Reliability of Ultrasound Findings in Patients with Lumbar Multifidus Myofascial Pain Syndrome

Document Type : RESEARCH PAPER

Authors

1 Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran

2 Neuroscience Research Center, Poorsina Hospital, Faculty of medicine, Guilan University of Medical Sciences, Rasht, Iran

Abstract

Background: Lumbar multifidus muscle provides stability to the spine. The present study aimed to evaluate the 
reliability of ultrasound findings in patients with lumbar multifidus myofascial pain syndrome (MPS).
Methods: A total of 24 cases (7 females, 17 males, mean age: 40.13± 5.69, BMI: 26.48±4.96) with multifidus MPS were 
assessed. The variables were muscle thickness in rest and contraction, thickness changes, and cross-sectional area 
(CSA) in rest and contraction. Two examiners performed the test and retest sessions.
Results: The active trigger points of lumbar multifidus on the right and left side of the cases were 45.8 % and 54.2%, 
respectively. The intraclass correlation coefficient (ICC) values for muscle thickness and thickness changes showed 
moderate to very high reliability for both within and between intra-examiner measurements. (ICC, 1st examiner: 0.78-
0.96; ICC, 2nd examiner: 0.86-0.95). In addition, the ICC values of within and between-session intra-examiner for CSA 
were high. (ICC, 1st examiner: 0.83-0.88; ICC, 2nd examiner: 0.84-0.89). The ICC and standard error of measurement 
(SEM) of inter-examiner reliability ranged between 0.75 to 0.93 and 0.19 to 0.88 for multifidus muscle thickness and 
thickness changes. The ICC and SEM of inter-examiner reliability ranged between 0.78 to 0.88 and 0.33 to 0.90 for 
CSA of the multifidus muscle. 
Conclusion: The within and between-session reliability of multifidus thickness, thickness changes, and CSA was 
moderate to very high in patients with lumbar MPS when taken by two examiners. Furthermore, the inter-examiner 
reliability of these sonographic findings was high. 
Level of evidence: III

