Accepted Manuscript Muscle activation during Pilates exercises in participants with chronic non-specific low back pain – a cross-sectional case control study Naiane Teixeira Bastos de Oliveira, MS, Sandra Maria Sbeghen Ferreira Freitas, PhD, Fernanda Ferreira Fuhro, MS, Maurício Antônio da Luz Júnior, MS, Cesar Ferreira Amorim, PhD, Cristina Maria Nunes Cabral, PhD PII:
S0003-9993(16)31097-8
DOI:
10.1016/j.apmr.2016.09.111
Reference:
YAPMR 56681
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 16 June 2016 Revised Date:
31 August 2016
Accepted Date: 2 September 2016
Please cite this article as: de Oliveira NTB, Ferreira Freitas SMS, Fuhro FF, da Luz Júnior MA, Amorim CF, Nunes Cabral CM, Muscle activation during Pilates exercises in participants with chronic nonspecific low back pain – a cross-sectional case control study, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2016), doi: 10.1016/j.apmr.2016.09.111. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Running head: Muscle activation during Pilates
Title: Muscle activation during Pilates exercises in participants with chronic non-
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Authors, academic degrees and institutional affiliations:
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specific low back pain – a cross-sectional case control study
Naiane Teixeira Bastos de Oliveira, MS, Master’s and Doctoral Program in Physical
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Therapy, Universidade Cidade de São Paulo, São Paulo SP, Brazil
Sandra Maria Sbeghen Ferreira Freitas, PhD, Master’s and Doctoral Program in Physical Therapy, Universidade Cidade de São Paulo, São Paulo SP, Brazil Fernanda Ferreira Fuhro, MS, Master’s and Doctoral Program in Physical Therapy,
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Universidade Cidade de São Paulo, São Paulo SP, Brazil
Maurício Antônio da Luz Júnior, MS, Department of Physical Therapy, Universidade Paulista, São Paulo SP, Brazil
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Cesar Ferreira Amorim, PhD, Master’s and Doctoral Program in Physical Therapy, Universidade Cidade de São Paulo, São Paulo SP, Brazil
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Cristina Maria Nunes Cabral, PhD, Master’s and Doctoral Program in Physical Therapy, Universidade Cidade de São Paulo, São Paulo SP, Brazil
Place were the study was performed: Clinic of Physical Therapy, Department of Physical Therapy, Universidade Cidade de São Paulo
ACCEPTED MANUSCRIPT Grant support: None
Corresponding author: Cristina Maria Nunes Cabral
Telephone number: +55 11 21781565
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[email protected]
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Rua Cesário Galeno 475, CEP 03071-000, São Paulo SP, Brazil
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Muscle activation during Pilates exercises in participants with chronic non-specific
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low back pain – a cross-sectional case control study
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ABSTRACT
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Objective: To determine the amplitude of the electromyographic activity of trunk
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muscles during Pilates exercises in women with and without chronic low back pain
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(LBP). Design: Case control study. Setting: Clinic of a school. Participants: Sixty
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women divided into LBP Group (LBPG) and Control Group (CG). Interventions: Not
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applicable. Main Outcome Measures: Amplitude of the electromyographic activity
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(root mean square values) of the gluteus maximus and external oblique muscles
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collected during three Pilates exercises: Shoulder bridge performed in the mat, and Hip
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roll and Breathing performed in equipment. Pain intensity was assessed in the LBPG.
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Results: The amplitude of the electromyographic activity was similar between groups
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(p ≥ 0.05). For both groups, the amplitude of the gluteus maximus was higher in the
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Shoulder Bridge exercise compared to the Hip Roll with 2 springs (CG: mean difference
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(MD) = 0.18, 95% Confidence interval (CI) = 0.05 to 0.41; LBPG: MD = 0.29, 95% CI
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= 0.16 to 0.31) and the Breathing exercise (CG: MD = -0.40, 95% CI = -0.55 to -0.26;
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LBPG: MD = -0.36, 95% CI = -0.52 to -0.20). The amplitude of the external oblique
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muscle was higher in the Shoulder Bridge compared to the Hip Roll with 2 springs (CG:
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MD = 0.13, 95% CI = 0.05 to 0.21; LBPG: MD = 0.18, 95% CI = 0.03 to 0.33). Pain
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intensity increased after exercises, but this increase was lower for the mat exercises.
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Conclusion: Similar muscle activation between groups was found. The findings suggest
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that mat exercises caused less pain and greater difference in the amplitude of muscle
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activation compared to the equipment-based exercises.
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Keywords: Low back pain; electromyography; Pilates-based exercises.
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List of abbreviations: CG (Control Group); LBP (Low Back Pain); LBPG (Low Back
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Pain Group); MVIC (Maximum Voluntary Isometric Contraction); RMS (Root Mean
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Square).
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Chronic low back pain (LBP) is a symptom with very high prevalence. A
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systematic review1 showed a prevalence of 38% for people who had LBP at some point
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in their lives. One of the most effective treatments for chronic LBP is exercise, because
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it reduces pain and disability2. Physical therapists have been using Pilates-based
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exercises in rehabilitation programs3 to treat chronic LBP. However, the selection
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criteria for some of the variables, such as the type of exercise and the springs, are still
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subjective4 due to the scarcity of studies on the subject.
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Several clinical trials have been conducted in order to verify the effectiveness of the Pilates method for improving LBP symptoms5-15. Nevertheless, the studies that
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included a biomechanical assessment4, 16-31, in particular studies evaluating the
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amplitude of muscle activation during Pilates, did not provide sufficient evidence to
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guide clinical practice in the treatment of patients with chronic LBP. A systematic
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review32 highlighted that the electromyographic activity of the lumbar extensors and
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abdominal muscles during Pilates exercises had only been evaluated in healthy subjects
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and suggested that this assessment be done in patients with LBP. To date, only one
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study20 evaluated muscle activation during the powerhouse (i.e. isometric contraction of
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the lumbar stabilizers) in patients with chronic LBP compared to healthy subjects.
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However, this study did not correspond to the suggestion of the systematic review32
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because it did not provide biomechanical information about the main Pilates exercises
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in order to clarify how they work and how to use them to treat patients with chronic
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LBP. Therefore, the objective of the present study was to compare the amplitude of the
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electromyographic activity of the gluteus maximus and external oblique during Pilates
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exercises in women with and without LBP. We hypothesized that women with LBP
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would present lower electromyographic activity than women without LBP.
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METHODS
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Study design and Setting
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Data of this cross-sectional case control study were collected between August 2012 and October 2013 in the clinic of Physical Therapy of an University.
