Rehabilitative Ultrasound Imaging (RUSI)

Hi there, Bestie. Grab a nice warm cup of something yummy and settle in. Let’s chat about rehabilitative ultrasound imaging (RUSI), sometimes also called real-time ultrasound (RTUS). This chat, in particular, is for all of my pelvic besties, including my pelvic health provider besties.

So, what was your first thought when I mentioned ultrasound? I bet you thought about one of those machines that allows you to see your baby during pregnancy. This is the exact same idea! An ultrasound is an imaging tool that produces the sonogram image you see on screen. With RUSI, we can view internal structures in black and white sonographic images. A probe is used along with a conductive gel. The probe is moved over the abdomen into different positions in order to view specific muscles and/or organs. The visualization of these structures help to improve understanding of any potential dysfunctions and can also act as a form of biofeedback. If you missed our talk about biofeedback or just want a refresher, find that here.

What can RUSI be used for?

In the pelvic health realm, there are a few diagnoses that can potentially benefit from the use of RUSI. First, we can use it to help visualize the pelvic floor muscles (PFMs) (1). When the bladder is full, it is possible to see the PFMs, which sit right underneath the bladder. As you contract your PFMs, you should be able to see them move upward on the screen. This can be useful to visualize in patients with PFM weakness who are having a difficult time with the “lift” portion of a PFM contraction. Remember, a PFM contraction has two parts: first, a squeeze, and second, an upward and frontward lift. The lift is important for maintaining urinary continence, and without it, urinary leakage can occur. Watching PFM contraction via RUSI can help a patient to see that lift of the PFMs in real-time and adjust as necessary.

Conversely, you can watch your PFMs lengthen, as well. If you are at pelvic physical therapy for PFM tension, pelvic pain, or difficulty emptying your bladder/bowels, you might be working on relaxing and lengthening your PFMs. The RUSI is a great way to see how well you are lengthening your PFMs. On screen, you will notice a downward motion when lengthening is performed correctly.

Secondly, RUSI can be used to view the bladder. The probe, also called the transducer, is placed right above the pubic bone. This can be slightly uncomfortable when you have a full bladder, but should be tolerable and should not be painful. In order to view the bladder, it should be fairly full. This will allow for the best view of the bladder itself. A full bladder will appear square-ish or toast-shaped on the screen and should be pretty symmetrical. Once you’ve seen your bladder filled with fluid, your therapist may have you empty your bladder completely and then return for a second viewing. This second viewing helps us to see how well you emptied your bladder. If you are at pelvic physical therapy due to a constant feeling of urinary urgency and you are rushing to the bathroom every thirty minutes, seeing that you’ve actually emptied your bladder fully, can be reassuring. An empty bladder will be more difficult to find via RUSI and almost impossible to see. If you are doing pelvic physical therapy due to true difficulty emptying your bladder, viewing your bladder before and after emptying will allow you and your therapist to see how much you are actually emptying. As you progress in therapy, you can continue to use this tool to see your improvement in emptying.

A third way RUSI is used in women’s health rehabilitation is in patients with diastasis rectus abdominis (DRA). DRA occurs when the rectus abdominis muscles move apart from each other, often times due to pregnancy and the growing baby. With the RUSI, you can visualize the structures of the abdomen, including the rectus abdominis muscle, the transversus abdominis muscle (TrA), the oblique muscles, and the linea alba. If you missed our chat about how the TrA and linea alba matter in DRA, catch that here. To briefly review, when you are experiencing DRA, it is important to contract the TrA because it adds tension to the linea alba and improves both aesthetics and function of the core (2). When you neglect to utilize the TrA, the linea alba buckles, forming a sort of crinkled appearance. This does not allow for maximal function of the core muscles. Using the RUSI, you will be able to visualize the linea alba with and without TrA contraction, and this can demonstrate the importance of strengthening that TrA muscle. You will notice a smoother linea alba during TrA contraction, and more buckling/crinkling in the linea alba without TrA contraction.

The use of RUSI can also allow the therapist to get a more accurate measure of inter-rectus distance (IRD) than they would be able to get just by measuring with their finger(s). The IRD is the distance between the two rectus abdominis muscles. Often times, this distance is increased after pregnancy. If you are seeing a therapist for DRA, they may use the RUSI to measure your IRD every few visits to track your progress.

What are the pros and cons of RUSI?

One of the best things about RUSI is that it is completely noninvasive. The abdominal muscles and bladder can all be observed with the probe placed along the abdomen. This makes it a great option for observing the PFMs, especially in folks with pelvic pain preventing any kind of internal examination. Because RUSI is not an invasive treatment option, there are no real negative side effects associated with its use. However, ultrasound machines can be expensive. Because of this, many clinics will not have access to RUSI machinery. You are more likely to come across this type of technology in a hospital-based outpatient clinic or a women’s health clinic. Keep in mind that RUSI is not an essential part of a typical treatment plan, but rather an extra tool that can be used to enhance a plan of care. If your provider has access to a RUSI and thinks you could benefit from it, then great, but if not, you can still achieve your goals and receive high quality care without it.

RUSI can be a great tool to utilize in many different types of care plans. I have found that patients really enjoy seeing what their anatomy looks like and it can be a fun and interactive treatment technique. Have you tried RUSI as a patient or a clinician? I’d love to hear about your experience!

Gah, I’m out of tea—until next time!

XOXO,

Your Pelvic Bestie

References:

1. Bø K, Sherburn M, Allen T. Transabdominal ultrasound measurement of pelvic floor muscle activity when activated directly or via a transversus abdominis muscle contraction. Neurourol Urodyn. 2003;22(6):582-8. doi: 10.1002/nau.10139. PMID: 12951667.

2. Lee D, Hodges PW. Behavior of the Linea Alba During a Curl-up Task in Diastasis Rectus Abdominis: An Observational Study. J Orthop Sports Phys Ther. 2016 Jul;46(7):580-9. doi: 10.2519/jospt.2016.6536. PMID: 27363572.

*The information contained in this article is for educational and informational purposes only and is not intended as health or medical advice. Always consult a qualified health provider regarding any questions you may have about a medical condition or health objectives.