Keywords

Main Subjects


1. Fatoye F, Gebrye T, Odeyemi I. Real-world incidence
and prevalence of low back pain using routinely
collected data. Rheumatol Int.2019;39(4):619-626.
doi: 10.1007/s00296-019-04273-0.
2. Wu A, March L, Zheng X, et al. Global low back pain
prevalence and years lived with disability from 1990
to 2017: estimates from the Global Burden of Disease
Study 2017. Ann Transl Med.2020;8(6):299. doi:
10.21037/atm.2020.02.175.
3. Noormohammadpour P, Mansournia MA, Koohpayehzadeh J, et al. Prevalence of chronic neck pain,
low back pain, and knee pain and their related
factors in community-dwelling adults in Iran. Clin
J Pain.2017 Feb;33(2):181-187. doi: 10.1097/
AJP.0000000000000396.
4. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low
back pain is and why we need to pay attention. Lancet.
2018;391(10137):2356-67. doi: 10.1016/S0140-
6736(18)30480-X.
5. Rozhkov D, Zinovyeva O, Barinov A, et al. Myofascial
pain syndrome in female patients with chronic
nonspecific back pain: diagnosis and treatment.
Neurology, Neuropsychiatry, Psychosomatics.
2020;12(2):57-63.
6. Yousefzadeh Chabok S, Ezzati K, Saberi A, Hosein Zadeh
J. Evaluating the Prevalence of Lumbar Myofascial Pain
Syndrome in Patients with Non-specific Chronic Low
Back Pain and a Normal MRI Study. Journal of Guilan
University of Medical Sciences. 2020;29(1):43-50.
7. Bourgaize S, Newton G, Kumbhare D, Srbely J.
A comparison of the clinical manifestation and
pathophysiology of myofascial pain syndrome and
fibromyalgia: implications for differential diagnosis
and management. J Can Chiropr Assoc.2018
Apr;62(1):26-41.
8. Motaqi M, Ghanjal A. Trigger and Tender Points
(Definitions, Similarities, Differences, Treatments).
International Journal of Musculoskeletal Pain
Prevention. 2020;5(4):393-5.
9. David G. Simons, Janet G. Travell, Lois S. Simons,eds
. Myofascial Pain and Dysfunction: The Trigger Point
Manual, Vol. 1 - Upper Half of Body. 2nd Edition.
Lippincott Williams & Wilkins; 2018.
10.Ribeiro DC, Belgrave A, Naden A, Fang H, Matthews
P, Parshottam S. The prevalence of myofascial trigger
points in neck and shoulder-related disorders: a
systematic review of the literature. BMC Musculoskelet
Disord.2018;19(1):252. doi: 10.1186/s12891-018-
2157-9.
11.Fernández-de-Las-Peñas C, Dommerholt J.
International consensus on diagnostic criteria and
clinical considerations of myofascial trigger points:
a Delphi study. Pain Med.2018;19(1):142-150. doi:
10.1093/pm/pnx207.
12.Rahmani N, Kiani A, Mohseni-Bandpei MA, Abdollahi
I. Multifidus muscle size in adolescents with and
without back pain using ultrasonography. J Bodyw
Mov Ther.2018;22(1):147-151. doi: 10.1016/j.
jbmt.2017.05.016.
13.Ezzati K, Khani S, Moladoust H, Takamjani IE, Nasiri E,
Ettehad H. Comparing muscle thickness and function
in healthy people and subjects with upper trapezius
myofascial pain syndrome using ultrasonography. J
Bodyw Mov Ther.2021;26:253-256. doi: 10.1016/j.
jbmt.2020.12.016.
14.Winter J, Kimber A, Montenegro S, Gao J.
Ultrasonography to assess the efficacy of osteopathic
manipulative treatment for lumbar spine asymmetry.
J Am Osteopath Assoc.2020;120(11):761-769. doi:
10.7556/jaoa.2020.127.
15.Arimi SA, Bandpei MAM, Rezasoltani A, Peolsson A,
Mohammadi M. Multifidus muscle size changes at
different directions of head and neck movements in
females with unilateral chronic non-specific neck pain
and healthy subjects using ultrasonography. J Bodyw
Mov Ther.2018;22(3):560-565. doi: 10.1016/j.jbmt.
2017.09.011.
16.Basha MAA, Eldib DB, Aly SA, et al. Diagnostic accuracy
of ultrasonography in the assessment of anterior knee
pain. Insights Imaging.2020;11(1):107. doi: 10.1186/
s13244-020-00914-2.
17.ShahAli S, Shanbehzadeh S, ShahAli S, Takamjani IE.
Application of ultrasonography in the assessment
