European Spine Journal

, Volume 21, Supplement 6, pp 750–759 | Cite as

Ultrasound assessment of transversus abdominis muscle contraction ratio during abdominal hollowing: a useful tool to distinguish between patients with chronic low back pain and healthy controls?

  • N. Pulkovski
  • A. F. Mannion
  • F. Caporaso
  • V. Toma
  • D. Gubler
  • D. Helbling
  • H. Sprott
Original Article


Spine stabilisation exercises, in which patients are taught to preferentially activate the transversus abdominus (TrA) during “abdominal hollowing” (AH), are a popular treatment for chronic low back pain (cLBP). The present study investigated whether performance during AH differed between cLBP patients and controls to an extent that would render it useful diagnostic tool. 50 patients with cLBP (46.3 ± 12.5 years) and 50 healthy controls (43.6 ± 12.7 years) participated in this case–control study. They performed AH in hook-lying. Using M-mode ultrasound, thicknesses of TrA, and obliquus internus and externus were determined at rest and during 5 s AH (5 measures each body side). The TrA contraction-ratio (TrA-CR) (TrA contracted/rest) and the ability to sustain the contraction [standard deviation (SD) of TrA thickness during the stable phase of the hold] were investigated. There were no significant group differences for the absolute muscle thicknesses at rest or during AH, or for the SD of TrA thickness. There was a small but significant difference between the groups for TrA-CR: cLBP 1.35 ± 0.14, controls 1.44 ± 0.24 (p < 0.05). However, Receiver Operator Characteristics (ROC) analysis revealed a poor and non-significant ability of TrA-CR to discriminate between cLBP patients and controls on an individual basis (ROC area under the curve, 0.60 [95% CI 0.495; 0.695], p = 0.08). In the patient group, TrA-CR showed a low but significant correlation with Roland Morris score (Spearman Rho = 0.328; p = 0.02). In conclusion, the difference in group mean values for TrA-CR was small and of uncertain clinical relevance. Moreover, TrA-CR showed a poor ability to discriminate between control and cLBP subjects on an individual basis. We conclude that the TrA-CR during abdominal hollowing does not distinguish well between patients with chronic low back pain and healthy controls.


Abdominal hollowing Ultrasound Transversus abdominis muscle Chronic low back pain 


