The content of a training package in diagnostic ultrasound for physiotherapists

Transcription

1 ORIGINAL ARTICLE The content of a training package in diagnostic ultrasound for physiotherapists Sharmaine McKiernan, Pauline Chiarelli, Helen Warren-Forward School of Health Sciences, The University of Newcastle, Callaghan, Australia Keywords curriculum, diagnostic ultrasound, physiotherapy, training, training methods. Correspondence Sharmaine McKiernan, Medical Radiation Sciences, School of Health Sciences, The University of Newcastle, University Drive, Callaghan, Australia. Sharmaine.McKiernan@ newcastle.edu.au Received: 19 May 2014; revised 17 September 2014; accepted 28 October 2014 doi: /sono Abstract Introduction: In recent years, the use of diagnostic ultrasound has expanded into the physiotherapy profession; however, training in the use of the modality is limited. It is widely accepted that ultrasound imaging is a user-dependent modality, so without training, physiotherapists are likely to struggle with its use within their profession. The purpose of this study is to report on the content of a training package for physiotherapists in diagnostic ultrasound. Method: Physiotherapists training needs were previously explored using focus groups and a national survey. Insight gained was then used to develop a training package to cover the basic theory of ultrasound and scanning of the abdominal muscles, multifidus and pelvic floor. A combination of lectures, practical scanning sessions and image interpretation was used to deliver the curriculum. Results: The training package was developed to be delivered flexibly using two methods: workshop and DVD. The same content was covered in both formats with recorded lectures, video footage and cine clips used on the DVD to replace the live content of the workshop. Discussion: A training package in diagnostic ultrasound for physiotherapists was developed, and from participant feedback, the content can be said to have improved participant knowledge and confidence when using diagnostic ultrasound Australasian Sonographers Association Introduction Diagnostic ultrasound has been traditionally used by radiologists and sonographers within radiology departments; however, over recent years, its use has expanded particularly into the physiotherapy profession.1 3 There are currently no restrictions on who can purchase and use a diagnostic ultrasound machine, and therefore, there are an unknown number of users who do not have any connection with diagnostic ultrasound societies or their registration bodies.4 It is acknowledged that continued clinical training is required to build user confidence in the modality.1,2,5 7 Users must be able to acquire high quality images and then distinguish normal from abnormal. For Funding: None Conflict of interest: None this, they must have training that should include knowledge of the mechanics of the equipment and a thorough understanding of anatomy.8 As physiotherapy practise is now expanding into diagnostic ultrasound, it is important that they receive education and training in this modality, and it is reasonable to suggest that the most effective training of physiotherapists should be guided by experts in the field of diagnostic ultrasound. This is where the radiology community has an important role and should step in and take charge of training and guidance for members of the physiotherapy profession. For this reason, focus groups and a national survey of physiotherapists were conducted by an accredited medical sonographer, to investigate training requirements and the outcomes of these studies underpinned the content development of a training package targeted at the physiotherapy profession.9,10 1

2 S. McKiernan et al. Content DU training package Diagnostic ultrasound use in physiotherapy Physiotherapists use diagnostic ultrasound mostly as a means of providing visual biofeedback to both the therapist and the patient, particularly for rehabilitation and the feedback of a task being mastered by the patient. Biofeedback is used as a part of motor relearning in which a patient learns what is required and how to perform a task. With time and practise, the aim is that gradually the task will become automatic and hopefully beneficial to the patients problem. Biofeedback is a teaching tool used to improve outcomes and helps the patient reliably perform the task. It allows for confirmation of a task being learnt and performed With the visual biofeedback of diagnostic ultrasound, physiotherapists look for such things as changes in associated structures such as the bladder base, tissue deformation and movement; it can however also be used to assess muscle structure and behaviour and to perform measurements of muscle thickness as evidence of muscle activation. 14 Several studies have shown that diagnostic ultrasound biofeedback is a useful method of assisting patients to learn to contract muscles and can be reliably used in the clinical setting. 