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European Spine Journal

, Volume 17, Issue 4, pp 494–501 | Cite as

Muscle thickness changes during abdominal hollowing: an assessment of between-day measurement error in controls and patients with chronic low back pain

  • Anne F. MannionEmail author
  • Natascha Pulkovski
  • Deborah Gubler
  • Mark Gorelick
  • David O’Riordan
  • Thanasis Loupas
  • Peter Schenk
  • Hans Gerber
  • Haiko Sprott
Original Article

Abstract

Spine stabilization exercises, in which patients are taught to perform isolated contractions of the transverses abdominus (TrA) during “abdominal hollowing”, are a popular physiotherapeutic treatment for low back pain (LBP). Successful performance is typically judged by the relative increase in TrA thickness compared with that of the internal (OI) and external (OE) oblique muscles, measured using ultrasound. The day-to-day measurement error (imprecision) associated with these indices of preferential activation has not been assessed but is important to know since it influences the interpretation of changes after treatment. On 2 separate days, 14 controls and 14 patients with chronic LBP (cLBP) performed abdominal hollowing exercises in hook-lying, while M-mode ultrasound images superimposed with tissue Doppler imaging (TDI) data were recorded from the abdominal muscles (N = 5 on each side). The fascial lines bordering the TrA, OI and OE were digitized, and muscle thicknesses were calculated. The between-day error (intra-observer) was expressed as the standard error of measurement, SEM; SEM as a percentage of the mean gave the coefficient of variation (CV). There were no significant between-day differences for the mean values of resting or maximal thickness for any muscle, in either group (P > 0.05). The median SEM and CV of all thickness variables was 0.71 mm and 10.9%, respectively for the controls and 0.80 mm or 11.3%, respectively for the cLBP patients. For the contraction ratios (muscle thickness contracted/thickness at rest), the CVs were 3–11% (controls) and 5–12% (patients). The CVs were unacceptably high (30–50%, both groups) for the TrA preferential activation ratio (TrA proportion of the total lateral abdominal muscle thickness when contracted minus at rest). In both the controls and patients, the precision of measurement of absolute muscle thickness and relative change in thickness during abdominal hollowing was acceptable, and commensurate with that typical of biological measurements. The TrA preferential activation ratio is too imprecise to be of clinical use. Knowledge of the SEM for these indices is essential for interpreting the clinical relevance of any changes observed following physiotherapy.

Keywords

Abdominal muscles Physiotherapy exercises Back pain Reliability Measurement error 

