RESEARCH ARTICLE

Trunk Muscle Activation During Different Quadruped Stabilization Exercises in Individuals with Chronic Low Back Pain† Tae-Lim Yoon1,2, Heon-Seock Cynn1*, Sil-Ah Choi1, Woo-Jeong Choi1, Hyo-Jung Jeong1, Ji-Hyun Lee1 & Bong-Sam Choi2 1

Applied Kinesiology and Ergonomic Technology Laboratory, Department of Physical Therapy, The Graduate School, Yonsei University,

Wonju, South Korea 2

Department of Physical Therapy, College of Health and Welfare, Woosong University, Daejeon, South Korea

Abstract Background and Purpose. The aim of this study was to compare the trunk muscle activities and the local/global activity ratios of the abdominal, back and trunk muscles during stabilization exercises such as one arm raise (AR), one leg raise (LR), and opposing arm/leg raise (ALR) in patients with chronic low back pain (LBP). Method. Ten individuals with chronic LBP (five men and five women) participated in this study. The external oblique abdominis, internal oblique abdominis, multifidus, thoracic part of the lumbar iliocostalis and the local/global activity ratio were assessed, while quadruped stabilization exercises were performed (AR, LR, and ALR); each exercise was carried out three times. Result. One-way repeated ANOVA was used to measure the differences in the trunk muscle activity and the local/global activity ratio. Post hoc analyses were performed (α = 0.05/3 = 0.017). In the right internal oblique, muscle activity during LR was significantly greater than that during AR. In the bilateral multifidus and lumbar iliocostalis, each ALR muscle activity was significantly greater than those of AR and LR. In addition, the local/global activity ratios of the back and trunk muscle in LR and ALR were significantly greater compared with AR. Conclusions. LR should be recommended over AR for individuals with chronic LBP. Moreover, the application of ALR should be approached carefully on the basis of progress and ability to stabilize the spine in this patient population. Copyright © 2014 John Wiley & Sons, Ltd. Received 11 July 2014; Accepted 24 September 2014 Keywords core muscles; electromyography; spine *Correspondence Heon-Seock Cynn, PT, PhD, Department of Physical Therapy, The Graduate School, Yonsei University, 1 Yonseidae-gil, Wonju, Kangwon-do 220–710, South Korea. E-mail: [email protected]

The protocol for this study was approved by the Yonsei University Wonju Institutional Review Board.

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.1611

Introduction Specific exercises for co-contraction of global and local muscles for trunk stability have been termed lumbar stabilization exercises (Imai et al., 2010). Such exercise

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ensures the sufficient stability of spine while training patterns of muscle activity and spine posture (McGill, 2007; Imai et al., 2010). Although there is controversy over using exercise for acute low back pain (LBP)

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patients, the patient populations with acute and chronic LBP may experience some gain from programmes involving the appropriate level of exercise (Hides et al., 1994; Ekstrom et al., 2008). Thus, stabilization exercise has become a major focus among physical therapists as an intervention for LBP patients (Kavcic et al., 2004b; Ekstrom et al., 2008). Stabilization exercises can be practiced to enhance the stability of spine in a variety of body positions such as sitting, standing, supine, prone, sidebridge, or quadruped (Souza et al., 2001; Kavcic et al., 2004b; Stevens et al., 2007; Liebenson et al., 2009; García-Vaquero et al., 2012; Rabin et al., 2013). In particular, stabilization exercises in quadruped position with the trunk in a horizontal position, including one arm raise (AR), one leg raise (LR), and opposing arm/leg raise (ALR) are popular stabilization exercises in rehabilitation (such as yoga and pilates) due to the advantage of reducing spinal loads and strengthening the lumbar extensor compared with other stabilization exercises (Richardson and Jull, 1995; McGill, 2002; Kavcic et al., 2004b; Liemohn et al., 2005; Stevens et al., 2007; Ekstrom et al., 2008). The appropriate level of stabilization exercise for should be prescribed with caution (Kavcic et al., 2004b; McGill and Karpowicz, 2009). Several studies have attempted to investigate the muscle activation level during quadruped stabilization exercises with healthy group and suggested selecting the stabilization exercises based on patients’ progress (Souza et al., 2001; Kavcic et al., 2004a; Kavcic et al., 2004b; Stevens et al., 2007; McGill and Karpowicz, 2009; GarcíaVaquero et al., 2012). In particular, there have been great emphases on the activation of local muscles such as the lumbar multifidus (MF), internal oblique (IO) abdominis, and transverse abdominis, in comparison with global muscles such as the rectus abdominis, external oblique (EO) abdominis, and thoracic part of the lumbar iliocostalis (ILT) in patients with chronic LBP (Danneels et al., 2000; O’Sullivan, 2000; McGill et al., 2003; Barker et al., 2004; Hodges et al., 2006) and acute LBP (Hides et al., 1996; Hides et al., 2008). Even with the common application of the quadruped stabilization exercise, however, there is only one study that has investigated the effect of the ALR stabilization exercise on trunk muscles in patients with chronic LBP (Arokoski et al., 2004). In general, different crosssectional surface areas and increased fatigability of the paraspinal muscles were revealed between individuals with LBP and a healthy group due to their characteristic differences. Therefore, investigation of the difficulty