12,15,16 The transversus abdominis and spinal multifidus muscles are seen to support and provide segmental stabilisation of the spine and therefore have an important role when treating patients for acute and chronic back pain. Physiotherapists train patients with lower back pain to perform an abdominal drawing in manoeuvre that involves activation of the multifidus and transversus abdominis muscles to stabilise the trunk and decrease symptoms associated with the pain. 12 Patients who present with pelvic floor muscle dysfunction can be specifically trained to perform a pelvic floor muscle contraction that elevates the bladder base and neck. This movement can be seen and assessed using transabdominal imaging and measured using transperineal imaging by visualising movement of the base of the urinary bladder. As the bladder base is supported directly by the pelvic floor muscles, the observed movement of the bladder base is a reflection of a pelvic floor muscle contraction. The movement is the reaction that a pelvic floor muscle contraction has on the base of the bladder. 17,18 demonstrations and allowing hands on practise, including the ability to scan each other and offering opportunities to ask questions of an expert. They requested help to navigate the components of the control panel in order to maximise image clarity. They also expressed a need to learn how to best recognise relevant anatomical structures including how to recognise specific muscles on an image. Physiotherapists indicated the need for training in how to scan the pelvic floor, transversus abdominis and multifidus muscle groups. They were very mindful of time, distance and costs of training and felt that training needed to be easily accessible to all physiotherapists, even those in rural areas. The availability of a specifically designed DVD was also highlighted as a possible useful training tool. The training package A training package was developed and delivered by an accredited medical sonographer with experience working with physiotherapists. The feedback received from the focus groups and survey, underpinned the content development of the training package that was delivered via two methods: workshop and DVD. Both delivery methods included the same content; however, where the workshop allowed for live scanning and didactic sessions, the DVD had video clips and recorded lectures. The content was delivered via a combination of lectures, scanning and image interpretation sessions (Figure 1). Content The training commenced with a 25-min introductory PowerPoint presentation covering basic ultrasound physics. As physiotherapists are familiar with the use of therapeutic ultrasound, the lecture began by explaining the term ultrasound and the difference between therapeutic and diagnostic ultrasound (Figure 2). Training needs of physiotherapists Outcomes from focus groups 10 and a national survey 9 of physiotherapists highlighted the fact that very little accessible training was available to physiotherapists. Physiotherapists indicated a preference for face-to-face training in the form of a workshop including expert Figure 1 Breakdown of the training package. 2

3 Content DU training package S. McKiernan et al. Figure 2 One of the basics of ultrasound lecture slides, including the difference between therapeutic and diagnostic ultrasound. Image formation was then discussed and how the scale of grey on the B mode image works and what position on an image means. Doppler ultrasound was covered in terms of pulsed wave and colour Doppler, including how they work and what they might be used for. To complete this initial section, bioeffects of ultrasound were covered, and The World Federation for Ultrasound in Medicine and Biology (2008) policy on safety was given. The second lecture was on equipment and explained the intricacies of the various transducers available for imaging. Topics covered included how the transducers work, the different shapes and types of transducers, frequencies and what each type of transducer would be used to image. Transducer position on the patient was discussed, and resultant image orientation was given. The last of the initial lectures was on instrumentation and covered the ultrasound machine control panel. The function of each button on the ultrasound control panel was discussed along with its importance and relevance to imaging and image manipulation. At this point, discussion of calculation of volume and area measurements was introduced so participants would be able to measure such parameters as bladder volumes and assess changes in thickness of muscle bodies. Participants were then encouraged to spend some time practising with the ultrasound machine, developing expertise with the control panel and manipulating and using the machine to better