c 5.hill - syllabus msk us, dx,inj,app to cycling hill...discuss uses of msk ultrasound related to...

8/18/2014

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Musculoskeletal Ultrasound: Diagnosis, Interventions,

Evidence and Applications to Cycling

2014 Medicine of Cycling ConferenceJohn Hill, DO, FAAFP, FACSMProfessor, University of Colorado

Saturday, August 23, 20142:30-3:30 PM

Disclosure Statement

Newton Shoes: Physician Advisory Board

MuscleSound: Inventor Physician advisor/shareholder:

Device & software development using ultrasound to determine muscle glycogen content.

MuscleSound, LLC; US Patents 8,512,247, 8,517,942 and additional patents pending

Objectives

Discuss uses of MSK ultrasound related to the shoulder and hip

Review scientific evidence related to diagnostic and interventional applications

Describe the importance of skeletal muscle glycogen content in cycling

Discuss a new application of ultrasound which can quantify muscle glycogen content and the results of recent validation study.

Objectives

1. Are guided injections Clinically Valid?

Remember…

Injections, whether image guided or palpation guided, require skill

Inherent differences amongst physicians regardless of level of training or experience

Mastery of a skill cannot be assessed by a simple number

No strict definition of accuracy Damage to / injection of

surrounding structures Number of attempts

Confirmation method MRI Fluoro

Needle placement ? Contrast?

Ultrasound Dissection Arthroscopy

Cadaveric model vs. clinical setting

Clinical response?

EFFICACY THE PAINFUL SHOULDER

Multiple studies Multiple indications Mixed results Most favor image guidance

regarding short term improvements in pain and function

Three systematic reviews Two felt there was adequate

evidence of increased improvement in pain and function at 6 weeks to recommend USG

One acknowledged increased accuracy with USG, But did not find clear evidence of

efficacy to justify increased cost Conclusion appeared heavily biased by

one study

Sage, W., et al.,. Rheumatology (Oxford), 2012.Soh, E., et al., . BMC Musculoskelet Disord, 2011. 12: p. 137.Bloom, J.E., et al., . Cochrane Database Syst Rev, 2012. 8: p. CD009147.

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ACCURACY GLENOHUMERAL JOINT

Palpation Guided Cadaveric model,

50% - 96%

Clinical setting 10% - 100%

Non-targeted structures injected Biceps tendon Rotator cuff ACJ Subacromial

Image Guided (Sonography) Cadaveric model

93% Clinical Setting

97% - 100%

Maffulli, N., et al.,High volume image guided injections for the management of chronic tendinopathy of the main body of the Achilles tendon. Phys Ther Sport, 2012.Sethi, P.M. and N. El Attrache, Accuracy of intra-articular injection of the glenohumeral joint: a cadaveric study. Orthopedics, 2006. 29(2)Rutten, M.J., et al., Glenohumeral joint injection: a comparative study of ultrasound and fluoroscopically guided techniques before MR arthrography. Eur Radiol, 2009. 19(3): p. 722-30.

ACCURACY ACROMIOCLAVICULAR JOINT

Palpation Guided Cadaveric model

40% - 72% Clinical setting

39% - 50%

Sonographically Guided Cadaveric model

90% - 100% Clinical setting

100%

-Peck, E., et al., Accuracy of ultrasound-guided versus palpation-guided acromioclavicular joint injections: a cadaveric study. PM R, 2010. 2(9): p. 817-21.-Wasserman, B.R., et al., Accuracy of Acromioclavicular Joint Injections. Am J Sports Med, 2012.-Sabeti-Aschraf, M., et al., The infiltration of the AC joint performed by one specialist: ultrasound versus palpation a prospective randomized pilot study. Eur J Radiol, 2010. 75(1): p. e37-40.

ACCURACY BICEPS TENDON SHEATH

Palpation only accuracy Marker placed Confirmed with sonography 5% (0 – 12%)

Palpation vs US guided Type 1 (only in tendon sheath)

Palpation 27% USG 87%

Type 2 (inside sheath, but also tendon and surrounding area) Palpation 40% USG 13%

Type 3 (only outside tendon sheath) Palpation 33% USG 0%

-Gazzillo, G.P., et al., Accuracy of palpating the long head of the biceps tendon: an ultrasonographic study. PM R, 2011. 3(11): p. 1035-40.-Hashiuchi, T., et al., Accuracy of the biceps tendon sheath injection: ultrasound-guided or unguided injection? A randomized controlled trial. J Shoulder Elbow Surg, 2011. 20(7): p. 1069-73.