of abdominal and lumbar trunk muscle activity
in participants with and without low back pain:
A systematic review. J Manipulative Physiol
Ther.2019;42(7):541-550. doi: 10.1016/j.jmpt.2019.
05.003.
18.Fortin M, Rizk A, Frenette S, Boily M, Rivaz H.
Ultrasonography of multifidus muscle morphology
and function in ice hockey players with and without
low back pain. Phys Ther Sport.2019;37:77-85. doi:
10.1016/j.ptsp.2019.03.004.
19.Patil P, Dasgupta BJTaimd. Role of diagnostic
ultrasound in the assessment of musculoskeletal
diseases. Ther Adv Musculoskelet Dis.2012;4(5):341-
55. doi: 10.1177/1759720X12442112..
20.Whittaker JL, Ellis R, Hodges PW, et al. Imaging with
ultrasound in physical therapy: What is the PT’s
scope of practice? A competency-based educational
model and training recommendations. Br J Sports
Med.2019;53(23):1447-1453. doi: 10.1136/bjsports2018-100193.
21.Djordjevic O, Konstantinovic L, Miljkovic N, Bijelic
G. Relationship between electromyographic signal
amplitude and thickness change of the trunk
muscles in patients with and without low back pain.
Clin J Pain.2015;31(10):893-902. doi: 10.1097/
AJP.0000000000000179.
22.Goubert D, De Pauw R, Meeus M, et al. Lumbar muscle structure and function in chronic versus
recurrent low back pain: a cross-sectional study.
Spine J.2017;17(9):1285-1296. doi: 10.1016/j.
spinee.2017.04.025.
23.Kim CY, Choi JD, Kim SY, Oh DW, Kim JK, Park JW.
Comparison between muscle activation measured by
electromyography and muscle thickness measured
using ultrasonography for effective muscle assessment.
J Electromyogr Kinesiol.2014 Oct;24(5):614-20. doi:
10.1016/j.jelekin.2014.07.002.
24.Ezzati K, Khani S, Moladoust H, et al. Comparing muscle
thickness and function in healthy people and subjects
with upper trapezius myofascial pain syndrome using
ultrasonography. J Bodyw Mov Ther.2021;26:253-
256. doi: 10.1016/j.jbmt.2020.12.016.
25. Kumbhare DA, Elzibak AH, Noseworthy MDJAJoPM,
Rehabilitation. Assessment of myofascial trigger
points using ultrasound. Am J Phys Med
Rehabil.2016;95(1):72-80. doi: 10.1097/PHM.00000
00000000376.
26.Taghipour M, Mohseni-Bandpei MA, Abdollahi
I, Rajabzadeh F, Naghdi N, Pourahmadi MR.
Reliability of B-mode ultrasonography to measure
lumbar multifidus muscle dimensions in patients
with unilateral lumbar disc herniation. J Bodyw
Mov Ther.2021;26:153-157. doi: 10.1016/j.
jbmt.2020.06.042.
27.Sions JM, Velasco TO, Teyhen DS, Hicks GE. Reliability
of ultrasound imaging for the assessment of lumbar
multifidi thickness in older adults with chronic low
back pain. J Geriatr Phys Ther.2015;38(1):33-9. doi:
10.1519/JPT.0000000000000021.
28.Romero-Morales C, Calvo-Lobo C, Navarro-Flores
E, et al. M-mode ultrasound examination of soleus
muscle in healthy subjects: intra-and inter-rater
reliability study. Healthcare (Basel).2020;8(4):555.
doi: 10.3390/healthcare8040555.
29.Djordjevic O, Djordjevic A, Konstantinovic L.
Interrater and intrarater reliability of transverse
abdominal and lumbar multifidus muscle thickness
in subjects with and without low back pain. J Orthop
Sports Phys Ther.2014;44(12):979-88. doi: 10.2519/
jospt.2014.5141.
30.Taghipour M, Mohseni-Bandpei MA, Abdollahi I,
et al. Reliability of B-mode ultrasonography to
measure lumbar multifidus muscle dimensions in
patients with unilateral lumbar disc herniation. J
Bodyw Mov Ther.2021;26:153-157. doi: 10.1016/j.
jbmt.2020.06.042.
31.Bujang MA, Baharum N. A simplified guide to
determination of sample size requirements for
estimating the value of intraclass correlation
coefficient: a review. Archives of Orofacial Science.
2017;12(1).
32.Ahmed S, Aggarwal A, Lawrence AJRI. Performance of
the American College of Rheumatology 2016 criteria
for fibromyalgia in a referral care setting. Rheumatol
Int.2019;39(8):1397-1403. doi: 10.1007/s00296-
019-04323-7.