understand how the diagnostic ultrasound machine works. At the commencement of the next session, setup of the ultrasound machine and room were discussed, along with the need for ancillary equipment. The training now moved into scanning specific areas of the body. To begin with the abdominal muscles, transversus abdominis and rectus, were discussed. Sonographic anatomy was covered along with patient position for scanning, transducer selection and orientation, as well as patient preparation for the scan. Ultrasound images of these body areas were then displayed and the sonographic anatomy highlighted so the muscles could be identified. Instruction was then given on what to look for on muscle contraction and measurements that could be taken. This process was repeated for the multifidus muscle. Following this, practical scanning of these areas was conducted. To assess transversus abdominis, during the practical scanning sessions, participants were instructed to lay the patient supine and use a 3 MHz curved transducer. Participants were instructed to place the transducer 10 cm lateral to the midline at the level of the umbilicus in a transverse plane. Participants were shown Figure 3 as a guide to the image they should achieve in the practical scanning session and that in real time, on contraction, the transversus abdominis muscle should be seen to move laterally and thicken. Participants were also encouraged to perform measurements of the linear thickness of the transversus abdominis, so they could quantify the change in muscle thickness. To assess the multifidus muscles, during the practical scanning sessions, participants were instructed to lay the patient prone and use a 3 MHz curved transducer. Participants were instructed to place the transducer Figure 3 Transverse image of the abdominal wall showing transversus abdominis anatomy and muscle change on contraction. EO, external oblique; IO, internal oblique; TA, transversus abdominis. 3

4 S. McKiernan et al. Content DU training package transverse, in the midline of the patient to assess and compare each lumbar level for localised wasting (Figure 4). Participants also assessed the multifidus in the longitudinal plane, looking for variations in the quality of contraction at the different lumbar levels. Participants were instructed that visually the muscle should be seen to thicken, and they were encouraged to perform cross-sectional area and depth measurements of muscle volume, precontraction and postcontraction, so they could quantify the change. The final area covered was scanning of the pelvic floor. This can be imaged via two approaches, and both the abdominal and transperineal approaches were discussed in detail. Also covered in the discussion were infection control and the calculation of bladder volumes required to image in both approaches. This again was followed by practical scanning with extension into scanning using a cough, Valsalva manoeuvre and assessing hold endurance. Figure 4 Transverse image showing multifidus muscle anatomy. To assess the pelvic floor during the practical scanning sessions, participants were instructed to commence with the transabdominal approach using a 3 MHz curved transducer placed on the anterior abdomen just above the symphysis pubis. Participants were instructed on the importance of angling the transducer down to image the base of the bladder, so a pelvic floor muscle contraction could be seen. Participants were shown Figure 5 as a guide to the image they should achieve and the elevation of the bladder base on pelvic floor contraction that should be observed in real time, during the practical scanning session. Participants were instructed to note that in the transverse plane, both the right and left sides of the bladder base, are viewed so the symmetry of the contraction can be seen. The bladder requires a moderate amount of fluid within it for this technique. Once participants were comfortable with the transabdominal approach, they were instructed to attempt the transperineal scan, again using the 3 MHz curved transducer. Before commencing, participants were instructed to empty their bladder so the bladder neck and proximal urethra could be more mobile. Participants were instructed on the need to place gel on the transducer, cover the transducer with a protective covering, such as a glove, and then place gel on top of the glove, before the transducer was placed in contact with the perineum in the sagittal plane. Participants were shown Figure 6 as a guide to the image they should achieve and the anterior and superior movement of the bladder and urethra on contraction. Participants were also encouraged to use the symphysis pubis as a static reference point and landmark to perform measurements so they could quantify this movement. Figure 5 Transabdominal, transverse images of a male urinary bladder. Arrows indicate the change in the shape of the bladder base from flat at rest, to convex on muscle contraction, indicating a pelvic floor muscle contraction. 4