ACCURACY HIP Palpation Guided

Cadaveric model 60% - 80% Contacted femoral nerve 27% of

anterior attempts Clinical setting

51% - 78% Sonographically Guided

Cadaveric model 97%

Clinical setting 100%

-Leopold, S.S., V. Battista, and J.A. Oliverio, Safety and efficacy of intraarticular hip injection using anatomic landmarks. Clin Orthop Relat Res, 2001(391): p. 192-7.-Kurup, H. and P. Ward, Do we need radiological guidance for hip joint injections? Acta Orthop Belg, 2010. 76(2): p. 205-7.-Pourbagher, M.A., M. Ozalay, and A. Pourbagher, Accuracy and outcome of sonographically guided intra-articular sodium hyaluronate injections in patients with osteoarthritis of the hip. J Ultrasound Med, 2005. 24(10): p. 1391-5.-Levi, D.S., Intra-articular hip injections using ultrasound guidance: accuracy using a linear array transducer. PM R, 2013. 5(2): p. 129-34.

EFFICACY BENEFIT OF DIAGNOSTIC INJECTIONS

Identify the pain generating structure with accurately placed LA injection

Optimize conservative treatment plan

Pre-surgical planning Theoretically

Improve patient outcomes Decrease cost associated with

“wrong” treatments including PT Injections Surgery

Routinely performed at some institutions

Accuracy appears key Role in evaluation and

management of MSK conditions needs to be further defined

SUMMARY

Image guidance increases the accuracy rate of peripheral joint and soft tissue injections

Injections are a skill, and accuracy rates are variable, even with image guidance

General efficacy appears to improve with image guidance, but this is not the correct outcome to pursue

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Objectives

2. Is Diagnostic MSK Ultrasound Sensitive and

Specific?

EFFICACY BENEFIT OF DIAGNOSTIC INJECTIONS

Identify the pain generating structure with accurately placed LA injection

Optimize conservative treatment plan

Pre-surgical planning Theoretically

Improve patient outcomes Decrease cost associated with

“wrong” treatments including PT Injections Surgery

Routinely performed at some institutions, why not ALL institutions?

Accuracy is the key Role in evaluation and

management of MSK conditions must be precisely defined

SHOULDER PAIN 33 y/o Female

Pain on in off for years in right shoulder No acute trauma

Pain is getting worse

Physical findings +Hawkins, +Neers, +Speeds,

+/- O Brien’s

X-Ray Normal GHJ, Mild ACJ DJD

Prior Treatments Rest, NSAIDS, PT, Subacromial bursa inj X 1


Working Dx – Rotator cuff syndrome Tendinopathy or Tendon tear?

Full or partial thickness tear?

Which tendons are involved?

Failed standard treatments PT? What kind of PT?

Injection? What was really injected?

Advanced (soft tissue) imaging appropriate MRI?

MR Arthrogram?

Role of US?

Rotator Cuff Ultrasonography

Long history - 1977

• Accumulated research • Meta-analysis, systematic reviews • Performance – MRI, MRI-Arthro, Surgery

Type SEN SPEC

FT-RCT >90% >90%

PT-RCT 60-75% >90%

(MRI 64%/MR arthro 86%) Smith, et.al. Clin Rad 2011

Kelly, et.al. Semin Roentgenol 2009;

DeJesus, et.al. AJR 2009

Best way to Diagnose a Suspected Rotator Cuff Tear?

Meta analysis of 38 cohort studies for U/S(evidence B)

MSK U/S used to evaluate both suspected full & partial thickness rotator cuff tears

Compared with: Clinical Exam MRI Arthrography MR arthrography

Diehr, et.al. J Fam Med, 55,7, July 2006

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Best way to Diagnose a Suspected Rotator Cuff Tear?