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Participants
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We evaluated women aged between 18 and 60 who walked independently and
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did not practice regular physical activity33 with and without LBP. The participants of
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the LBP Group (LBPG) should have non-specific chronic LBP lasting more than three
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months, and the Control Group (GG) participants had to be healthy. The age, height,
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physical exercise were evaluated34. The exclusion criteria for both groups were:
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previous experience with the Pilates method; pregnancy; prior surgery in the spine,
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upper or lower limbs; history of spinal fracture; inflammatory, rheumatic, or
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neurological disorders; uncontrolled systemic metabolic disease; herniated disc; tumors;
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infection; osteoporosis; structural deformity; and physical therapy treatment for chronic
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LBP in the last six months5, 6. All participants signed an informed consent form to take
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part in the study, which was approved by the Research Ethics Committee of the
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University (CAAE: 0056.0186.000-11).
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Sample calculation
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The sample size calculation was performed in GPower, version 3.1, based on a
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pilot study with four participants from the LBPG and eight from the CG. We used the
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mean and standard deviation of the normalized Root Mean Square (RMS) value of the
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right and left external oblique muscle during the Shoulder Bridge exercise to determine
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a difference between groups of 0.65. For the LBPG, the mean muscle activation was
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1.22 and standard deviation 0.10, and the mean muscle activation for the CG was 1.14
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and standard deviation 0.14. Considering a statistical power of 80% and alpha of 5%,
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the sample size was determined to be 30 participants per group.
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Data collection
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Procedure and equipment
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On the first day of assessment, the participants received basic instruction on the Pilates technique and training on the activation of the powerhouse, which is the
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isometric contraction of the pelvic floor muscles, pelvic and lumbar stabilizers at
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exhalation during diaphragmatic breathing35. On the same day, there was a training
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session to familiarize the participants with the proposed exercises.
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Muscle activation was recorded on the second day of evaluation, which took place at least two days after the first evaluation. We used an electromyographic device
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with 16-bit analog-to-digital convertera connected to an electrogoniometerb and to the
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WinDaq Data Acquisition programc with a sampling frequency of 2000 Hz per channel.
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Data were acquired using a fourth order Butterworth bandpass filter with cutoff
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frequency of 20 to 500 Hz, noise < 3 µV, impedance of 109 Ohm, and common mode
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rejection > 100 dB. The electrogoniometer (with accuracy of 0.1 degree) was also used
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to determine the onset and termination of each repetition of the exercise.
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Ag-AgCl bipolar surface electrodesd pre-amplified with 20x gain were used with shielded cable and pressure clips coupled to disposable electrodes. Prior to electrode
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placement, the skin was shaved (when necessary) and cleansed with alcohol. The
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electrodes were placed 2 cm apart over the muscle belly, along the direction of the
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muscle fibers36. To capture the electromyographic signal, all recommended procedures37
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were strictly followed. The reference electrode was placed over the spinous process of
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the seventh cervical vertebra. For the gluteus maximus, the electrodes were placed
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bilaterally midway between the sacral vertebrae and the greater trochanter, facing
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toward the line from the superior-posterior iliac spine to the posterior medial face of the
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thigh38. For the external oblique muscle, the electrodes were bilaterally midway
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between the anterior-superior iliac spine and the lowest point of the costal margin (at the
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level of the third lumbar vertebra)39. These muscles were chosen because they are
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superficial, easy to assess using electromyography and represent the hip extensors and
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lumbar flexors, recruited in the performed exercises.
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The electrogoniometer was placed on the hip joint as a way to synchronize the
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capture of electromyographic activity and determine the analysis interval of the
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electromyographic signals. Prior to placement, the electrogoniometer was calibrated
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with the acquisition system using an universal goniometer. Two angles of the hip joint
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were used for calibration: 0º and 90º. The goniometer was placed with its central axis
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over the greater trochanter of the femur, with the fixed arm on the lateral line of the
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trunk and the moving arm on the lateral line of the thigh aligned with the center of the
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lateral condyle of the femur. After placement of the electrodes and electrogoniometer,
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the participants were instructed on the performance of each of the Pilates exercises.
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Exercises
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The exercises performed were the Shoulder Bridge on the mat, Hip Roll with
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one spring or two springs on the Reformere, and the Breathing exercise on the Cadillace.
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These exercises were chosen because they activate the stabilizing muscles of the lumbar
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spine and they are the most commonly used in the treatment of patients with chronic
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LBP. During the exercises, the evaluator instructed the participants through the
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exercising. During the exercise, take a deep breath, exhaling through the mouth and
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performing the contraction of the powerhouse muscles”. For all exercises, after the
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specific positioning described in Table 1 and Figure 1, the participant was instructed to
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elevate the trunk forming a bridge from the shoulders to the knees then return to the
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starting position after a few seconds40.
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The participants performed 12 repetitions of each exercise at a comfortable pace
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and with a 2-minute interval between exercises. In addition, the order of the exercises
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was randomized on Matlabf (version 7.12.0.635). The Pain Numerical Rating scale41
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was applied before and after each exercise only in the LBPG. The scale assessed pain
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intensity using an 11-point scale, where 0 was "no pain" and 10 "pain as bad as could
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be".
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Data processing and statistical analysis
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The data of the electromyographic activity were processed through routines defined in Matlabf. The angular variation obtained with the electrogoniometer was
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filtered with a fourth order Butterworth filter and a cutoff frequency of 3 Hz. The
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analysis of the electromyographic signal took into account the start and end of the hip
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movement acquired by the electrogoniometer, which were defined by minimum values
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obtained in the initial position and after performing the exercise. To reduce variability,
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only the four central repetitions were used in the analysis, excluding the first four and
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last four of the 12 repetitions for each participant42. The amplitude of the
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electromyographic activity was evaluated by the RMS of the recorded signal and then
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normalized by the mean value obtained in the four central repetitions of all tasks. Next,
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the mean amplitude of the four central repetitions of all exercises was obtained for each
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muscle.
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For the statistical analysis, the mean activation between the right and left sides of each muscle was considered, since the objective of this study was to verify muscle
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activation for trunk activation and not asymmetry between the muscles. We used the
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Shapiro-Wilk normality test and Levene’s test of homogeneity of variance. With the
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hypothesis of normal distribution of the data confirmed, the following analyses were
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performed: a) Student's t test for independent samples for intergroup comparison of the
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mean amplitude of muscle activation during the four exercises; b) t test for paired
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samples for intragroup comparison of the mean amplitude of muscle activation between
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the exercises classified according to level of difficulty in increasing order (i.e. Shoulder
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Bridge; Hip Roll with 2 springs; Hip Roll with one spring; and Breathing). The level of
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difficulty was established considering that the equipment-based exercises with fewer
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springs would generate more instability and, consequently, could require greater muscle
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activation; c) t test for paired samples for intragroup comparison of the mean amplitude
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of activation between the muscles recorded in each exercise; and d) descriptive analysis
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comparing the difference in pain intensity before and after the exercises in the LBPG.
