Activation of Lumbar Paraspinal and Abdominal Muscles

During Therapeutic Exercises in Chronic Low Back Pain

Patients
Jari P. Arokoski, DMSc, Taru Valta, PT, Markku Kankaanpaa, DMSc, Olavi Airaksinen, DMSc
ABSTRACT. Arokoski JP, Valta T, Kankaanpaa M,
Airaksinen O. Activation of lumbar paraspinal and abdominal
muscles during therapeutic exercises in chronic low back pain
patients. Arch Phys Med Rehabil 2004;85:823-32.
Objectives: To assess the activities of paraspinal and ab-
dominal muscles during therapeutic exercises for the treatment
of patients with nonspecic chronic low back pain (CLBP), and
to study the effects of active physical rehabilitation on these
activities.
Design: A cross-sectional study comparing muscle activities
during 18 stabilization exercises, and a prospective follow-up
of patients with CLBP during rehabilitation.
Setting: Rehabilitation clinic in university hospital in Fin-
land.
Participants: Nine volunteers (5 men, 4 women) aged 27 to
58 years.
Intervention: Three months of active outpatient rehabilita-
tion (4 to 6 times in a rehabilitation clinic, supplemented with
self-motivated exercise at home) supervised by a physiothera-
pist.
Main Outcome Measures: Surface electromyography was
recorded bilaterally from L5 level paraspinal, rectus abdominis,
and obliquus externus abdominis muscles. The recorded signal
was averaged and normalized to the maximal electromyo-
graphic amplitude obtained during the maximal voluntary con-
traction. The measurements were taken before and after the
exercise treatment period.
Results: CLBP patients showed variable trunk muscle ac-
tivity patterns during the different therapeutic exercises, similar
to those that we reported earlier in healthy subjects. The
maximal trunk isometric extension (pre, 147.375.9Nm; post,
170.172.3Nm) and exion (pre, 72.037.9Nm; post,
93.542.5Nm) torques did not show a signicant changes
during the exercise period. However, trunk rotation-exion
torque (pre, 52.926.5Nm; post, 82.465.8Nm) increased sig-
nicantly (35.8%) after the exercise period (P.05). The cor-
responding maximal electromyographic amplitudes of back
and abdominal muscles remained unchanged. Disability, as
assessed by visual analog scale and Oswestry Disability Index,
did not change.
Conclusions: The CLBP patients performed therapeutic ex-
ercises with similar abdominal and back extensor muscle ac-
tivities in the same way as the healthy subjects in our earlier
studies. In this study, active physical rehabilitation had no
effect on the abdominal and back muscle activities or on pain
and functional disability indices.
Key Words: Electromyography; Low back pain; Muscles;
Rehabilitation.
2004 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
T
HE STABILITY OF THE lumbar spine is determined by
osteoligamentous structures and trunk muscles. Because
motion takes place in all 3 dimensions simultaneously, com-
plex loading patterns act on the passive structures of osteoli-
gamentous spine and, if unprotected, the lumbar spine is vul-
nerable to being damaged. Therefore, it is essential that the
motions are precisely controlled by lumbar and abdominal
muscles to produce the stiffness required to optimize the load-
ing on the lumbar spine, and to prevent overload injury.
1-4
For
example, human osteoligamentous lumbar spine becomes me-
chanically unstable (in vitro) under a compressive load of
approximately 90N, a load much less than the weight of the
upper body.
5
The multidus muscles are the most important
back extensor muscles involved in providing the required stiff-
ness for the lumbar spine.
6
Spinal stability is additionally
increased with trunk exor-extensor muscle coactivation,
which increases intra-abdominal pressure and produces abdom-
inal spring force.
7
Although all trunk muscles may participate
in stabilizing the spine, transversus abdominis and multidus
muscles are thought to be the most important in this respect.
8
The function and coordination of the muscles that stabilize
the lumbar spine, especially the lumbar back extensor muscles,
are often impaired in patients with low back pain
9-12
(LBP).
This is because in patients with chronic low back pain (CLBP),
the paraspinal muscles exhibit histomorphologic and structural
changes, mainly type II muscle ber atrophy, which results
from disuse and deconditioning.
13-16
Therefore, specic trunk
muscle exercise programs are aimed at restoring the structural
and functional impairments, although recent studies have found
that back muscle function can be restored even when there are
no major structural changes.
17,18
Active physical rehabilitation is now extensively prescribed
as a treatment for CLBP. The efcacy of the active exercise-
based treatment programs has been documented in several
randomized controlled studies; the treatment guidelines still
recommend an active physical therapy approach for CLBP,
although there have been some conicting opinions.