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levels of quadruped stabilization exercises by determining the trunk muscle activity in chronic LBP individuals may be necessary. Consequently, investigation of the muscle activity in the trunk muscle during quadruped stabilization exercises in patients with chronic LBP will provide the foundation to recommend the appropriate level of stabilization exercises for both patients and clinicians. The purpose of our study was to compare the trunk muscle activity and the local/global muscle activity ratio among different levels of quadruped stabilization exercises in individuals with chronic LBP. We hypothesized that there would be different trunk muscle activities and the local/global muscle ratios among such exercises in the study population.

Methods Study design The trunk muscle (EO, IO, MF, and ILT) activity and the local/global muscle activity (IO/MF, EO/ILT, and IO + MF/EO + ILT) ratio were compared during quadruped stabilization exercises (AR, LR, and ALR) in individuals with chronic LBP.

Subjects Ten individual with chronic LBP (five men and five women) participated in this study. The inclusion criteria were as follows: subjects had had LBP for more than 3 months without radicular symptoms such as radiating pain below knee, loss of sensation, or loss of reflexes (Arokoski et al., 2004). Exclusion criteria were as follows: 1) current use of medication for LBP; 2) previous back surgery; 3) thoracic and cervical pain; and 4) other specific and serious causes of back pain (Lariviere et al., 2000; Arokoski et al., 2004). The duration of LBP, Oswestry disability index score and visual analogue scale score for LBP were determined to assess LBP in the subjects before the exercise period. With the Oswestry disability index score, subject added up the points for each section and calculated the level of disability (point total/50 × 100 = % disability) (Fairbank and Pynsent, 2000). With the visual analogue scale score for LBP, participants subjectively estimated the intensity of their current LBP by marking it on a 100-mm horizontal line (0 mm, no pain; 100 mm, worst possible pain) (Arokoski et al., 2004). All of the general characteristics Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.

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are described in Table 1. The subjects were informed of the experimental protocol and possible risks. In addition, written consent was obtained prior to their participation. This study was approved by Yonsei University Wonju Institutional Review Board.

Materials Surface electromyography (EMG) signals were collected using the Tele-Myo 2400 T EMG instrument (Noraxon Inc., Scottsdale, AZ, USA). EMG data were recorded at a 1,000 Hz sampling rate and analysed using Myo-Research Master Edition 1.06 XP software (Noraxon Inc., Scottsdale, AZ 85260-1656, USA). The raw signal was filtered with a digital band-pass filter between 20 and 400 Hz and notch filter (60 Hz). Root mean square values were calculated with a moving window of 50 ms. The EMG signals were collected bilaterally in the following muscles and locations: the EO, approximately 15 cm lateral to the umbilicus; the IO, with the electrode positioned at the midpoint between the anterior superior iliac spine and the pubic tubercle; the MF, on a line from the caudal tip of the posterior superior iliac spine to the interspace between L1 and L2, at the level of the L5 spinous process; and the ILT, at the L1 level, midway between the lateral palpable border of the erector spinae and a vertical line through the posterior superior iliac spine (Ng et al., 1998; Queiroz et al., 2010; De Ridder et al., 2013). Before electrode placement, the skin was cleaned carefully with an alcohol wipe to reduce the skin impedance. Disposable Ag/AgCl surface electrodes were positioned parallel to the muscle fibres with a 2-cm centre-to-centre spacing. For normalization, the volunteers were asked to perform three different isometric exercises twice for 5 seconds each to determine the maximal voluntary isometric contraction (MVIC) of each muscle, as described by Kendall et al. (2005). A resting Table 1. General characteristics (n = 10) Variable

