiotherapists who utilize real time ultrasound imaging in their clinical practice have successfully completed a specified accreditation process for real time ultrasound imaging. This accreditation process should be outlined by the licensing body of the physiotherapists jurisdiction. Physiotherapists who have not taken the appropriate education and examinations should not be permitted to utilize ultrasound imaging in their practice.
- A comprehensive physiotherapy regime for assessment and treatment augmented by real time ultrasound imaging consists of;
- A preliminary physical assessment to determine if real time ultrasound imaging evaluation is appropriate. This includes a history, scanning and biomechanical examination.
- Ultrasound imaging assessment
- Education and lifestyle modification
- Treatment augmented by biofeedback provided by real time ultrasound imaging.
- Home exercise regime
RTUS Imaging Accreditation Process
Physiotherapists who wish to utilize real time ultrasound imaging in their practice require specialized knowledge and skills which are not traditionally acquired in their post-secondary programs. As such this section is devoted to topics related to the format, curriculum and instruction of a generic accreditation process.
Suggested accreditation process format:
The use of real time ultrasound imaging (RTUS) for the assessment and treatment of neuromuscular control by physiotherapists is in its infancy both in the world and more specifically in North America. Consequently it is important that the credentialing mechanisms be rigorous. Physiotherapists and their clients must insist upon the highest standards of quality control and self-policing.
The skills involved in all clinical applications of ultrasound imaging is twofold; image generation, (developing the ability to get a clear image on the screen) and image interpretation. The obvious difference between the traditional medical applications and those in the physiotherapy field is that the medical applications generally involve generation and interpretation of static images, where as in the physiotherapy field the examiner is primarily viewing dynamic images. Consequently the challenge with physiotherapy applications is image interpretation which requires substantial background theoretical knowledge and repeated exposure to the multitude of possibilities. Hence an accreditation process must take this into consideration.
It is recommended that a physiotherapist attain certification before being allowed to perform RTUS without supervision on patients, and before documenting their RTUS results in a physical therapy chart. To become a certified practitioner it is suggesting that after having taken an introductory RTUS course, (16hrs), a physiotherapist must complete and interpret ten scans of four different muscle groups. All of these scans must be dynamic and two must involve a static measurement of muscle size, (one linear and one circumferential). These scans must be supervised and reviewed by a senior certified practitioner (i.e. an instructor).
Suggested accreditation process curriculum - course outline
The purpose of this course is to provide physiotherapists with the basic knowledge and skills required for the safe integration of ultrasound imaging into clinical or research practices in a two day (16 hr) format. It is acknowledged that this technology has the potential to be applied to imaging many muscle groups throughout the body however the example of the lumbopelvic region has been used here. Imaging of muscle and motor control is generic in some regards however, all scans require very specific anatomical knowledge. This accreditation process is aimed at providing only the generic principles from which clinicians can base further training upon.
- Pre-reading - to be completed prior to the course.
- Selected articles from peer reviewed journals and texts that cover topics such as the technical, safety and practical aspects of ultrasound imaging.
- Goals and objectives of the course
- Diagnostic vs. Therapeutic Ultrasound
- Physiotherapy and RTUS
- History of the use of RTUS in physiotherapy
- Scope of practice issues
- Uses of RTUS in physiotherapy
- Limitations to the use of RTUS in physiotherapy
- Nature of US waves
- Image generation
- Effects of different tissue densities
- Modes of transmission, (brightness and motion modes).
- Frequency, resolution, and penetration
- 2-D representations of 3-D structures
- Planes of view, motion
- Image modulation
- Tissue identification, (bone, fascia, fluid, muscle, tendon etc.).
- Thermal considerations
- Mechanical considerations
- ALARA (As low as reasonably achievable) principle
- Identification of specific individuals or situations at higher risk of harm
- Identification of individuals with neuromuscular dysfunction (particularly in the vertebral column).
- Overview of contemporary approaches regarding neuromuscular control of the spine.
- Discussion of the literature surrounding the topic of spinal segmental stabilization. Including a review of the anatomy and activation studies of the muscles responsible for segmental stabilization.
- Overview of the functions of the Ultrasound Machine being used, (transducer specifics, probe orientation, control buttons etc).
- Didactic sessions,
- Instruction in the generation of RTUS images of the abdominal wall, lumbar spine and pelvic floor.
- Presentation of various normal and abnormal images, both as static images and a movie clips.
- Interpretation of various normal and abnormal images from the abdominal wall, lumbar spine and pelvic floor.
- Demonstration of the uses of RTUS for measuring muscle girth, mass.
- Practical sessions,
- Demonstration of technique to generate images of the abdominal wall, lumbar spine, and pelvic floor
- Practice generating images of the abdominal wall, lumbar spine and pelvic floor.
- Practice interpreting images of load transfer through the lumbo-pelvic region, abdominal wall, lumbar spine and pelvic floor in both normals and abnormals.
- Practice measuring muscle girth and volume with the ultrasound device.
- Final evaluation will involve instructor supervision and review of ten scans, and their interpretation, of four different muscle groups. All of the scans must be dynamic and two must involve a static measurement of muscle size, (one linear and one circumferential). This evaluation will take place during the last several hours of the course.