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The significance level was p< 0.05. Data were analyzed using SPSSg (version 20.0.0)
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and are presented as mean and standard deviation.
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RESULTS
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The demographic characteristics of each group are shown in Table 2. Table 3
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shows the results of the intergroup comparison for muscular activation. There was no
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statistically significant difference (p≥ 0.05) in amplitude of muscle activation of the
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gluteus maximus and external oblique muscles between the groups.
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Table 4 shows the results of the within-group comparison of the mean amplitude of muscle activation among the exercises according to level of difficulty. There were
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statistically significant differences among exercises (p< 0.05). For the LBPG, muscle
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activation of the gluteus maximus was greater in the Shoulder Bridge compared to Hip
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Roll with 2 springs (p< 0.001) and Breathing (p< 0.001) and greater in the Hip Roll
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with 2 springs compared to Hip Roll with 1 spring (p= 0.023). The activation of the
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external oblique muscle in the same group was greater in the Breathing exercise
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compared to the Shoulder Bridge (p= 0.033) and Hip Roll with 1 spring (p< 0.001) and
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greater in the Shoulder Bridge compared to the Hip Roll with 2 springs (p= 0.021). For
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the CG, muscle activation of the gluteus maximus was greater in the Shoulder Bridge
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compared to Hip Roll with 2 springs (p< 0.001) and Breathing (p< 0.001) and greater in
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the Hip Roll with 2 springs compared to Hip Roll with 1 spring (p= 0.012). The
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activation of the external oblique muscle was greater in the Shoulder Bridge compared
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to Hip Roll with 2 springs (p= 0.003) and greater in Breathing compared to Hip Roll
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with 1 spring (p< 0.001).
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Table 5 shows the results of within-group comparison of the mean amplitude of
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activation of the gluteus maximus and external oblique muscles in each exercise. There
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was a statistically significant difference between the muscles for all exercises (p< 0.05),
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greater in the Shoulder Bridge and Hip Roll with two springs. Table 6 shows the results
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of the descriptive analysis of the mean of the differences in pain intensity in the LBPG,
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indicating a slight increase in pain in all exercises. The Breathing exercise generated a
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greater increase in pain and the Shoulder Bridge generated a smaller increase in pain.
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DISCUSSION
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The amplitude of the electromyographic activity did not differ between groups;
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however, there was a significant difference between exercises regarding the activation
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of the gluteus maximus and external oblique muscles. In both groups, the activation of
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the gluteus maximus was greater in the Shoulder Bridge and the Hip Roll with 2 springs
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and the activation of the external oblique muscle was higher in the Shoulder Bridge and
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the Breathing exercise. Regarding the activation of the external oblique muscle in the
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LBPG, it was only higher in the Breathing exercise compared to the Shoulder Bridge.
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The LBPG also presented a small increase in pain after each of the exercises, but this
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increase was lower after the Shoulder Bridge exercise.
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This study is among the first to evaluate muscle activation during Pilates
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exercises and to specifically compare the electrical activation of the gluteus maximus
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and the external oblique muscles during the performance of four different exercises in
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women with and without chronic LBP. A recent study20 evaluated the performance of
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the powerhouse through the electromyographic activity of the trunk muscles in subjects
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with and without LBP and showed increased activation of the internal oblique and
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This difference in results can be attributed to the type of exercise. In the present study,
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we evaluated dynamic exercises performed by sedentary participants, while Marques et
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al.20 assessed physically active participants during static contraction and provided visual
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feedback from the electromyographic signal during the assessment. Another study43 that
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evaluated the effects of electromyographic-based feedback on the musculoskeletal
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system showed that, for the lower back, visual feedback is an effective way to correct
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posture. Therefore, performing the powerhouse with the help of visual feedback may
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have influenced the results obtained by Marques et al.20. In addition, the use of visual
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feedback makes the results differ from clinical practice, given that electromyographic-
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based feedback during a Pilates session is not a common procedure.
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The results of the present study showed a significant difference in the intragroup analysis of the exercises. For the gluteus maximus, both groups showed greater muscle
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activation in the mat exercise Shoulder Bridge compared to the equipment-based
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exercises. Thus, it appears that, contrary to our initial hypothesis, the more stable
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exercises require greater muscle contraction. The results of recent studies2, 34
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corroborate our findings. Peace et al.28 compared isometric Pilates exercises performed
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with and without the Swiss ball and found that the activity of the erector spinae was
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greater on the stable surface. Another study26 also noted that the iliocostalis and
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multifidus muscles were more activated during exercises on a stable surface. Thus, it is
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possible that the muscles responsible for stabilization of the lumbar spine are contracted
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correctly on a stable surface, preventing the use of other compensatory muscles during
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performance of the movement.
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The findings of the present study also showed that pain intensity increased slightly after all exercises in the LBPG. However, the exercise Shoulder Bridge
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generated less increase in pain compared to other exercises and the Breathing exercise
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generated the greatest pain intensity. Therefore, it is possible to suggest starting the
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rehabilitation of patients with chronic LBP with the Shoulder Bridge, since it offers
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greater comfort with respect to pain, and then progress to exercises causing little pain
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(Hip Roll with one and two springs) and finally advance to the Breathing exercise,
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which causes the most discomfort with regard to pain. It is possible that these results
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were influenced by the fact that the exercises have similar execution and that maximum
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range of motion of the exercise was adapted to the physical abilities of each participant.
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Some studies4, 17, 19, 21-23 that conducted biomechanical evaluation during Pilates
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exercises normalized the electromyographic signals to a maximum voluntary isometric
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contraction (MVIC), but other studies16, 44 suggest that MVIC depends on some factors,
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such as the evaluator’s training and motivation, to be achieved. Therefore, one study45
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recommends that the mean electromyographic from the task under investigation be used
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as the normalization reference value to reduce inter-individual variability, and this was
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the procedure used in the present study.
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There is a lack of scientific studies on the muscle pattern of the trunk muscles
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during Pilates exercises. More studies are needed to assess other exercises and other
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muscle groups in these exercises with significant samples that include different age
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groups, genders, and populations, particularly patients with LBP and with or without
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previous experience with the Pilates method. This type of study will allow a better
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understanding of the effect of exercise on muscle activation and may assist in the choice
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of exercises and variables during the prescription of exercises in the rehabilitation
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program using the Pilates method.
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Study Limitations
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One limitation of this study was that it did not evaluate other muscles such as the hamstrings. The muscles evaluated in this study were chosen because they are
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superficial trunk stabilizers that can be easily assessed with surface electromyography.