33.Asghari A, Saed F, Dibajnia P. Psychometric properties
of the Depression Anxiety Stress Scales-21 (DASS21) in a non-clinical Iranian sample. Int J psychol.
2008;2(2):82-102.
34.Lo LC, Hatfield BD, Wu CT, Chang CC, Hung TM.
Elevated state anxiety alters cerebral cortical
dynamics and degrades precision cognitive-motor
performance. Sport, Exercise, and Performance
Psychology. 2019;8(1):21.
35.Magee DJ, Manske RC,eds. Orthopedic physical
assessment-E-Book.1st ed. Elsevier Health Sciences;
2020 .
36.Koppenhaver S, Kniss J, Lilley D, et al. Reliability of
ultrasound shear-wave elastography in assessing
low back musculature elasticity in asymptomatic
individuals. J Electromyogr Kinesiol.2018;39:49-57.
doi: 10.1016/j.jelekin.2018.01.010..
37.Mehta S, Bastero-Caballero RF, Sun Y, et al.
Performance of intraclass correlation coefficient (ICC)
as a reliability index under various distributions in
scale reliability studies. Stat Med.2018;37(18):2734-
2752. doi: 10.1002/sim.7679.
38.Carter R, Lubinsky J,eds. Rehabilitation research:
principles and applications.5st ed. Elsevier Health
Sciences; 2015.
39.Mohammadi-Rad S, Mohseni Bandpei M, Salavati
M, et al. Reliability of Center of Pressure measures
of Postural Stability in Anterior Cruciate Ligament
Reconstructed Athletes: Effect of Vibration and
Cognitive Load. Arch Bone Jt Surg.2022;10(2):171-
182. doi: 10.22038/ABJS.2021.54007.2700.
40.Cheung WK, Cheung JPY, Lee W-N. Role of
ultrasound in low back pain: a review. Ultrasound
Med Biol.2020;46(6):1344-1358. doi: 10.1016/j.
ultrasmedbio.2020.02.004.
41.Wong AY, Parent E, Kawchuk G. Reliability of 2
ultrasonic imaging analysis methods in quantifying
lumbar multifidus thickness. J Orthop Sports
Phys Ther.2013;43(4):251-62. doi: 10.2519/
jospt.2013.4478. Epub 2012 Dec 7.
42. Skeie EJ, Borge JA, Leboeuf-Yde C, Bolton J, Wedderkopp
N. Reliability of diagnostic ultrasound in measuring the
multifidus muscle. Chiropr Man Therap.2015;23:15.
doi: 10.1186/s12998-015-0059-6.
43.Plaza-Manzano G, Navarro-Santana MJ, ValeraCalero JA, Fabero-Garrido R, Fernández-de-lasPeñas C, López-de-Uralde-Villanueva I. Reliability
of lumbar multifidus ultrasound assessment
during the active straight leg raise test. Eur J Clin
Invest.2022;52(5):e13728. doi: 10.1111/eci.13728.
44.Sánchez Romero EA, Alonso Pérez JL, Muñoz
Fernández AC, et al. Reliability of Sonography
Measures of the Lumbar Multifidus and Transversus
Abdominis during Static and Dynamic Activities in
Subjects with Non-Specific Chronic Low Back Pain.
Diagnostics (Basel).2021;11(4):632. doi: 10.3390/
diagnostics11040632..
45.Farragher J, Pranata A, El-Ansary D, et al. Reliability
of lumbar multifidus and iliocostalis lumborum
thickness and echogenicity measurements using
ultrasound imaging. Australas J Ultrasound
Med.2021;24(3):151-160. doi: 10.1002/ajum.12273.
46.Cuellar W, Blizzard L, Callisaya M, et al. Test-retest reliability of measurements of abdominal
and multifidus muscles using ultrasound imaging
in adults aged 50–79 years. Musculoskelet Sci
Pract.2017;28:79-84. doi: 10.1016/j.msksp.2016.
11.013..
47.Sions JM, Velasco TO, Teyhen DS, Hicks GE. Ultrasound
imaging: intraexaminer and interexaminer reliability
for multifidus muscle thickness assessment in adults
aged 60 to 85 years versus younger adults. J Orthop
Sports Phys Ther.2014;44(6):425-34. doi: 10.2519/
jospt.2014.4584.
48.Kiesel KB, Uhl TL, Underwood FB, Rodd DW, Nitz
AJ. Measurement of lumbar multifidus muscle
contraction with rehabilitative ultrasound imaging.
Man Ther.2007;12(2):161-6. doi: 10.1016/j.
math.2006.06.011.
49.Taghipour M, Mohseni-Bandpei MA, Behtash H,
et al. Reliability of Real-time Ultrasound Imaging
for the Assessment of Trunk Stabilizer Muscles: A
Systematic Review of the Literature. J Ultrasound
Med.2019;38(1):15-26. doi: 10.1002/jum.14661.