Diehr, et.al. J Fam Med, 55,7, July 2006

Test SN SPClin Ex

0.9 0.54

U/S 0.87 0.96MRI 0.89 0.93Arth 0.50 0.96MR Arth

0.95 0.96

Test SN SPClin Ex

N N

U/S 0.67 0.94MRI 0.44 0.9Arth N NMR Arth

In In

Full Thickness Tear Partial Thickness Tear

Supraspinatus Tendon

Instruct patient to place their arm in INTERNAL rotation

Place hand in back pocket (Long axis)45 degrees Coronal/

Sagittal

SST WNLSST Normal Long Axis view



Place hand in back pocket (Long axis)45 degrees Coronal/

Sagittal (Short axis) 90 degrees Rotation of

long axis

SST WNLSST with Tendinopathy



Place hand in back pocket (Short axis) 90 degrees Rotation of

long axis

SST Short Axis WNLSST, internal shoulder rotation SA view

Supraspinatus Tendon-Long Axis

Subacromial Bursa

Supraspinatous, birds beak view (insertion)

GT

Supraspinatus Tendon-Short Axis

WNL

SAB

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Calcific Tendinopathy

Full thickness tearPartial thickness tear

Normal


Partial thickness bursalsided tear

Counseling

USG SAB injection

Rehab scapula stabilization

Clinical follow-up

Smith, T.O., et al. (2011). “Diagnostic accuracy of ultrasound for rotator cuff tears in adults: a systematic review and meta-analysis.” Clin Radiol 66:1036-48

Management and outcome of this shoulder will be different

SHOULDER PAINFull Thickness Tear

Ultrasound accurately identifies Extent of retraction (to acromion)

Tear size A-P width (# tendons)

Ferri AJR 05; Teefey JBJS 04; Nazarian Radiology 13

Full thickness tearNo tear, mild tendinosis

Non-Invasive Glycogen Measurement: The Next Frontier of Sports

Performance in Cycling

Quantification of glycogen content in a non-invasive way

Hill, JC and San Millan, I. Validation of Musculoskeletal Ultrasound to Assess Muscle Glycogen Content. A Novel Approach. 2014, Phys & SpMed,Submitted

What is Glycogen?

• Glycogen is the storage form of glucose.

• Glucose is the most important form of carbohydrate used by humans, and is an essential fuel source for the body.

• Fat and glucose are the predominant fuels for humans.

• During exercise and competition, glucose is the most important fuel for the muscles.

What is Glycogen?

• Fat storage is unlimited….glycogen storage is VERY LIMITED!

• Glycogen is stored in muscles and liver.

• Maximal Glycogen storage capacity in muscles and liver is about 1.1-1.3 lbs, equivalent to approximately 90-120 minutes of physical activity.

• Maintaining adequate Glycogen content is crucial, especially in athletic performance.

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Importance of Glycogen Storage

Glycogen

Muscle

Glucose

Liver

Glycogen is thestorage form of

glucose in liver and skeletal muscle

Importance of Glycogen Storage

Glycogen

Muscle

Glucose

Liver

During exercise, skeletal muscle uses

glucose deliveredfrom the liver as wellas from the glycogen

storage in muscle.

Glycogen Depletion During Exercise(Muscle Biopsy)

Before

Optimal Levels

After

Glycogen Depletion

Glycogen Will Be Utilized During Exercise Very Rapidly!

As soon as 80 minutes!

Hermansen L, Hultman E, Saltin B. Muscle glycogen during prolonged severe exercise. Acta Physiol Scand. 1967 Oct-Nov;71(2):129-39.

Multiple scientific studies show the direct relationship between glycogen levels and

performance

Bangsbo J, Graham TE, Kiens B & Saltin B (1992). J Physiol 451,205–227Bergström J, Hermansen L, Hultman E & Saltin B (1967). Acta Physiol Scand 71, 140–150Costill DL, Pascoe DD, Fink WJ, Robergs RA, Barr SI, Pearson D. J Appl Physiol, 1990; 69: 46-50.San Millán I, González-Haro C, Hill J. Med Sci Sports Exerc, 2011; 43: S48

The relationship of muscle glycogen content, work time and dietary carbohydrate intake (adapted from Borgström et al. 1967).