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Another limitation was that the evaluator could not be blinded, because the participants
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reported difficulty performing some of the exercises, making it clear to the evaluator
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who belonged to the LBPG. Moreover, the last limitation was that the study included
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only women with chronic LBP. Therefore, the results of this study can not be
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generalized to the general population.
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CONCLUSION
There was no difference in muscle activation between participants with and
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without chronic LBP during the evaluated Pilates exercises. Thus, it can be assumed
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that these exercises recruit the assessed muscles in a similar pattern and can be used to
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treat chronic LBP, given that both groups reached the same muscle recruitment despite
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increased pain. However, our results showed significant difference within-groups in the
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Shoulder Bridge exercise for the gluteus maximus. Thus, we recommend that, in clinical
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practice, the mat exercises be performed in the initial stage of treatment, considering the
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low increase in pain and the difference in the amplitude of muscle activation compared
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to equipment-based exercises.
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SUPPLIERS
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a
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Campos SP, Brazil;
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EMG System do Brasil Ltda, Rua Porto Príncipe 50, CEP 12245-572, São José dos
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b
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Campos SP, Brazil;
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EMG System do Brasil Ltda, Rua Porto Príncipe 50, CEP 12245-572, São José dos
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Dataq Instruments, Rua Arandu 205, CEP 04572-030, São Paulo SP, Brazil;
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Covidien, 15 Hampshire Street, Zip code 02048, Mansfield, Massachusetts, United
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States;
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e
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362, CEP 88106-500, São José, SC, Brazil;
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Metalife Indústria e Comércio de Móveis Ltda., Rua Vereador Arthur Manoel Mariano
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States;
MathWorks, 1 Apple Hill Drive, Zip code 01760-2098, Natick, Massachusetts, United
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IBM Brasil, Rua Tutoia 1157, CEP 04007-900, São Paulo, SP, Brazil.
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LM. Clinimetric testing of three self-report outcome measures for low back pain
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patients in Brazil: which one is the best? Spine 2008;33(22):2459-63.
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muscle
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precisely studied
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FIGURE LEGEND
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be
by surface
Burden A. How should we normalize electromyograms obtained from healthy
Figure 1: Initial (left) and final position (right) of the evaluated exercises.
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coordination
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Hug
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Park SY, Yoo WG. Effect of EMG-based feedback on posture correction during
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Menacho MO, Obara K, Conceicao JS, Chitolina ML, Krantz DR, da Silva RA,
ACCEPTED MANUSCRIPT TABLE 1: Description of the Pilates exercises
Name of the exercise
Description
Shoulder Bridge
The participant was positioned supine, with neutral pelvis
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and spine, knees bent, feet flat on the mat, legs parallel and hip-width apart, arms to the sides, palms facing up, and stabilized shoulder blades.
The participant remained in the supine position with neutral
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Hip Roll
pelvis and spine, knees bent, feet on the bar of the Reformer,
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legs parallel and hip-width apart, arms to the sides, and palms facing up. In this exercise, the participant pushed with her feet on the bar, moving the sliding carriage without fully extending the knees. In addition, the equipment was adapted
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according to the participant's height. The exercises on the Reformer were performed with one or two red springs, each one with 473 cm in length and 0.2 kgf/cm² tension,
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according to the manufacturer. When only one spring was
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used, it was expected that the exercise would be more unstable and therefore require greater activation of the assessed muscles to control the movements. With two springs, the exercise was expected to be more stable, requiring less activation of the assessed muscles.
Breathing
The participant was positioned supine on the Cadillac, head toward the roll down bar, neutral pelvis and spine, knees bent, arms extended to the side of the body, stabilized
ACCEPTED MANUSCRIPT shoulder blades, and feet on the trapeze handle using the red spring, 473 cm in length and 0.69 kgf/cm² tension, according to the manufacturer. In this exercise, the participant’s feet would balance on the trapeze handle, generating a force
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toward the ground before starting the movements.
ACCEPTED MANUSCRIPT TABLE 2: Characteristics of the participants. Low Back Pain
Control Group
Group (n = 30)
(n = 30)
Age (years), mean (SD)
35.7 (12.9)
34.2 (9.9)
Duration of low back pain (months), mean (SD)
91 (129.5)
NA
Height (m), mean (SD)
1.6 (0.1)
1.6 (0.1)
Body mass index (kg/m2), mean (SD)
23.3 (2.8)
22.7 (2.1)
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Marital status, n (%) Single
Divorced Widowed Academic level, n (%)
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Tertiary education
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Primary education Secondary education
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Income (in minimum wages), mean (SD) NA: Not applicable.
11 (36.7)
12 (40)
17 (56.7)
14 (46.7)
2 (6.7)
3 (10)
0 (0)
1 (3.3)
6 (20)
6 (20)
16 (53.3)
21 (90)
8 (26.7)
0 (0)
0 (0)
2 (6.7)
5.4 (4.6)
8.5 (6.5)
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Married
Postgraduate
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Characteristics
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in Low Back Pain and Control Groups (n = 30 each group).