Mean ± SD

Age (years) Height (cm) Weight (kg) 2 BMI (kg m ) Duration of LBP (years) Oswestry disability index score (%) Visual analogue scale score (mm)

23.0 ± 1.0 168.9 ± 7.5 62.7 ± 12.3 21.7 ± 2.8 3.9 ± 3.1 27.6 ± 4.2 27.3 ± 24.2

SD; standard deviation; BMI; body mass index, LBP; low back pain.

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interval of 1 minute was included between the test trials. We used the centre 3 seconds of data to determine the mean amplitude of MVIC. The EMG signals were presented as a percentage of the calculated root mean square of %MVIC. Because coordination between the local and global muscle systems is essential in stabilizing the spine, the local/global activity ratios of abdominal, back and trunk muscles during quadruped stabilization exercises were also investigated (Stevens et al., 2007). The normalized IO was divided by the MF amplitude to calculate the local/global activity ratio of the abdominal muscle. The normalized EO was divided by the ILT amplitude to calculate the local/global activity ratio of the back muscle. The sum of normalized IO and MF amplitudes was divided by the sum of normalized EO and ILT amplitudes to calculate the local/global activity ratio of the trunk muscle.

Procedures Subjects performed 20-minute familiarization sessions for AR, LR, and ALR until the appropriate motions were carried out; they then had 15 minutes of rest to avoid muscle fatigue. The quadruped stabilization exercises (AR, LR, and ALR) were performed three times each. In addition, a 1-minute interval was included between trials (García-Vaquero et al., 2012). The recording order was randomized to eliminate any possible effects of measurement order by using the randomnumber generator in Microsoft Excel (Microsoft Corp., Redmond, WA, USA). The muscle activations from the middle 3 seconds window of normalized EMG data were averaged. During data collection, all the subjects completed the activities in quadruped position without increased LBP or discomfort.

The quadruped stabilization exercises (AR, LR and ALR) The subjects were initially positioned in quadruped position by placing their hands and knees on a table (shoulders, hips, and knees at 90° of flexion). Because the AR, LR, and ALR exercises consist of raising one hand, one leg, or one hand and the opposite leg, the balancing on the other hand and leg, the dominant side needed to be identified to compare the muscle activation on trunk muscles during quadruped stabilization exercises. We used leg dominance because the functions of the lumbar spine might change depending on

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whether a subject is using the dominant hip (Sung and Kim, 2011). All of our subjects were asked which leg they preferred to use when kicking a ball (Sung and Kim, 2011). From this, it was determined that all of the subjects had right leg dominance. For AR, the subjects raised the left arm while balancing on the other arm and both legs. For LR, the subjects raised the right leg while balancing on the other leg and both arms. Finally, for ALR, the subjects raised the left arm and right leg while balancing on the other arm and knee (Figure 1). To confirm that the arm and leg were raised to the horizontal position, two target bars (height-adjustable horizontal bars on a vertical pole with a base) were set at the lateral side of each subject’s raised wrist and ankle. In addition, we asked the subjects to keep their shoulders and hips square to avoid leaning of the body.