References

  1. 1.
    Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, Mannion AF, Reis S, Staal JB, Ursin H, Zanoli G (2006) Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 15(Suppl 2):S192–S300PubMedCrossRefGoogle Scholar
  2. 2.
    Allison GT, Kendle K, Roll S, Schupelius J, Scott Q, Panizza J (1998) The role of the diaphragm during abdominal hollowing exercises. Aust J Physiother 44:95–102PubMedGoogle Scholar
  3. 3.
    Beaton DE (2000) Understanding the relevance of measured change through studies of responsiveness. Spine 25:3192–3199PubMedCrossRefGoogle Scholar
  4. 4.
    Bunce SM, Moore AP, Hough AD (2002) M-mode ultrasound: a reliable measure of transversus abdominis thickness? Clin Biomech (Bristol, Avon) 17:315–317CrossRefGoogle Scholar
  5. 5.
    Cairns MC, Harrison K, Wright C (2000) Pressure biofeedback: a useful tool in the quantification of abdominal muscle dysfunction? Physiotherapy 86:127–138CrossRefGoogle Scholar
  6. 6.
    Critchley DJ, Coutts FJ (2002) Abdominal muscle function in chronic low back pain patients. Physiotherapy 88:322–332CrossRefGoogle Scholar
  7. 7.
    Currier DP (1990) Elements of research in physical therapy. Williams and Wilkins, BaltimoreGoogle Scholar
  8. 8.
    Elfving B, Nemeth G, Arvidsson I, Lamontagne M (1999) Reliability of EMG spectral parameters in repeated measurements of back muscle fatigue. J Electromyogr Kinesiol 9:235–243PubMedCrossRefGoogle Scholar
  9. 9.
    Ferreira PH, Ferreira ML, Maher CG, Herbert RD, Refshauge K (2006) Specific stabilisation exercise for spinal and pelvic pain: a systematic review. Aust J Physiother 52:79–88PubMedGoogle Scholar
  10. 10.
    Henry SM, Westervelt KC (2005) The use of real-time ultrasound feedback in teaching abdominal hollowing exercises to healthy subjects. J Orthop Sports Phys Ther 35:338–345PubMedGoogle Scholar
  11. 11.
    Hides J, Wilson S, Stanton W, McMahon S, Keto H, McMahon K, Bryant M, Richardson C (2006) An MRI investigation into the function of the transversus abdominis muscle during “drawing-in” of the abdominal wall. Spine 31:E175–E178PubMedCrossRefGoogle Scholar
  12. 12.
    Hides JA, Jull GA, Richardson CA (1998) Use of real-time ultrasound imaging for feedback in rehabilitation. Man Ther 3:125–131CrossRefGoogle Scholar
  13. 13.
    Hodges P, Richardson C, Jull G (1996) Evaluation of the relationship between laboratory and clinical tests of transversus abdominis function. Physiother Res Int 1:30–40PubMedCrossRefGoogle Scholar
  14. 14.
    Hodges PW (2005) Ultrasound imaging in rehabilitation: just a fad? J Orthop Sports Phys Ther 35:333–337PubMedGoogle Scholar
  15. 15.
    Hodges PW, Pengel LH, Herbert RD, Gandevia SC (2003) Measurement of muscle contraction with ultrasound imaging. Muscle Nerve 27:682–692PubMedCrossRefGoogle Scholar
  16. 16.
    Hopkins WG (2000) Measures of reliability in sports medicine and science. Sports Med 30:1–15PubMedCrossRefGoogle Scholar
  17. 17.
    Howe T, Oldham J (1995) Functional tests in elderly osteoarthritic subjects: variability of performance. Nurs Stand 9:35–38PubMedGoogle Scholar
  18. 18.
    John EK, Beith ID (2007) Can activity within the external abdominal oblique be measured using real-time ultrasound imaging? Clin Biomech (Bristol, Avon) 22:972–979CrossRefGoogle Scholar
  19. 19.
    Luoto S, Hupli M, Alaranta H, Hurri H (1996) Isokinetic performance capacity of trunk muscles. Part II: coefficient of variation in isokinetic measurement in maximal effort and in submaximal effort. Scand J Rehabil Med 28:207–210PubMedGoogle Scholar
  20. 20.
    McMeeken JM, Beith ID, Newham DJ, Milligan P, Critchley DJ (2004) The relationship between EMG and change in thickness of transversus abdominis. Clin Biomech 19:337–342CrossRefGoogle Scholar
  21. 21.
    Misuri G, Colagrande S, Gorini M, Iandelli I, Mancini M, Duranti R, Scano G (1997) In vivo ultrasound assessment of respiratory function of abdominal muscles in normal subjects. Eur Respir J 10:2861–2867PubMedCrossRefGoogle Scholar
  22. 22.
    Rackwitz B, de Bie R, Limm H, von Garnier K, Ewert T, Stucki G (2006) Segmental stabilizing exercises and low back pain. What is the evidence? A systematic review of randomized controlled trials. Clin Rehabil 20:553–567PubMedCrossRefGoogle Scholar
  23. 23.
    Rankin G, Stokes M (1998) Reliability of assessment tools in rehabilitation: an illustration of appropriate statistical analyses. Clin Rehabil 12:187–199PubMedCrossRefGoogle Scholar
  24. 24.
    Rankin G, Stokes M, Newham DJ (2006) Abdominal muscle size and symmetry in normal subjects. Muscle Nerve 34:320–326PubMedCrossRefGoogle Scholar
  25. 25.
    Richardson C, Jull G, Hodges P, Hides J (1999) Therapeutic exercise for spinal stabilisation: scientific basis and practical techniques. Churchill Livingstone, EdinburghGoogle Scholar
  26. 26.
    Shrout PE, Fleiss JL (1979) Intraclass correlations: uses in assessing rater reliability. Psychol Bull 86:420–428CrossRefPubMedGoogle Scholar
  27. 27.
    Stokes M (1985) Reliability and repeatability of methods for measuring muscle in physiotherapy. Physiother Theory Prac 1:71–76CrossRefGoogle Scholar
  28. 28.
    Storheim K, Bo K, Pederstad O, Jahnsen R (2002) Intra-tester reproducibility of pressure biofeedback in measurement of transversus abdominis function. Physiother Res Int 7:239–249PubMedCrossRefGoogle Scholar
  29. 29.
    Teyhen DS, Miltenberger CE, Deiters HM, Del Toro YM, Pulliam JN, Childs JD, Boyles RE, Flynn TW (2005) The use of ultrasound imaging of the abdominal drawing-in maneuver in subjects with low back pain. J Orthop Sports Phys Ther 35:346–355PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • Anne F. Mannion
    • 1
    Email author
  • Natascha Pulkovski
    • 2
  • Deborah Gubler
    • 2
  • Mark Gorelick
    • 1
  • David O’Riordan
    • 1
  • Thanasis Loupas
    • 3
  • Peter Schenk
    • 2
  • Hans Gerber
    • 4
  • Haiko Sprott
    • 2
  1. 1.Spine Center Division, Department of Research and DevelopmentSchulthess KlinikZurichSwitzerland
  2. 2.Department of Rheumatology and Institute of Physical MedicineUniversity Hospital ZürichZurichSwitzerland
  3. 3.Philips Medical SystemsAthensGreece
  4. 4.Department of Mechanical and Process EngineeringInstitute for Biomechanics, Swiss Federal Institute of TechnologyZurichSwitzerland

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