Hip Roll (1 spring)
Mean (SD)
Mean (SD)
(95% CI)
1.22 (0.22)
0.03 (-0.09 to 0.15)
0.894
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Mean difference
p
Gluteus Maximus
1.25 (0.24)
External Oblique
1.05 (0.23)
1.06 (0.16)
-0.01 (-0.11 to 0.10)
0.132
Gluteus Maximus
0.89 (0.25)
0.82 (0.24)
0.08 (-0.05 to 0.21)
0.795
External Oblique
1.20 (0.21)
1.12 (0.23)
0.08 (-0.03 to 0.19)
0.394
0.89 (0.15)
0.92 (0.14)
-0.03 (-0.11 to 0.04)
0.961
0.87 (0.15)
0.89 (0.12)
-0.02 (-0.09 to 0.05)
0.243
Gluteus Maximus
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External Oblique Gluteus Maximus
0.96 (0.16)
1.04 (0.21)
-0.08 (-0.17 to 0.02)
0.267
External Oblique
0.87 (0.21)
0.93 (0.12)
-0.06 (-0.15 to 0.03)
0.195
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Hip Roll (2 springs)
Control Group
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Breathing
Low Back Pain Group
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Shoulder Bridge
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TABLE 3: Between-group comparison of the activation of the gluteus maximus and external oblique muscles during the four evaluated exercises
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Low Back Pain Group
Shoulder Bridge vs Hip Roll (2
External oblique
Mean difference
Mean difference
(95% CI)
(95% CI)
0.29 (0.16 to 0.41)
S0003-9993(16)31097-8
DOI:
10.1016/j.apmr.2016.09.111
Reference:
YAPMR 56681
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 16 June 2016 Revised Date:
31 August 2016
Accepted Date: 2 September 2016
Please cite this article as: de Oliveira NTB, Ferreira Freitas SMS, Fuhro FF, da Luz Júnior MA, Amorim CF, Nunes Cabral CM, Muscle activation during Pilates exercises in participants with chronic nonspecific low back pain – a cross-sectional case control study, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2016), doi: 10.1016/j.apmr.2016.09.111. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Running head: Muscle activation during Pilates
Title: Muscle activation during Pilates exercises in participants with chronic non-
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Authors, academic degrees and institutional affiliations:
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specific low back pain – a cross-sectional case control study
Naiane Teixeira Bastos de Oliveira, MS, Master’s and Doctoral Program in Physical
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Therapy, Universidade Cidade de São Paulo, São Paulo SP, Brazil
Sandra Maria Sbeghen Ferreira Freitas, PhD, Master’s and Doctoral Program in Physical Therapy, Universidade Cidade de São Paulo, São Paulo SP, Brazil Fernanda Ferreira Fuhro, MS, Master’s and Doctoral Program in Physical Therapy,
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Universidade Cidade de São Paulo, São Paulo SP, Brazil
Maurício Antônio da Luz Júnior, MS, Department of Physical Therapy, Universidade Paulista, São Paulo SP, Brazil
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Cesar Ferreira Amorim, PhD, Master’s and Doctoral Program in Physical Therapy, Universidade Cidade de São Paulo, São Paulo SP, Brazil
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Cristina Maria Nunes Cabral, PhD, Master’s and Doctoral Program in Physical Therapy, Universidade Cidade de São Paulo, São Paulo SP, Brazil
Place were the study was performed: Clinic of Physical Therapy, Department of Physical Therapy, Universidade Cidade de São Paulo
ACCEPTED MANUSCRIPT Grant support: None
Corresponding author: Cristina Maria Nunes Cabral
Telephone number: +55 11 21781565
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[email protected]
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Rua Cesário Galeno 475, CEP 03071-000, São Paulo SP, Brazil
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Muscle activation during Pilates exercises in participants with chronic non-specific
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low back pain – a cross-sectional case control study
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ABSTRACT
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Objective: To determine the amplitude of the electromyographic activity of trunk
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muscles during Pilates exercises in women with and without chronic low back pain
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(LBP). Design: Case control study. Setting: Clinic of a school. Participants: Sixty
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women divided into LBP Group (LBPG) and Control Group (CG). Interventions: Not
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applicable. Main Outcome Measures: Amplitude of the electromyographic activity
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(root mean square values) of the gluteus maximus and external oblique muscles
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collected during three Pilates exercises: Shoulder bridge performed in the mat, and Hip
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roll and Breathing performed in equipment. Pain intensity was assessed in the LBPG.
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Results: The amplitude of the electromyographic activity was similar between groups
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(p ≥ 0.05). For both groups, the amplitude of the gluteus maximus was higher in the
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Shoulder Bridge exercise compared to the Hip Roll with 2 springs (CG: mean difference
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(MD) = 0.18, 95% Confidence interval (CI) = 0.05 to 0.41; LBPG: MD = 0.29, 95% CI
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= 0.16 to 0.31) and the Breathing exercise (CG: MD = -0.40, 95% CI = -0.55 to -0.26;
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LBPG: MD = -0.36, 95% CI = -0.52 to -0.20). The amplitude of the external oblique
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muscle was higher in the Shoulder Bridge compared to the Hip Roll with 2 springs (CG:
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MD = 0.13, 95% CI = 0.05 to 0.21; LBPG: MD = 0.18, 95% CI = 0.03 to 0.33). Pain
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intensity increased after exercises, but this increase was lower for the mat exercises.
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Conclusion: Similar muscle activation between groups was found. The findings suggest
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that mat exercises caused less pain and greater difference in the amplitude of muscle
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activation compared to the equipment-based exercises.
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Keywords: Low back pain; electromyography; Pilates-based exercises.
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List of abbreviations: CG (Control Group); LBP (Low Back Pain); LBPG (Low Back
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Pain Group); MVIC (Maximum Voluntary Isometric Contraction); RMS (Root Mean
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Square).
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Chronic low back pain (LBP) is a symptom with very high prevalence. A
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systematic review1 showed a prevalence of 38% for people who had LBP at some point
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in their lives. One of the most effective treatments for chronic LBP is exercise, because
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it reduces pain and disability2. Physical therapists have been using Pilates-based
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exercises in rehabilitation programs3 to treat chronic LBP. However, the selection
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criteria for some of the variables, such as the type of exercise and the springs, are still
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subjective4 due to the scarcity of studies on the subject.
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Several clinical trials have been conducted in order to verify the effectiveness of the Pilates method for improving LBP symptoms5-15. Nevertheless, the studies that
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included a biomechanical assessment4, 16-31, in particular studies evaluating the
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amplitude of muscle activation during Pilates, did not provide sufficient evidence to
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guide clinical practice in the treatment of patients with chronic LBP. A systematic
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review32 highlighted that the electromyographic activity of the lumbar extensors and
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abdominal muscles during Pilates exercises had only been evaluated in healthy subjects
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and suggested that this assessment be done in patients with LBP. To date, only one
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study20 evaluated muscle activation during the powerhouse (i.e. isometric contraction of
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the lumbar stabilizers) in patients with chronic LBP compared to healthy subjects.
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However, this study did not correspond to the suggestion of the systematic review32
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because it did not provide biomechanical information about the main Pilates exercises
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in order to clarify how they work and how to use them to treat patients with chronic
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LBP. Therefore, the objective of the present study was to compare the amplitude of the
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electromyographic activity of the gluteus maximus and external oblique during Pilates
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exercises in women with and without LBP. We hypothesized that women with LBP
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would present lower electromyographic activity than women without LBP.
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METHODS
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Study design and Setting
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Data of this cross-sectional case control study were collected between August 2012 and October 2013 in the clinic of Physical Therapy of an University.
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Participants
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We evaluated women aged between 18 and 60 who walked independently and
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did not practice regular physical activity33 with and without LBP. The participants of
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the LBP Group (LBPG) should have non-specific chronic LBP lasting more than three
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months, and the Control Group (GG) participants had to be healthy. The age, height,
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ACCEPTED MANUSCRIPT and body mass index were matched between the groups. The contraindications for
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physical exercise were evaluated34. The exclusion criteria for both groups were:
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previous experience with the Pilates method; pregnancy; prior surgery in the spine,
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upper or lower limbs; history of spinal fracture; inflammatory, rheumatic, or
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neurological disorders; uncontrolled systemic metabolic disease; herniated disc; tumors;
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infection; osteoporosis; structural deformity; and physical therapy treatment for chronic
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LBP in the last six months5, 6. All participants signed an informed consent form to take
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part in the study, which was approved by the Research Ethics Committee of the
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University (CAAE: 0056.0186.000-11).