Statistics The Kolmogorov–Smirnov Z-test was performed to investigate whether continuous data had normal distribution. We used a one-way repeated ANOVA with a significance level of 0.05 to measure the differences in the normalized EMG signals of the EO, IO, MF, and ILT, as well as the local/global ratio of trunk muscle activity during quadruped stabilization exercises (AR, LR and, ALR). Post hoc analyses were performed using Bonferroni correction to evaluate the significance of

Figure 1. Stabilization exercises in quadruped position

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between-exercise pairwise comparisons. The statistical significance level was set at α = 0.05/3 = 0.017. SPSS ver. 18.0 software was used for all data analyses (SPSS Inc., Chicago, IL, USA).

Results All continuous data were normally distributed. There were no significant differences in muscle activity in the bilateral EO and left IO among three different quadruped stabilization exercises. A significant difference in muscle activity was noted in the right IO (F = 6.850, p = 0.006), and pairwise comparisons demonstrated that right IO muscle activity in LR was significantly greater than in AR. There were significant differences in muscle activity in the bilateral MF (right MF: F = 13.724, p = 0.001; left MF: F = 16.291, p = 0.001) and the ILT (right ILT: F = 13.909, p = 0.013; left ILT: F = 17.347, p = 0.001) among the three different quadruped stabilization exercises. Pairwise comparisons revealed that each ALR muscle activity was significantly greater than for AR and LR (Figure 2). The local/global ratio of the abdominal, back, and trunk muscle activities during quadruped stabilization exercises are shown in Figure 3. The local/global activity ratio of the abdominal muscle showed no significant difference among the quadruped stabilization exercises. The local/global activity ratios of the back and trunk muscles showed significant differences [F(2.22 = 8.494), p = 0.003 for back muscle; F(2.22 = 17.548), p = 0.001 for trunk

Figure 2. Comparison of trunk muscle activation during different levels of quadruped stabilization exercise (AR: one arm raise, LR: one leg raise, ALR: opposing arm/leg raise, MF: lumbar multifidus, IO: internal oblique abdominis, EO: external oblique abdominis, ILT: thoracic part of lumbar iliocostalis).* p < 0.017

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Figure 3. Local/global activity ratio of abdominal, back and trunk muscles (AR: one arm raise, LR: one leg raise, ALR: opposing arm/leg raise). *p < 0.017

muscle] among the quadruped stabilization exercises, while pairwise comparisons showed that the local/global activity ratios of the back and trunk muscle in LR and ALR were significantly greater compared with that of AR.

Discussion The purpose of our study was to compare trunk muscle activity and the local/global muscle activity ratio among different levels of quadruped stabilization exercises in subjects with chronic LBP. In the abdominal muscles, there were no significant muscle activity differences in the bilateral EO and left IO, but a significant difference was found for the right IO. The IO muscle activity in LR was significantly greater than that in AR. In the back muscles, the bilateral MF and ILT showed similar activation patterns. Each muscle in ALR exhibited significantly greater activity compared with AR and LR. In addition, the local/global muscle activity ratios in both LR and ALR were significantly greater than that of the AR. In the abdominal muscles, the bilateral EO showed no significant difference in terms of muscle activity, and comparable ranges of muscle activation of 21–28% MVIC during AR, LR and ALR were noted in this study. Previous studies with healthy groups have generally presented lower levels of EO muscle activation (range of 6–13%) during AR, LR and ALR compared with our study (McGill and Karpowicz, 2009; García-Vaquero et al., 2012). This different level of bilateral EO activity, which is relatively greater activation in subjects with chronic LBP compared with healthy subjects, may imply that bilateral EO muscle activity increased to perform AR, LR, and ALR during quadruped stabilization exercise in subjects with chronic LBP, although we did not measure trunk muscle activity in matched healthy subjects. Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.

