Volume 32, Issue 1 (3-2025)
RJMS 2025, 32(1): 1-13 |
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ShahAli S, Dadgoo M, Shahabi S. Applications of Ultrasound Imaging in Physiotherapy: A Narrative Review. RJMS 2025; 32 (1) :1-13
URL: http://rjms.iums.ac.ir/article-1-9077-en.html
URL: http://rjms.iums.ac.ir/article-1-9077-en.html
1- Associate Professor, Iranian Center of Excellence in Physiotherapy, Rehabilitation Research Center, Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran , shabnamshahali@yahoo.com
2- Professor, Iranian Center of Excellence in Physiotherapy, Rehabilitation Research Center, Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
3- Assistance Professor, Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
2- Professor, Iranian Center of Excellence in Physiotherapy, Rehabilitation Research Center, Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
3- Assistance Professor, Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
Abstract: (329 Views)
Background & Aims: The use of ultrasound imaging has expanded considerably in recent decades, primarily due to its distinct advantages over other diagnostic modalities, including cost-effectiveness, portability, non-invasiveness, and the ability to provide real-time imaging across a broad spectrum of patient populations. The application of ultrasound imaging in rehabilitation, referred to as rehabilitative ultrasound imaging, originated with its use in evaluating tissue morphology rather than detecting pathological abnormalities (1). This technique was developed in the 1980s and continued to evolve over subsequent decades, culminating in the first International Symposium on rehabilitative ultrasound imaging held in 2006 in San Antonio, Texas (2, 3). The second symposium, conducted in Madrid in 2016, demonstrated a substantial expansion in the application of ultrasound within physiotherapy practice (4).
In recent years, ultrasound imaging has been increasingly incorporated into physiotherapy. Its applications include rehabilitative ultrasound imaging for assessing muscle morphology and function and providing biofeedback (2, 6), diagnostic ultrasound imaging for the evaluation of muscle injuries (2, 7), interventional ultrasound imaging such as dry needling, and research-based ultrasound applications (8). Beyond its established role in musculoskeletal and sports physiotherapy (3, 9), ultrasound imaging is increasingly used in emerging areas, including pelvic floor health in women (10–12) and men (13), cardiorespiratory physiotherapy (14), pediatric care (15, 16), and neurological physiotherapy (17, 18).
The growing use of ultrasound imaging in physiotherapy necessitates a comprehensive understanding of its clinical applications and limitations. Improved insight into the global use of ultrasound by physiotherapists may inform the development of educational guidelines, curriculum standards, and evidence-based clinical protocols. Therefore, the primary focus of this narrative review was to examine the application of ultrasound imaging in neuro-musculoskeletal assessments performed by physiotherapists.
Methods: A comprehensive literature search was conducted in PubMed, Scopus, Google Scholar, the Cochrane Library, and Web of Science databases from inception to June 2025. Studies were included if they investigated the use of ultrasound imaging for neuromusculoskeletal assessment conducted by physiotherapists.
Results: The findings indicate that ultrasound imaging demonstrates acceptable reliability and validity for evaluating muscle morphometry. Previous studies have reported satisfactory intra-rater, inter-rater, same-day, and between-day reliability for ultrasound-based measurements (34–36). Reliability has been established across a variety of muscle groups, including those of the spine (37, 38), trunk (15, 39, 40), pelvis (41, 42), and extremities (33, 43), and different populations.
Validity has commonly been assessed by comparison with established reference standards. Magnetic resonance imaging (MRI) is frequently used as the reference standard for assessing muscle morphology, whereas electromyography is considered the reference standard for evaluating muscle function (6). Evidence suggests that ultrasound imaging has acceptable validity for assessing muscle activity of the trunk and lumbar spine during most isometric and submaximal contractions (45, 47).
The clinical significance of ultrasound imaging in rehabilitation lies in its ability to assess muscle groups during contraction. This capability is particularly important for evaluating motor control and activation patterns of deep muscles that are difficult to assess using non-invasive techniques. Consequently, recent studies have increasingly used changes in muscle thickness measured by ultrasound as an indirect indicator of muscle activity (12, 45, 47, 51). Compared with fine-wire electromyography, it enables the visualization of a broader region of the muscle than can be assessed with intramuscular electrodes (21, 52, 53).
However, most studies evaluating validity have been conducted under resting or static conditions. Since assessing muscle parameters during dynamic tasks presents greater methodological challenges, further research is required to establish validity in functional contexts. Additionally, changes in muscle thickness measured by ultrasound are influenced by multiple factors, with muscle activity being only one contributor. Factors such as the resting state of the muscle, structural and mechanical properties of the muscle–tendon unit, type of contraction (isometric, concentric, or eccentric), and external influences including fascial attachments, intra-abdominal pressure, and activity of adjacent muscles may affect measurements. Methodological factors related to probe placement, orientation, and applied pressure can also influence outcomes. To control these variables, strict standardization during imaging is required. For example, when assessing trunk muscles, imaging should be avoided during activities that markedly increase intra-abdominal pressure, such as coughing, sneezing, or limb movements. Consistent probe positioning, orientation, and pressure must be maintained to avoid probe displacement and misinterpretation of muscle function (10).
In rehabilitative settings, the most commonly used ultrasound imaging modes include B-mode (brightness), M-mode (motion), and elastography (7). B-mode ultrasound is the most frequently applied modality and is primarily used to assess muscle structural characteristics such as thickness, width, and cross-sectional area across different groups, time points, or clinical conditions (7, 10, 12, 48, 49). M-mode ultrasound allows assessment of temporal changes in muscle thickness and has been used to evaluate the onset of muscle activity, demonstrating accuracy comparable to electromyography, albeit with a slight temporal delay (27–29). Elastography provides a direct, non-invasive method for quantifying soft tissue stiffness and has demonstrated utility in monitoring muscle changes associated with neurological disorders and evaluating responses to interventions targeting muscle stiffness and spasticity (30, 31).
Ultrasound imaging is also used as a biofeedback tool in physiotherapy, particularly for rehabilitation of the pelvic floor and lateral abdominal wall muscles in individuals with urinary incontinence, low back pain, and pelvic girdle pain (42, 54, 55). Additionally, ultrasound imaging has been utilized to safely guide the insertion of dry needles for various interventions, including acupuncture (61), trigger point release (62), and percutaneous electrolysis (63).
Conclusion: This narrative review indicates that ultrasound imaging demonstrates acceptable reliability and validity for the assessment of muscle morphological properties in neuro-musculoskeletal physiotherapy. Although ultrasound-derived changes in muscle thickness are influenced by muscle activity, they are also affected by multiple confounding factors and should not be interpreted as direct surrogate measures of muscle activation without appropriate consideration. Ultrasound imaging also serves as a valuable biofeedback and interventional guidance tool. Future research should focus on improving methodological quality, evaluating cost-effectiveness, and determining the clinical efficacy of ultrasound imaging in the physiotherapy management of neuro-musculoskeletal conditions.
Type of Study: review article |
Subject:
Physiotherapy
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