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Sample calculation
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The sample size calculation was performed in GPower, version 3.1, based on a
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pilot study with four participants from the LBPG and eight from the CG. We used the
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mean and standard deviation of the normalized Root Mean Square (RMS) value of the
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right and left external oblique muscle during the Shoulder Bridge exercise to determine
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a difference between groups of 0.65. For the LBPG, the mean muscle activation was
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1.22 and standard deviation 0.10, and the mean muscle activation for the CG was 1.14
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and standard deviation 0.14. Considering a statistical power of 80% and alpha of 5%,
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the sample size was determined to be 30 participants per group.
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Data collection
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Procedure and equipment
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On the first day of assessment, the participants received basic instruction on the Pilates technique and training on the activation of the powerhouse, which is the
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isometric contraction of the pelvic floor muscles, pelvic and lumbar stabilizers at
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exhalation during diaphragmatic breathing35. On the same day, there was a training
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session to familiarize the participants with the proposed exercises.
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Muscle activation was recorded on the second day of evaluation, which took place at least two days after the first evaluation. We used an electromyographic device
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with 16-bit analog-to-digital convertera connected to an electrogoniometerb and to the
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WinDaq Data Acquisition programc with a sampling frequency of 2000 Hz per channel.
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Data were acquired using a fourth order Butterworth bandpass filter with cutoff
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frequency of 20 to 500 Hz, noise < 3 µV, impedance of 109 Ohm, and common mode
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rejection > 100 dB. The electrogoniometer (with accuracy of 0.1 degree) was also used
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to determine the onset and termination of each repetition of the exercise.
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Ag-AgCl bipolar surface electrodesd pre-amplified with 20x gain were used with shielded cable and pressure clips coupled to disposable electrodes. Prior to electrode
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placement, the skin was shaved (when necessary) and cleansed with alcohol. The
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electrodes were placed 2 cm apart over the muscle belly, along the direction of the
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muscle fibers36. To capture the electromyographic signal, all recommended procedures37
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were strictly followed. The reference electrode was placed over the spinous process of
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the seventh cervical vertebra. For the gluteus maximus, the electrodes were placed
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bilaterally midway between the sacral vertebrae and the greater trochanter, facing
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toward the line from the superior-posterior iliac spine to the posterior medial face of the
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thigh38. For the external oblique muscle, the electrodes were bilaterally midway
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between the anterior-superior iliac spine and the lowest point of the costal margin (at the
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level of the third lumbar vertebra)39. These muscles were chosen because they are
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superficial, easy to assess using electromyography and represent the hip extensors and
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lumbar flexors, recruited in the performed exercises.
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The electrogoniometer was placed on the hip joint as a way to synchronize the
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capture of electromyographic activity and determine the analysis interval of the
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electromyographic signals. Prior to placement, the electrogoniometer was calibrated
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with the acquisition system using an universal goniometer. Two angles of the hip joint
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were used for calibration: 0º and 90º. The goniometer was placed with its central axis
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over the greater trochanter of the femur, with the fixed arm on the lateral line of the
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trunk and the moving arm on the lateral line of the thigh aligned with the center of the
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lateral condyle of the femur. After placement of the electrodes and electrogoniometer,
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the participants were instructed on the performance of each of the Pilates exercises.
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143 144 145
Exercises
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The exercises performed were the Shoulder Bridge on the mat, Hip Roll with
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one spring or two springs on the Reformere, and the Breathing exercise on the Cadillace.
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These exercises were chosen because they activate the stabilizing muscles of the lumbar
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spine and they are the most commonly used in the treatment of patients with chronic
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LBP. During the exercises, the evaluator instructed the participants through the
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ACCEPTED MANUSCRIPT following verbal command: “Inhale deeply through your nose before you start
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exercising. During the exercise, take a deep breath, exhaling through the mouth and
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performing the contraction of the powerhouse muscles”. For all exercises, after the
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specific positioning described in Table 1 and Figure 1, the participant was instructed to
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elevate the trunk forming a bridge from the shoulders to the knees then return to the
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starting position after a few seconds40.
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The participants performed 12 repetitions of each exercise at a comfortable pace
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and with a 2-minute interval between exercises. In addition, the order of the exercises
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was randomized on Matlabf (version 7.12.0.635). The Pain Numerical Rating scale41
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was applied before and after each exercise only in the LBPG. The scale assessed pain
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intensity using an 11-point scale, where 0 was "no pain" and 10 "pain as bad as could
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be".
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Data processing and statistical analysis
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The data of the electromyographic activity were processed through routines defined in Matlabf. The angular variation obtained with the electrogoniometer was
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filtered with a fourth order Butterworth filter and a cutoff frequency of 3 Hz. The
170
analysis of the electromyographic signal took into account the start and end of the hip
171
movement acquired by the electrogoniometer, which were defined by minimum values
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obtained in the initial position and after performing the exercise. To reduce variability,
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only the four central repetitions were used in the analysis, excluding the first four and
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last four of the 12 repetitions for each participant42. The amplitude of the
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electromyographic activity was evaluated by the RMS of the recorded signal and then
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normalized by the mean value obtained in the four central repetitions of all tasks. Next,
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the mean amplitude of the four central repetitions of all exercises was obtained for each
178
muscle.
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For the statistical analysis, the mean activation between the right and left sides of each muscle was considered, since the objective of this study was to verify muscle
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activation for trunk activation and not asymmetry between the muscles. We used the
183
Shapiro-Wilk normality test and Levene’s test of homogeneity of variance. With the
184
hypothesis of normal distribution of the data confirmed, the following analyses were
185
performed: a) Student's t test for independent samples for intergroup comparison of the
186
mean amplitude of muscle activation during the four exercises; b) t test for paired
187
samples for intragroup comparison of the mean amplitude of muscle activation between
188
the exercises classified according to level of difficulty in increasing order (i.e. Shoulder
189
Bridge; Hip Roll with 2 springs; Hip Roll with one spring; and Breathing). The level of
190
difficulty was established considering that the equipment-based exercises with fewer
191
springs would generate more instability and, consequently, could require greater muscle
192
activation; c) t test for paired samples for intragroup comparison of the mean amplitude
193
of activation between the muscles recorded in each exercise; and d) descriptive analysis
194
comparing the difference in pain intensity before and after the exercises in the LBPG.
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The significance level was p< 0.05. Data were analyzed using SPSSg (version 20.0.0)
196
and are presented as mean and standard deviation.