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In the right IO, the muscle activation in LR was significantly greater than in AR, while the left IO showed no significant difference of muscle activity among AR, LR, and ALR. In addition, this was the only statistically significant difference between AR and LR exercises among all the muscles. This result may imply that the difficulty levels between AR and LR are mostly equivalent, except that LR requires more IO muscle activation in the raised leg side to stabilize the lumbopelvic spine for chronic LBP subjects. Furthermore, previous studies comparing the muscle activity between AR and LR with healthy groups reported relatively similar levels of muscle activation between AR and LR (Stevens et al., 2007; McGill and Karpowicz, 2009). In the back muscles, the muscle activation of the bilateral MF in ALR was significantly greater than in AR or LR. Moreover, there was no difference in muscle activation between AR and LR in this study. Similarly, a previous study claimed that ALR requires higher stability, while LR requires moderate stability in healthy individuals (Kavcic et al., 2004b). Therefore, ALR can be considered as a more pertinent stability exercise, requiring increased bilateral MF muscle activation, than AR and LR. However, the previous study with healthy individuals reported less muscle activation in the bilateral MF during LR (5–15% MVIC) and ALR (15–25% MVIC) (Kavcic et al., 2004b). Although direct comparisons between various previous studies are problematic, subjects with chronic LBP needed to generate almost twice as much muscle activation in the MF to stabilize their lumbopelvic spine during LR and ALR. Consequently, the target stabilization exercise level in subjects with chronic LBP should be carefully determined on the basis of their progress. In the bilateral ILT, ALR muscle activity was significantly greater than that of AR and LR during quadruped stabilization exercises. Moreover, there was no difference in muscle activation between AR and LR. Several previous studies also reported that the muscle activation in the bilateral ILT during ALR was higher than during LR among healthy individuals (Kavcic et al., 2004b; Stevens et al., 2007; García-Vaquero et al., 2012). Therefore, we assumed that ALR causes augmented muscle activation in the bilateral ILT in relation to AR and LR. In addition, the muscle activations of the bilateral ILT were similar during AR and LR, while that of the left ILT was much higher than the right ILT during ALR. The higher muscle activation of the left ILT may be explained in terms of an

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excessive effort to balancing the subjects’ trunk with the left arm and the right leg extension in the quadruped position among individuals with chronic LBP. The local/global muscle activity ratio was significantly greater in LR and ALR compared with AR. Interestingly, the local/global muscle activity ratio during LR was higher than ALR, although the difference was not statistically significant. Correspondingly, a previous study with healthy subjects reported higher muscle activity in the EO and ILT during ALR compared with LR. These results suggest that prescribing LR may be more appropriate than AR or ALR due to the higher local/global muscle activity ratio. The local/global activity ratios of the back and trunk muscles showed significant differences, while the local/global activity ratios of abdominal muscle activity showed no significant difference among quadruped stabilization exercises; pairwise comparisons showed that the local/global activity ratios of the back and trunk muscle in LR and ALR were significantly greater compared with AR. Our study had several limitations. First, the crosstalk issue may have been problematic in surface EMG, although our electrode placements were consistent with those of other previous researchers. In addition, there is a chance that subjects did not produce a true MVIC for each muscle due to a lack of effort. Second, kinematic data would have been preferable for confirmation of each quadruped stabilization exercise. Although we installed the target bars on the arm and leg for control, movement of pelvis was observed during quadruped stabilization exercises. Finally, longitudinal research on the effect of quadruped stabilization exercises on lumbar spine stability will be necessary for future study.

Implications The purpose of our study was to compare trunk muscle activity and local/global muscle activity among different levels of quadruped stabilization exercises in individuals with chronic LBP. Mostly, the muscle activities between AR and LR were considered to exhibit a similar level, but LR showed the advantages of strengthening the IO of the leg-raised side and higher local/global muscle activity. ALR showed the highest muscle activation trunk extension muscles among all quadruped stabilization exercises. However, the local/global muscle activity ratio was not higher for ALR than for LR. Consequently, we

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concluded that LR should be recommended for individuals with chronic LBP among the quadruped stabilization exercises. Moreover, the application of ALR in individuals with chronic LBP should be approached carefully based on their progress and ability to stabilize the spine. These data may guide physical therapists when prescribing easier to more intense stabilization exercises based on the patient’s progress.

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Trunk muscle activation during different quadruped stabilization exercises in individuals with chronic low back pain.

The aim of this study was to compare the trunk muscle activities and the local/global activity ratios of the abdominal, back and trunk muscles during ...
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