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Ultrasound Imaging in Podiatry and Physiotherapy musculoskeletal assessment, protocols and policy

Ultrasound imaging diagram
Ultrasound imaging

Pioneering the global uptake of Ultrasound Imaging in Podiatry and Physiotherapy musculoskeletal assessment, protocols and policy

About the research

Musculoskeletal conditions are the highest contributor to global disability. Ultrasound imaging (USI) offers a safe, accessible, relatively inexpensive alternative to magnetic resonance imaging (MRI) for diagnosis of pathology/dysfunction and for monitoring effects of musculoskeletal rehabilitation by allied health professionals.

Through 15 years of collaborative research, we have pioneered USI in allied health and underpinned clinical uptake of two distinct applications of USI now used worldwide to advance expertise in musculoskeletal services (see infographic).


Technique 1: Embedding Diagnostic Ultrasound Imaging in Podiatry

In 2008, research led by Professor Cathy Bowen was the first to highlight that podiatrists could use diagnostic USI (DUSI) reliably in foot and ankle assessment.

The subsequent funded programme of work, the ‘FeeTURA study’ (2010-2017), increased understanding of foot problems in rheumatic diseases. It involved collaboration with radiologists (Dr Keith Dewbury, Dr Madeleine Sampson, Dr Leonard King), rheumatologists (Professor Nigel Arden, Professor Christopher Edwards) and podiatrists (Dr Lindsey Cherry, Dr Charlotte Dando, Dr Lucy Gates) from University Hospital Southampton and the Universities of Southampton and Oxford.

Findings indicated that foot DUSI was more beneficial than clinical examination alone, for diagnosis and implementation of effective care pathways for patients with foot symptoms and those undergoing biotherapy. Our expanding research team enabled wider translation of the DUSI imaging protocols to produce clinically useful definitions of foot and ankle osteoarthritis.


Technique 2: Driving Ultrasound Imaging in Physiotherapy

In 2006, Professor Maria Stokes was a delegate at an international symposium that established the field of Rehabilitative USI (RUSI), having carried out fundamental research to develop USI as a powerful tool for visualising and estimating a muscle’s strength from its size. Assessing and retraining muscle are difficult if the muscle is too deep to see or feel, so the Southampton team, also involving Dr Peter Worsley, Dr Jackie Whittaker and Dr Martin Warner, developed robust protocols for accurate assessment of muscles through studying technical aspects, reliability of repeated measurements and validity against the gold standard of MRI. The group also established normal reference ranges in cohorts such as the US Army.

Novel translation includes routine monitoring of muscle health in astronauts pre-and post-flight. An exciting development is a research project involving Paul Muckelt, Dr Martin Warner and Professor Stokes performing remote real-time imaging of muscles in astronauts living on the International Space Station. Knowing the effects of inactivity on muscles helps inform management of disabling conditions on Earth.


Implications for policy and practice

· Our work has extended allied health practice and has supported the health policy agenda (Framing the Contribution of Allied Health Professionals, Department of Health, 2008).

· Use of DUSI by Podiatrists has changed care pathways in practice, exemplified by a local foot and ankle DUSI clinic shaped by our research, which has reduced care pathway times from 42 to 9 weeks, and clinical visits from 6 to 2.

· Foot and ankle DUSI is included as a separate section in UK guidelines for management of foot health for people with rheumatoid arthritis.

· International surveys have confirmed: 1) our research has directly informed podiatric training (pre and post-registration) and clinical practice, with uptake across the world; 2) USI in Physiotherapy has enhanced management of challenging conditions such as back pain, and driven clinical uptake in 50 countries.

· An International Position Statement (2019) illustrated how USI in Physiotherapy has evolved into several specialties: 1) diagnostic; 2) rehabilitative; 3) interventional, e.g. guided acupuncture; 4) research. 

· Remote monitoring of astronauts provided valuable lessons for rapid implementation of virtual Physiotherapy clinics during the COVID-19 pandemic.

Professor Catherine Bowen and Professor Maria Stokes and colleagues, Active Living for Health Research Group, Health Sciences

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