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RESULTS
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The demographic characteristics of each group are shown in Table 2. Table 3
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shows the results of the intergroup comparison for muscular activation. There was no
203
statistically significant difference (p≥ 0.05) in amplitude of muscle activation of the
204
gluteus maximus and external oblique muscles between the groups.
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205 206
Table 4 shows the results of the within-group comparison of the mean amplitude of muscle activation among the exercises according to level of difficulty. There were
208
statistically significant differences among exercises (p< 0.05). For the LBPG, muscle
209
activation of the gluteus maximus was greater in the Shoulder Bridge compared to Hip
210
Roll with 2 springs (p< 0.001) and Breathing (p< 0.001) and greater in the Hip Roll
211
with 2 springs compared to Hip Roll with 1 spring (p= 0.023). The activation of the
212
external oblique muscle in the same group was greater in the Breathing exercise
213
compared to the Shoulder Bridge (p= 0.033) and Hip Roll with 1 spring (p< 0.001) and
214
greater in the Shoulder Bridge compared to the Hip Roll with 2 springs (p= 0.021). For
215
the CG, muscle activation of the gluteus maximus was greater in the Shoulder Bridge
216
compared to Hip Roll with 2 springs (p< 0.001) and Breathing (p< 0.001) and greater in
217
the Hip Roll with 2 springs compared to Hip Roll with 1 spring (p= 0.012). The
218
activation of the external oblique muscle was greater in the Shoulder Bridge compared
219
to Hip Roll with 2 springs (p= 0.003) and greater in Breathing compared to Hip Roll
220
with 1 spring (p< 0.001).
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221 222
Table 5 shows the results of within-group comparison of the mean amplitude of
223
activation of the gluteus maximus and external oblique muscles in each exercise. There
224
was a statistically significant difference between the muscles for all exercises (p< 0.05),
10
ACCEPTED MANUSCRIPT except for the Hip Roll with 1 spring. Muscle activation of the gluteus maximus was
226
greater in the Shoulder Bridge and Hip Roll with two springs. Table 6 shows the results
227
of the descriptive analysis of the mean of the differences in pain intensity in the LBPG,
228
indicating a slight increase in pain in all exercises. The Breathing exercise generated a
229
greater increase in pain and the Shoulder Bridge generated a smaller increase in pain.
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230 231
DISCUSSION
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232 233
The amplitude of the electromyographic activity did not differ between groups;
235
however, there was a significant difference between exercises regarding the activation
236
of the gluteus maximus and external oblique muscles. In both groups, the activation of
237
the gluteus maximus was greater in the Shoulder Bridge and the Hip Roll with 2 springs
238
and the activation of the external oblique muscle was higher in the Shoulder Bridge and
239
the Breathing exercise. Regarding the activation of the external oblique muscle in the
240
LBPG, it was only higher in the Breathing exercise compared to the Shoulder Bridge.
241
The LBPG also presented a small increase in pain after each of the exercises, but this
242
increase was lower after the Shoulder Bridge exercise.
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This study is among the first to evaluate muscle activation during Pilates
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exercises and to specifically compare the electrical activation of the gluteus maximus
246
and the external oblique muscles during the performance of four different exercises in
247
women with and without chronic LBP. A recent study20 evaluated the performance of
248
the powerhouse through the electromyographic activity of the trunk muscles in subjects
249
with and without LBP and showed increased activation of the internal oblique and
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ACCEPTED MANUSCRIPT multifidus muscles in the participants without pain, unlike the present study results.
251
This difference in results can be attributed to the type of exercise. In the present study,
252
we evaluated dynamic exercises performed by sedentary participants, while Marques et
253
al.20 assessed physically active participants during static contraction and provided visual
254
feedback from the electromyographic signal during the assessment. Another study43 that
255
evaluated the effects of electromyographic-based feedback on the musculoskeletal
256
system showed that, for the lower back, visual feedback is an effective way to correct
257
posture. Therefore, performing the powerhouse with the help of visual feedback may
258
have influenced the results obtained by Marques et al.20. In addition, the use of visual
259
feedback makes the results differ from clinical practice, given that electromyographic-
260
based feedback during a Pilates session is not a common procedure.
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The results of the present study showed a significant difference in the intragroup analysis of the exercises. For the gluteus maximus, both groups showed greater muscle
264
activation in the mat exercise Shoulder Bridge compared to the equipment-based
265
exercises. Thus, it appears that, contrary to our initial hypothesis, the more stable
266
exercises require greater muscle contraction. The results of recent studies2, 34
267
corroborate our findings. Peace et al.28 compared isometric Pilates exercises performed
268
with and without the Swiss ball and found that the activity of the erector spinae was
269
greater on the stable surface. Another study26 also noted that the iliocostalis and
270
multifidus muscles were more activated during exercises on a stable surface. Thus, it is
271
possible that the muscles responsible for stabilization of the lumbar spine are contracted
272
correctly on a stable surface, preventing the use of other compensatory muscles during
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performance of the movement.
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The findings of the present study also showed that pain intensity increased slightly after all exercises in the LBPG. However, the exercise Shoulder Bridge
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generated less increase in pain compared to other exercises and the Breathing exercise
278
generated the greatest pain intensity. Therefore, it is possible to suggest starting the
279
rehabilitation of patients with chronic LBP with the Shoulder Bridge, since it offers
280
greater comfort with respect to pain, and then progress to exercises causing little pain
281
(Hip Roll with one and two springs) and finally advance to the Breathing exercise,
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which causes the most discomfort with regard to pain. It is possible that these results
283
were influenced by the fact that the exercises have similar execution and that maximum
284
range of motion of the exercise was adapted to the physical abilities of each participant.
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Some studies4, 17, 19, 21-23 that conducted biomechanical evaluation during Pilates
287
exercises normalized the electromyographic signals to a maximum voluntary isometric
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contraction (MVIC), but other studies16, 44 suggest that MVIC depends on some factors,
289
such as the evaluator’s training and motivation, to be achieved. Therefore, one study45
290
recommends that the mean electromyographic from the task under investigation be used
291
as the normalization reference value to reduce inter-individual variability, and this was
292
the procedure used in the present study.
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There is a lack of scientific studies on the muscle pattern of the trunk muscles
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during Pilates exercises. More studies are needed to assess other exercises and other
296
muscle groups in these exercises with significant samples that include different age
297
groups, genders, and populations, particularly patients with LBP and with or without
298
previous experience with the Pilates method. This type of study will allow a better
299
understanding of the effect of exercise on muscle activation and may assist in the choice
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of exercises and variables during the prescription of exercises in the rehabilitation
301
program using the Pilates method.
302 303
Study Limitations
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One limitation of this study was that it did not evaluate other muscles such as the hamstrings. The muscles evaluated in this study were chosen because they are
308
superficial trunk stabilizers that can be easily assessed with surface electromyography.