5 Content DU training package S. McKiernan et al. Figure 6 Transperineal images of a female bladder at rest and on contraction. Dashes indicate the urethra, which can be seen to elongate and move anteriorly towards the symphysis pubis (S) on contraction. The urinary bladder (B) has also moved anteriorly and superiorly on contraction, so it is now mostly hiding under the shadow of the symphysis pubis. The final part of the lecture series looked at the role of diagnostic ultrasound within physiotherapy. Its strengths and weaknesses for the profession were explored. The lecture concluded with ethical issues that use of the modality within the profession raises. This was covered as an open discussion with participants giving their experiences, solutions and suggestions. The first issue covered was how to educate and inform patients of the difference in the physiotherapists use of diagnostic ultrasound when compared with the medical imaging department. Secondly, the need for physiotherapy specific educational brochures and consent forms for use of diagnostic ultrasound within their practice was addressed. Lastly, how physiotherapists should handle a situation where pathology was suspected, and how to refer the patient to a doctor was discussed. Workshop format The workshop format was designed for a 1 day session from 9.00 am 5.00 pm (Table 1). It can be seen how scanning was integrated throughout the day with plenty of time for discussion and questions. The workshop met the physiotherapists requirements in relation to face-toface training with demonstrations, scanning practise and the ability to ask questions. DVD format The DVD had an initial layout (Figure 7), where participants could select from any of the links and then the information would be presented. In this way, the DVD menu items could be watched in any order and multiple times. The lectures appeared as recordings that showed a Table 1 Timetable for a 1 day workshop Time Topic Format 8:45 9:00 Course registration 9:00 10:00 Diagnostic ultrasound: Lecture, discussion The basics Transducers Image orientation Machine buttons 10:00 10:30 Supervised practise session: Machine buttons Demonstration, practical 10:30 10:45 Morning tea 10:45 11:30 How to image: Lecture, discussion Abdominal muscles Multifidus 11:30 12:30 Supervised practise session: Abdominal muscles Multifidus Demonstration, practical 12:30 13:00 Lunch 13:00 14:00 How to image: Lecture, discussion Pelvic floor via abdominal 14:00 14:15 Afternoon tea 14:15 15:00 How to image: Lecture, discussion Pelvic floor via transperineal 15:00 16:30 Supervised practise session: Pelvic floor 16:30 17:00 Questions and course evaluation Demonstration, practical Discussion PowerPoint presentation and audio of the lecturer s voice. The practical sessions and demonstrations were included as video clips and cine loops. The video clips demonstrated 5

6 S. McKiernan et al. Content DU training package Figure 7 DVD menu of viewing options. the sonographic examination with carefully planned, sequential talking through each step, clearly demonstrating whichcontrolsonthemachinewerebeingmanipulated to adjust the image. Cine loops of the resultant ultrasound images were then included to show the viewer the images that were achieved. The DVD can be accessed at any time and on multiple occasions; interested physiotherapists have a resource they can access when needed with the option of refreshing or reviewing the content whenever suitable and convenient. The disadvantage of DVD training is that it lacks the provision to ask questions that is inherent with the face-to-face workshop format. Participant learning outcomes A total of 180 physiotherapists participated in the training, 84 attended a workshop and 96 viewed the DVD. To assess participant learning outcomes, participants were given an assessment prior to and at the completion of the training. As such, the learning outcomes of the training were assessed, although participants were not assessed on their scanning competence or provided with any diagnostic ultrasound credentials as part of this training. The learning outcome assessment questions explored all aspects of the taught material with 8 physics questions (worth 8 marks), 8 questions on technique (worth 8 marks) and 6 questions on image anatomy worth 14 marks. It can be seen in Figure 8; that for all categories, participants demonstrated improvement, with a decrease in score range and an elevation in median scores. Figure 8 Breakdown of assessment results by category. Participant feedback In the assessment at the completion of the training, some true/false questions were included in relation to participant perception of the training, and an open comment area was also included. All of the 180 participants indicated the content covered in the training package was good, 99.4% enjoyed the training and 98.9% said the speed content was covered in was good. False responses were all in the DVD group and stated a little long winded and too wordy in explaining some aspects. The participant comments about the workshop and DVD indicate that participants felt there was an improvement in their knowledge and confidence when using diagnostic ultrasound. Comments included, I have learnt heaps, I do feel more confident in using my ultrasound machine, I came away with confidence in being able to use the ultrasound to get the best possible picture and understanding why and how the image can be improved, 6

