PHYSIOTHERAPY PIECE
THE REAL TIME ULTRASOUND FOR ASSESSING TRANSVERSUS ABDOMINIS:
We have all heard of ultrasound. This is a useful diagnostic and assessment tool for a range of conditions; including monitoring a growing foetus, observing abdominal symptoms or assessing possible ligament, muscle or tendon damage. The ultrasound also plays a physio-therapeutic role in the treatment and management of a sprained ankle or sore shoulder.
The use of real time ultrasound (RTUS) in measuring the ability of transversus abdominis (TVA), is an invaluable tool for the therapist as well as the client. On the screen, we are able to see and educate our clients on the four layers of the abdominal muscle tissue. It allows us to demonstrate where these muscles sit in relation to each other, the orientation of fibres relative to the body and the isolation of one set of muscles compared to another.
During assessment, I work through the muscle layers, their origin and insertion and the direction of fibre-pull by using one of the many anatomy applications on a Smart Device. I believe a key point In educating about the TVA, is to ensure that the client is aware that the muscle, although thin, has an extensive surface area and does expand up to the ribcage, sternum and upper lumbar spine. Secondly, I ensure that they understand that the fibres pull outward and posteriorly to the vertebra, like the wrap around effect of a corset. TVA in isolation does not create any global skeletal movement, but instead ‘holds’ the lumbo-sacral segments in place. Once these concepts have been worked through, we can then begin to trial different cues to activate a suitable contraction. This is often a trial and error, as cues work differently for individuals. I love the advantage of the visual feedback of the RTUS, where a client can literally watch their TVA glide. With this, they are able to firstly see the direction of fibre-pull and this enhances their awareness and ability. Secondly we can see whether the TVA can indeed glide in isolation, or whether it works in conjunction with the internal oblique (IO), or even at times the external oblique (EO). A cue that I may use here is … ‘retry that contraction, but just at 20% of your effort’. Here the client begins to understand the subtleness of a TVA isolation. As much as necessary, as little as possible.
The three main results I see are overactivity of IO, especially in our global splinters, a disconnect/lack of neuromuscular awareness of a TVA glide and thirdly, adhesions between the TVA and IO, preventing any dissociative glide between the two.
With an overactive IO, I continue with RTUS and work, using cues and repetition, to reduce the effort. With practice the client will be able to isolate more efficiently by using visual feedback. This is of benefit, since the client should not feel the contraction in the same way as when their globals contract.
If there is disconnect, ensure that you check both sides of the TVA/IO complex. If it does not appear to be working on either side, and endless cues fail to create the isolation we would desire, I then look at beginning the client on safe but unstable apparatus exercises. Placing the body in a slightly unsteady environment to create perturbation and ‘trick’ the body into utilising core. We may start in this unstable environment and work backwards into stability (and therefore isolation) from a gross pattern of movement. If we see isolation on one side, we can conclude that the neuromuscular pathway is set up, but if it is not working on the opposite side, we may need to consider that there are some adhesions between the fascial layers of TVA and IO.
In the case of adhesions, the client will never be able to create isolation with neuromuscular power or repetition alone. Even if it were Joseph H. Pilates himself taking the client !! In this case, the client will need some soft tissue release work to separate the fascial layers. Tearing up of these adhesions using manual techniques will create some superficial bruising but provides evidence that adhesions are being broken down. a second attempt at observing the isolation may then be more fruitful. Clinically, I find that a client will only need 2-4 treatments of adhesion release before they can perfect their isolation.
So, I love to use RTUS as an assessment and education tool as well as for reassessment down the track. We can print out data and create an active video of the muscles working (or not working) as a quantitative measure. Seeing the amazement on a client’s face when they see the muscle gliding correctly and just how small that isolation can be, is priceless!
JEN GUEST
PAA Secretary
PHYSIOTHERAPIST
SENIOR EDUCATOR POLESTAR PILATES AUSTRALIA
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