309
Another limitation was that the evaluator could not be blinded, because the participants
310
reported difficulty performing some of the exercises, making it clear to the evaluator
311
who belonged to the LBPG. Moreover, the last limitation was that the study included
312
only women with chronic LBP. Therefore, the results of this study can not be
313
generalized to the general population.
314
317 318
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CONCLUSION
There was no difference in muscle activation between participants with and
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319
without chronic LBP during the evaluated Pilates exercises. Thus, it can be assumed
320
that these exercises recruit the assessed muscles in a similar pattern and can be used to
321
treat chronic LBP, given that both groups reached the same muscle recruitment despite
322
increased pain. However, our results showed significant difference within-groups in the
323
Shoulder Bridge exercise for the gluteus maximus. Thus, we recommend that, in clinical
324
practice, the mat exercises be performed in the initial stage of treatment, considering the
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low increase in pain and the difference in the amplitude of muscle activation compared
326
to equipment-based exercises.
327 328
SUPPLIERS
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329 330 331
a
332
Campos SP, Brazil;
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EMG System do Brasil Ltda, Rua Porto Príncipe 50, CEP 12245-572, São José dos
333 334
b
335
Campos SP, Brazil;
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EMG System do Brasil Ltda, Rua Porto Príncipe 50, CEP 12245-572, São José dos
336 c
Dataq Instruments, Rua Arandu 205, CEP 04572-030, São Paulo SP, Brazil;
339
d
Covidien, 15 Hampshire Street, Zip code 02048, Mansfield, Massachusetts, United
340
States;
337
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338
342
e
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362, CEP 88106-500, São José, SC, Brazil;
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Metalife Indústria e Comércio de Móveis Ltda., Rua Vereador Arthur Manoel Mariano
345
f
346
States;
MathWorks, 1 Apple Hill Drive, Zip code 01760-2098, Natick, Massachusetts, United
347 348 349
g
IBM Brasil, Rua Tutoia 1157, CEP 04007-900, São Paulo, SP, Brazil.
15
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activity of healthy adult females. J Manipulative Physiol Ther 2010;33(9):672-8.
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FIGURE LEGEND
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be
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Figure 1: Initial (left) and final position (right) of the evaluated exercises.
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coordination
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Hug
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Park SY, Yoo WG. Effect of EMG-based feedback on posture correction during
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Menacho MO, Obara K, Conceicao JS, Chitolina ML, Krantz DR, da Silva RA,
ACCEPTED MANUSCRIPT TABLE 1: Description of the Pilates exercises
Name of the exercise
Description
Shoulder Bridge
The participant was positioned supine, with neutral pelvis
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and spine, knees bent, feet flat on the mat, legs parallel and hip-width apart, arms to the sides, palms facing up, and stabilized shoulder blades.
The participant remained in the supine position with neutral
SC
Hip Roll
pelvis and spine, knees bent, feet on the bar of the Reformer,
M AN U
legs parallel and hip-width apart, arms to the sides, and palms facing up. In this exercise, the participant pushed with her feet on the bar, moving the sliding carriage without fully extending the knees. In addition, the equipment was adapted
TE D
according to the participant's height. The exercises on the Reformer were performed with one or two red springs, each one with 473 cm in length and 0.2 kgf/cm² tension,
EP
according to the manufacturer. When only one spring was
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used, it was expected that the exercise would be more unstable and therefore require greater activation of the assessed muscles to control the movements. With two springs, the exercise was expected to be more stable, requiring less activation of the assessed muscles.
Breathing
The participant was positioned supine on the Cadillac, head toward the roll down bar, neutral pelvis and spine, knees bent, arms extended to the side of the body, stabilized
ACCEPTED MANUSCRIPT shoulder blades, and feet on the trapeze handle using the red spring, 473 cm in length and 0.69 kgf/cm² tension, according to the manufacturer. In this exercise, the participant’s feet would balance on the trapeze handle, generating a force
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toward the ground before starting the movements.
ACCEPTED MANUSCRIPT TABLE 2: Characteristics of the participants. Low Back Pain
Control Group
Group (n = 30)
(n = 30)
Age (years), mean (SD)
35.7 (12.9)
34.2 (9.9)
Duration of low back pain (months), mean (SD)
91 (129.5)
NA
Height (m), mean (SD)
1.6 (0.1)
1.6 (0.1)
Body mass index (kg/m2), mean (SD)
23.3 (2.8)
22.7 (2.1)
SC
Marital status, n (%) Single
Divorced Widowed Academic level, n (%)
EP
Tertiary education
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Primary education Secondary education
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Income (in minimum wages), mean (SD) NA: Not applicable.
11 (36.7)
12 (40)
17 (56.7)
14 (46.7)
2 (6.7)
3 (10)
0 (0)
1 (3.3)
6 (20)
6 (20)
16 (53.3)
21 (90)
8 (26.7)
0 (0)
0 (0)
2 (6.7)
5.4 (4.6)
8.5 (6.5)
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Married
Postgraduate
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Characteristics
ACCEPTED MANUSCRIPT
in Low Back Pain and Control Groups (n = 30 each group).
Hip Roll (1 spring)
Mean (SD)
Mean (SD)
(95% CI)
1.22 (0.22)
0.03 (-0.09 to 0.15)
0.894
SC
Mean difference
p
Gluteus Maximus
1.25 (0.24)
External Oblique
1.05 (0.23)
1.06 (0.16)
-0.01 (-0.11 to 0.10)
0.132
Gluteus Maximus
0.89 (0.25)
0.82 (0.24)
0.08 (-0.05 to 0.21)
0.795
External Oblique
1.20 (0.21)
1.12 (0.23)
0.08 (-0.03 to 0.19)
0.394
0.89 (0.15)
0.92 (0.14)
-0.03 (-0.11 to 0.04)
0.961
0.87 (0.15)
0.89 (0.12)
-0.02 (-0.09 to 0.05)
0.243
Gluteus Maximus
EP
External Oblique Gluteus Maximus
0.96 (0.16)
1.04 (0.21)
-0.08 (-0.17 to 0.02)
0.267
External Oblique
0.87 (0.21)
0.93 (0.12)
-0.06 (-0.15 to 0.03)
0.195
AC C
Hip Roll (2 springs)
Control Group
M AN U
Breathing
Low Back Pain Group
TE D
Shoulder Bridge
RI PT
TABLE 3: Between-group comparison of the activation of the gluteus maximus and external oblique muscles during the four evaluated exercises
ACCEPTED MANUSCRIPT
Low Back Pain Group
Shoulder Bridge vs Hip Roll (2
External oblique
Mean difference
Mean difference
(95% CI)
(95% CI)
0.29 (0.16 to 0.41)