  1. 1.
    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
  2. 2.
    Bergmark A (1989) Stability of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand Suppl 230:1–54PubMedGoogle Scholar
  3. 3.
    Bland JM, Altman DG (1996) The use of transformation when comparing two means. BMJ 312:1153PubMedCrossRefGoogle Scholar
  4. 4.
    Bunce SM, Hough AD, Moore AP (2004) Measurement of abdominal muscle thickness using M-mode ultrasound imaging during functional activities. Man Ther 9:41–44PubMedCrossRefGoogle Scholar
  5. 5.
    Bunce SM, Moore AP, Hough AD (2002) M-mode ultrasound: a reliable measure of transversus abdominis thickness? Clin Biomech 17:315–317CrossRefGoogle Scholar
  6. 6.
    Cairns MC, Harrison K, Wright C (2000) Pressure biofeedback: a useful tool in the quantification of abdominal muscle dysfunction? Physiotherapy 86:127–138CrossRefGoogle Scholar
  7. 7.
    Critchley DJ, Coutts FJ (2002) Abdominal muscle function in chronic low back pain patients. Physiotherapy 88:322–332CrossRefGoogle Scholar
  8. 8.
    Eliasson K, Elfving B, Nordgren B, Mattsson E (2008) Urinary incontinence in women with low back pain. Man Ther 13:206–212PubMedCrossRefGoogle Scholar
  9. 9.
    Exner V, Keel P (2000) Erfassung der Behinderung bei Patienten mit chronischen Rückenschmerzen. Schmerz 14:392–400PubMedCrossRefGoogle Scholar
  10. 10.
    Ferreira PH, Ferreira ML, Hodges PW (2004) Changes in recruitment of the abdominal muscles in people with low back pain: ultrasound measurement of muscle activity. Spine 29:2560–2566PubMedCrossRefGoogle Scholar
  11. 11.
    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 52:79–88PubMedCrossRefGoogle Scholar
  12. 12.
    Gorbet N, Selkow NM, Hart JM, Saliba S (2010) No difference in transverse abdominis activation ratio between healthy and asymptomatic low back pain patients during therapeutic exercise. Rehabil Res Pract 2010:Article ID 459738. doi:10.1155/2010/459738
  13. 13.
    Han TS, Schouten JS, Lean ME, Seidell JC (1997) The prevalence of low back pain and associations with body fatness, fat distribution and height. Int J Obes Relat Metab Disord 21:600–607PubMedCrossRefGoogle Scholar
  14. 14.
    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
  15. 15.
    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
  16. 16.
    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
  17. 17.
    Hodges PW, Pengel LH, Herbert RD, Gandevia SC (2003) Measurement of muscle contraction with ultrasound imaging. Muscle Nerve 27:682–692PubMedCrossRefGoogle Scholar
  18. 18.
    Hodges PW, Richardson C (1998) Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limb. J Spin Disord 11:46–56Google Scholar
  19. 19.
    Hodges PW, Richardson CA (1996) Inefficient muscular stabilisation of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis. Spine 21:2640–2650PubMedCrossRefGoogle Scholar
  20. 20.
    Kermode F (2004) Benefits of utilizing real-time ultrasound imaging in the rehabilitation of the lumbar spine stabilizing muscles following low back injury in the elite athlete: a singe case study. Phys Ther Sport 5:13–16CrossRefGoogle Scholar
  21. 21.
    Kiesel KB, Uhl T, Underwood FB, Nitz AJ (2008) Rehabilitative ultrasound measurement of select trunk muscle activation during induced pain. Man Ther 13:132–138PubMedCrossRefGoogle Scholar
  22. 22.
    Kiesel KB, Underwood FB, Mattacola CG, Nitz AJ, Malone TR (2007) A comparison of select trunk muscle thickness change between subjects with low back pain classified in the treatment-based classification system and asymptomatic controls. J Orthop Sports Phys Ther 37:596–607PubMedGoogle Scholar
  23. 23.
    Kriese M, Clijsen R, Taeymans J, Cabri J (2010) Segmental stabilization in low back pain: a systematic review. Sportverletz Sportschaden 24:17–25PubMedCrossRefGoogle Scholar
  24. 24.
    Leboeuf-Yde C, Kyvik KO, Bruun NH (1999) Low back pain and lifestyle. Part II–obesity. Information from a population-based sample of 29,424 twin subjects. Spine (Phila Pa 1976) 24:779–783 (discussion 774–783)CrossRefGoogle Scholar
  25. 25.
    Mannion AF, Pulkovski N, Gubler D, Gorelick M, O’Riordan D, Loupas T, Schenk P, Gerber H, Sprott H (2008) Muscle thickness changes during abdominal hollowing: an assessment of between-day measurement error in controls and patients with chronic low back pain. Eur Spine J 17:494–501PubMedCrossRefGoogle Scholar
  26. 26.
    Mannion AF, Pulkovski N, Toma V, Sprott H (2008) Abdominal muscle size and symmetry at rest and during abdominal hollowing exercises in healthy control subjects. J Anat 213:173–182PubMedCrossRefGoogle Scholar
  27. 27.
    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
  28. 28.
    Mew R (2009) Comparison of changes in abdominal muscle thickness between standing and crook lying during active abdominal hollowing using ultrasound imaging. Man Ther 14:690–695PubMedCrossRefGoogle Scholar
  29. 29.
    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
  30. 30.
    Neumann P, Gill V (2002) Pelvic floor and abdominal muscle interaction: EMG activity and intra-abdominal pressure. Int Urogynecol J Pelvic Floor Dysfunct 13:125–132PubMedCrossRefGoogle Scholar
  31. 31.
    O’Sullivan PB (2000) Lumbar segmental ‘instability’: clinical presentation and specific stabilizing exercise management. Man Ther 5:2–12PubMedCrossRefGoogle Scholar
  32. 32.
    Panjabi MM (1992) The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Disord 5:390–397PubMedCrossRefGoogle Scholar
  33. 33.
    Pulkovski N, Sprott H, Michel B, Gubler D, Mannion AF (2005) Do low back pain patients with unilateral symptoms show side differences in deep abdominal muscle function? In: 11th World Congress on Pain, Sydney, AustraliaGoogle Scholar
  34. 34.
    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
  35. 35.
    Richardson C, Jull G, Hodges P, Hides J (1999) Therapeutic exercise for spinal segmental stabilization in low back pain: scientific basis and clinical approach. Churchill Livingstone, EdinburghGoogle Scholar
  36. 36.
    Richardson CA, Jull GA (1995) Muscle control–pain control. What exercises would you prescribe? Man Ther 1:2–10PubMedCrossRefGoogle Scholar
  37. 37.
    Roland M, Morris R (1983) A study of the natural history of back pain. Part 1: development of a reliable and sensitive measure of disability in low-back pain. Spine 8:141–144PubMedCrossRefGoogle Scholar
  38. 38.
    Sapsford RR, Hodges PW, Richardson CA, Cooper DH, Markwell SJ, Jull GA (2001) Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourol Urodyn 20:31–42PubMedCrossRefGoogle Scholar
  39. 39.
    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
  40. 40.
    Teyhen DS (2006) Rehabilitative ultrasound imaging symposium. San Antonio 36:A1–A3Google Scholar
  41. 41.
    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
  42. 42.
    Teyhen DS, Williamson JN, Carlson NH, Suttles ST, O’Laughlin SJ, Whittaker JL, Goffar SL, Childs JD (2009) Ultrasound characteristics of the deep abdominal muscles during the active straight leg raise test. Arch Phys Med Rehabil 90:761–767PubMedCrossRefGoogle Scholar
  43. 43.
    Urquhart DM, Barker PJ, Hodges PW, Story IH, Briggs CA (2005) Regional morphology of the transversus abdominis and obliquus internus and externus abdominis muscles. Clin Biomech 20:233–241CrossRefGoogle Scholar
  44. 44.
    von Garnier K, Koveker K, Rackwitz B, Kober U, Wilke S, Ewert T, Stucki G (2009) Reliability of a test measuring transversus abdominis muscle recruitment with a pressure biofeedback unit. Physiotherapy 95:8–14CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • N. Pulkovski
    • 1
    • 3
  • A. F. Mannion
    • 2
  • F. Caporaso
    • 1
  • V. Toma
    • 1
  • D. Gubler
    • 1
  • D. Helbling
    • 1
  • H. Sprott
    • 1
  1. 1.Department of Rheumatology and Institute of Physical MedicineUniversity Hospital ZürichZurichSwitzerland
  2. 2.Spine Center Division, Department of Research and DevelopmentSchulthess ClinicZurichSwitzerland
  3. 3.LausenSwitzerland

Personalised recommendations