Glycogen and Performance

Time to Exhaustion

Bergström J, Hermansen L, Hultman E & Saltin B (1967). Acta Physiol Scand 71, 140–150

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Glycogen Intake and Performance

Bergström J, Hermansen L, Hultman E & Saltin B (1967). Diet muscle glycogen and physical performance. Acta Physiol Scand 71, 140–150

Glycogen Storage and Performance

Bergström J, Hermansen L, Hultman E & Saltin B (1967). Diet muscle glycogen and physical performance. Acta Physiol Scand 71, 140–150

The Importance of CHO and Gycogen Storage

Muscle Glycogen depleted

glycogen glycogen

Muscle with plenty of glycogen



FAT

glycogen

Muscle Protein(BCAA’s)

During High Exercise intensities(Competition, hard training)



glycogen

Catabolism Z-Lines

Sarcomere

Muscle Damage Low glycogen levels during hard training and competition will not onlydecrease performance but will also cause muscle damage!!!

Normal Muscle

Damaged Muscle

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Z-Lines

Sarcomere

Muscle Damage Damaged muscle impairs proper muscle glycogen storage capacity!!...This may create a vicious cycle and lead to overtraining!.

Impaired muscle glycogen resynthesis after eccentric exercise. Costil, DL., et al.,J Appl Physiol69: 46-50, 1990

To maintain glycogen storages it is recommended tohave a daily intake of CHO of 6-9g/CHO/Kg

However…Glycogen content can vary among individuals

Nutritional study with Professional Cyclists

4.3 4

6-10

0

1

2

3

4

5

6

7

8

Professional Cyclists Normal Population Recommended Cyclist

CHO

/Kg/

Day

Mean Carbohydrates/Kg/Day

Nutritional study with Professional Cyclists

Even they have a low CHO diet!!

San Millán I, González-Haro C, Hill J. Med Sci Sports Exerc, 2011; 43: S48

We measure the level of gasoline in the tanks of our cars all the time, right?

Glycogen is the Gasoline of our MusclesWhy Don’t We Measure the Gasoline Levels

in Our Muscles?

What if we could?

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It is possible…But…up until now the only way to measureglycogen levels was by a MUSCLE BIOPSY

Traditional Muscle Biopsy Techniques

Invasive and aggressive

Impractical and notclinically applicable

Open Technique

Borgström Technique

Bergstrom, J. Percutaneous needle biopsy of skeletal muscle in physiological and clinical research. Scand J Clin Lab Invest. 1975 Nov;35(7):609-16

Through high frequency ultrasound we can assess muscle glycogen content in a rapid, non-

invasive method in about 15 seconds!

Dr. John Hill measures the glycogen levels of Garmin-Transitions Tour de France cyclist Christian Van de Velde.

Glycogen Measurement: Performance Advantages

• If an athlete’s glycogen levels could be tested before, during and after competition, you can ensure the athlete is performing with a full energy stores.

• It would be possible to control the nutrition of the athlete to a level that has never been done before.

• If the athlete does not respond to diet changes, this could be an early method for detecting over training.

Measuring Muscle Glycogen: Does it Work?

• January 2010 – Dr’s. John Hill and Inigo San Millan developed an ultrasound technique to detect changes in muscle glycogen content with ultrasound.

• This same method was applied during the 2010 Tour of California to help the Garmin riders improve their performance, and win the Tour.

• In June 2014, Dr. San Millan and I completed the validation study comparing muscle biopsy to ultrasound. This is the first report of that study

How does it Work?

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Graphic representation of ScanGraphic Views of Muscle Glycogen

Content with Ultrasound

Glycogen stores empty

When glycogen leaves the tissue

It takes water with it

Glycogen stores full

Graphic Views of Muscle Glycogen Content with Ultrasound

Numerical values for each boxNumerical values glycogen partially depleted


Further depletion of glycogen Glycogen stores almost empty


Over time total numerical value

Drops as glycogen is depleted

Software design can process just the

Key elements and exclude the artifact


These past slides demonstrate graphically how the subjective ultrasound image is converted to an objectivenumerical value which anyone can understand

Connective tissue is a critical artifactWhich can be digitally subtracted

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Garmin Cyclist before and after Maximal Exertion (V02 test)