7 Content DU training package S. McKiernan et al. the lectures were really good, appropriate, easy to understand, I will use the ultrasound more often and with more confidence as an adjunct to my treatment, able to now fully utilise my ultrasound machine, loved the practical nature of the workshop, great videos, good use of cine loops in the DVD, I think the DVD is a great way to learn. Thanks for putting together a great training package, even after this training we are able to access the lectures and videos on the DVD to refer back to, very happy to have access to up to date training info and a really user friendly way of doing this. Great! Conclusion Because of demand and feedback from physiotherapists, a training package in diagnostic ultrasound was developed for physiotherapists. This package covered the basics of ultrasound and scanning of the abdominal muscles, multifidus and the pelvic floor. This training package was developed to be delivered via the two methods most desired by the physiotherapists that being workshop and DVD format. Although both methods have their advantages, it was important that the content covered by both methods was identical. From participant feedback, the training package can be said to have improved participant knowledge and confidence when using diagnostic ultrasound. References 1 Abu-Zidan FM, Freeman P, Mandavia D. The first Australian workshop on bedside ultrasound in the emergency department. New Zeal Med J. 1999; 112(1094): Australasian Society for Ultrasound in Medicine. Policies and statements. 2014; Accessed 8 August, McKiernan S, Chiarelli P, Warren-Forward H. Diagnostic ultrasound use in physiotherapy, emergency medicine and anaesthesiology. Radiography 2010; 16: Barnett SB, Ter Haar GR, Ziskin MC, Rott HD, Duck FA, Maeda K. International recommendations and guidelines for the safe use of diagnostic ultrasound in medicine. Ultrasound Med Biol 2000; 26(3): Langlois S. Focused ultrasound training for clinicians. Crit Care Med 2007; 35(5): Butter J, Grant TH, Egan M, Kaye M, Wayne DB, Carrion-Carire V et al. Does ultrasound training boost year 1 medical student competence and confidence when learning abdominal examination? Med Educ 2007; 41: Mandavia DP, Aragona J, Chan L, Chan D, Henderson SO. Ultrasound training for emergency physicians a prospective study. Acad Emerg Med 2000; 7: Frezza EE, Solis RL, Silich RJ, Spence RK, Martin M. Competencybased instruction to improve the surgical resident technique and accuracy of the trauma ultrasound. Am Surg 1999; 65(9): McKiernan S, Chiarelli P, Warren-Forward H. A survey of diagnostic ultrasound within the physiotherapy profession for the design of future training tools. Radiography 2011; 17(2): McKiernan S, Chiarelli P, Warren-Forward H. Professional issues in the use of diagnostic ultrasound biofeedback in physiotherapy of the female pelvic floor. Radiography 2013; 19: Baessler K, Schussler B, Burgio KL, Moore KH, Norton PA, Stanton SL. Pelvic Floor Re-education Principles and Practice, 2nd edn. London: Springer; Teyhen DS, Miltenberger CE, Deiters HM et al. The Use of ultrasound imaging of the abdominal drawing in maneuver in subjects with low back pain. J Orthop Sports Phys Ther 2005; 35(6): Frost N, Clarke J. Ultrasound for biofeedback in physiotherapy. soundeffects 2004; 4: Whittaker JL, Teyhen DS, Elliott JM et al. Rehabilitative ultrasound imaging: understanding the technology and its applications. J Orthop Sports Phys Ther 2007; 37(8): Pressler JF, Heiss DG, Buford JA, Chidley JV. Between-day repeatability and symmetry of multifidus cross-sectional area measured using ultrasound imaging. J Orthop Sports Phys Ther 2006; 36(1): Van K, Hides JA, Richardson CA. The use of real-time ultrasound imaging for biofeedback of lumbar multifidus muscle contraction in healthy subjects. J Orthop Sports Phys Ther 2006; 36(12): Thompson JA, O Sullivan PB, Briffa K, Neumann P, Court S. Assessment of pelvic floor movement using transabdominal and transperineal ultrasound. Int Urogynecol J 2005; 16: Whittaker JL, Thompson JA, Teyhen DS, Hodges P. Rehabilitative ultrasound imaging of pelvic floor muscle function. J Orthop Sports Phys Ther 2007; 37(8):