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.
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References
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–S300
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 44:95–102
Beaton DE (2000) Understanding the relevance of measured change through studies of responsiveness. Spine 25:3192–3199
Bunce SM, Moore AP, Hough AD (2002) M-mode ultrasound: a reliable measure of transversus abdominis thickness? Clin Biomech (Bristol, Avon) 17:315–317
Cairns MC, Harrison K, Wright C (2000) Pressure biofeedback: a useful tool in the quantification of abdominal muscle dysfunction? Physiotherapy 86:127–138
Critchley DJ, Coutts FJ (2002) Abdominal muscle function in chronic low back pain patients. Physiotherapy 88:322–332
Currier DP (1990) Elements of research in physical therapy. Williams and Wilkins, Baltimore
Elfving B, Nemeth G, Arvidsson I, Lamontagne M (1999) Reliability of EMG spectral parameters in repeated measurements of back muscle fatigue. J Electromyogr Kinesiol 9:235–243
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 52:79–88
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 35:338–345
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–E178
Hides JA, Jull GA, Richardson CA (1998) Use of real-time ultrasound imaging for feedback in rehabilitation. Man Ther 3:125–131
Hodges P, Richardson C, Jull G (1996) Evaluation of the relationship between laboratory and clinical tests of transversus abdominis function. Physiother Res Int 1:30–40
Hodges PW (2005) Ultrasound imaging in rehabilitation: just a fad? J Orthop Sports Phys Ther 35:333–337
Hodges PW, Pengel LH, Herbert RD, Gandevia SC (2003) Measurement of muscle contraction with ultrasound imaging. Muscle Nerve 27:682–692
Hopkins WG (2000) Measures of reliability in sports medicine and science. Sports Med 30:1–15
Howe T, Oldham J (1995) Functional tests in elderly osteoarthritic subjects: variability of performance. Nurs Stand 9:35–38
John EK, Beith ID (2007) Can activity within the external abdominal oblique be measured using real-time ultrasound imaging? Clin Biomech (Bristol, Avon) 22:972–979
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 28:207–210
McMeeken JM, Beith ID, Newham DJ, Milligan P, Critchley DJ (2004) The relationship between EMG and change in thickness of transversus abdominis. Clin Biomech 19:337–342
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 10:2861–2867
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 20:553–567
Rankin G, Stokes M (1998) Reliability of assessment tools in rehabilitation: an illustration of appropriate statistical analyses. Clin Rehabil 12:187–199
Rankin G, Stokes M, Newham DJ (2006) Abdominal muscle size and symmetry in normal subjects. Muscle Nerve 34:320–326
Richardson C, Jull G, Hodges P, Hides J (1999) Therapeutic exercise for spinal stabilisation: scientific basis and practical techniques. Churchill Livingstone, Edinburgh
Shrout PE, Fleiss JL (1979) Intraclass correlations: uses in assessing rater reliability. Psychol Bull 86:420–428
Stokes M (1985) Reliability and repeatability of methods for measuring muscle in physiotherapy. Physiother Theory Prac 1:71–76
Storheim K, Bo K, Pederstad O, Jahnsen R (2002) Intra-tester reproducibility of pressure biofeedback in measurement of transversus abdominis function. Physiother Res Int 7:239–249
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 35:346–355
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This project was supported by the National Research Programme NRP 53 “Musculoskeletal Health—Chronic Pain” of the Swiss National Science Foundation (Project 405340-104787/2). The authors wish to thank Marlies Hug de los Santos, Mahmud Kiani-Ford, Judith Reutimann and Daniel Helbling for their assistance with the data collection and analysis.
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Mannion, A.F., Pulkovski, N., Gubler, D. et al. 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, 494–501 (2008). https://doi.org/10.1007/s00586-008-0589-x
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DOI: https://doi.org/10.1007/s00586-008-0589-x