Pre-exercise cross section of

Rectus FemorisPost-exercise same muscle

Garmin Cyclist at Baseline and after 4hour hard training ride

Baseline hypoechoic (dark)

muscle appearance

After 4 hour ride, glycogen is partially depleted but not as much as after VO2test because the rider is able to eat and continue replacing glycogen stores

Novel Methodology for Muscle Glycogen Content Assessment through High Frequency Ultrasound

How are the Images Processed?Baseline Rectus Femoris SA Post-Exercise Rectus Femoris SA

Same exact muscle after 90 minutes of moderately intense exertion on cyclergometer

How are the Images Processed?

Original Baseline RF LA view Original Post Ex RF SA view

MuscleSound, LLC; US Patents 8,512,247, 8,517,942 and additional patents pending


Baseline RF LA view Post-Exercise Rectus Femoris SA

-Chrome is cropped, leaving only the ultrasound image

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How are the Images Processed?Baseline RF LA view Post-Exercise Rectus Femoris SA

-Sides are cropped, image is smoothed using Gaussian blur


-Thresholding; converting to binary image (black and white)


-Morphing technique to fill in holes which connects all muscle-Image is returned to Gray Scale


Baseline RF LA view Post-Exercise Rectus Femoris SA

-Image extraction performed which removes skin and fat-Bottom crop removes connective tissue and artifact-Pixel intensity of all connective tissue is 255-Muscle glycogen score is determined from Pixels with 1-254 intensities


Combined SA & LA , Rectus Femoris 3 Different Scans of RF SA view

-Pixels are averaged and compared across linked images, -This allows individual scans to be tested for consistency and reliability-Pixel intensity is changed from 0-255 to 0-100 which simplifies the interpretation (Entire process takes

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Methods 22 male competitive cyclists, Pro, Cat 1-4

Perform steady state cyclergometer test for 90 minutes at mod-high exercise intensity CHOox of 2-3 gm/min Lactate levels, 2-3 mM

Age Height Weight % Body

Fat*

BMI #

Races/yea

r

31.3 +/‐

5.1

183.7 +/‐

4.9 cm

76.8 +/‐7.8

kg

12.1+/‐

2.4 %

22.7 +/‐

1.8

27.1 +/‐

19.7

Methods

Pre- and Post-exercise glycogen content of right and left Rectus Femoris was measured using: Histochemical analysis through muscle biopsy

High frequency ultrasound scans using MuscleSound® technology to measure and quantify glycogen

Muscle Biopsy Technique

Why rectus femoris muscle rather than the vastus lateralis? Less connective tissue reduces potential artifact in

the ultrasound images Less connective tissue in the muscle biopsy samples

Reducing potential artifacts may improve both sensitivity and specificity

More precisely detect changes in muscle glycogen content Many competitive cyclists believe the RF region of the

quadriceps feels empty and fatigued before VL region


Ultrasound guided muscle biopsy Precisely directs biopsy

Color flow Doppler Avoid vascular structures

No complications were encountered with 88 consecutive biopsies No hematoma No hemorrhages

Hill, JC and San Millan, I. Validation of Musculoskeletal Ultrasound to Assess Muscle Glycogen Content. A Novel Approach. 2014, Phys & SpMed, Submitted


Bard MonoptyDisposable Core Biopsy Instrument (Liver biopsy) 12 gauge X 10 cm length

biopsy needle 2 passes made at Baseline

and Post-exercise

Correlation Results


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Correlation Results


Correlation Results


Individual Subjects Change

Muscle Biopsy Glycogen Change Ultrasound Glycogen Change


Correlation of Different Muscles


Correlation of Different Muscles


Conclusions of Validation Study

Pre- and post-exercise ultrasound scans using MuscleSound® technology were highly correlated with histochemical glycogen assessment through muscle biopsy.

Changes in glycogen content from pre- and post-exercise were also highly correlated between MuscleSound® technology and muscle biopsy histochemical analysis.


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Conclusions of Validation Study

Results show that the use of high-frequency ultrasound through MuscleSound® technology Accurate and reliable method to measure skeletal

muscle glycogen It is practical, rapid and non-invasive.


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