19,20
There
is considerable variation in active physical treatment programs
for LBP patients, both with respect to their duration and their
physical intensity. Furthermore, there appears to be no direct
dose-response relationship. Aerobic exercise alone has been as
effective as the specic low back and abdominal muscle exer-
cises in the treatment of CLBP.
21
The cost-effectiveness of the
guided aerobic exercise program is claimed to be greater than
the specic outpatient programs, mostly because it minimizes
From the Department of Physical and Rehabilitation Medicine (Arokoski, Kan-
kaanpaa, Airaksinen); and Rehabilitation Clinic (Valta), Kuopio University Hospital,
Kuopio; and Kuopio University, Kuopio (Arokoski), Finland.
Supported by the Kuopio University Hospital.
No commercial party having a direct nancial interest in the results of the research
supporting this article has or will confer a benet upon the authors(s) or upon any
organization with which the author(s) is/are associated.
Reprint requests to Jari Arokoski, DMSc, Dept of Physical and Rehabilitation
Medicine, Kuopio University Hospital, PL 1777, 70211 Kuopio, Finland, e-mail:
Jari.Arokoski@kuh..
0003-9993/04/8505-8146$30.00/0
doi:10.1016/j.apmr.2003.06.013
823
Arch Phys Med Rehabil Vol 85, May 2004
the amount of individual guidance needed during the treat-
ment.
21
Therefore, self-motivated exercise would be desirable
and more convenient as a part of an active outpatient rehabil-
itation program, because it would minimize the need for indi-
vidual guidance and the number of visits to an outpatient clinic.
In our recent electromyography study,
22
simple therapeutic
exercises were effective in activating lumbar paraspinal and
abdominal muscles in healthy volunteers; surface and intra-
muscular electromyographic measurements were highly com-
parable in the assessment of lumbar multidus muscle func-
tion. By changing the limb and trunk positions, or by
unbalancing trunk movements, it is possible to increase trunk
muscle activities.
22-24
This is a simple and straight forward way
to select exercises with progressive resistance during an exer-
cise therapy program. However, Daneels et al
25
have recently
claimed that healthy subjects are better able to activate their
paraspinal muscles (multidus and iliocostalis lumborum mus-
cles) during strength exercises than are patients with subacute
or CLBP. However, no such group differences were observed
in exercises that involved less muscular activity. Few studies
have examined the muscle activity levels during therapeutic
exercises in patients with LBP, and the results obtained in the
studies are controversial.
26,27
Our purpose in this study was to assess the L5 level paraspi-
nal, rectus abdominis, and obliquus externus abdominis muscle
activities during different therapeutic exercises before and after
a 3-month exercise period. The hypothesis was that the abdom-
inal and paraspinal muscle activity would be enhanced during
that period. The mean values of these results were compared
with earlier published results that involved healthy sub-
jects.
22-24
We hypothesized that patients with CLBP could not
activate their lumbar paraspinal muscles as well as could
healthy subjects.
METHODS
Participants
Nine patients (5 men, 4 women), aged 27 to 58 years, with
nonspecic CLBP participated after signing a voluntary con-
sent form. The subjects characteristics are shown in table 1. In
an initial clinical examination at the rehabilitation clinic, the
cause of the back pain was conrmed to be nonspecic; thus,
patients with nerve root compression or disk prolapse, spon-
dylarthrosis, previous back surgery, or other specic and seri-
ous causes of back pain were excluded. In addition, the CLBP
diagnosis included the criteria that patients had had LBP for
more than 3 months and that they did not have radicular
symptoms (radiating pain below knee, loss of sensation, loss of
reexes). None of the subjects had participated previously in
similar testing or training. The study was approved by the
ethics committee of the Kuopio University Hospital, Kuopio,
Finland.
Questionnaires
The Oswestry Disability Index
28
(ODI) and back pain inten-
sity (visual analog scale [VAS]) were recorded to assess LBP
in the subjects before and after the training period. With the
VAS, participants evaluated subjectively the intensity of their
present back pain by marking it on a 100-mm horizontal line
(0mm, no pain at all; 100mm, worst possible pain).
Rehabilitation
Active rehabilitation included 4 to 6 exercises sessions over
12 weeks in an outpatient clinic. Each session lasted approxi-
mately 45 to 60 minutes. The patients trained individually
under the guidance of a physiotherapist. The treatment in-
cluded the physical exercises described below, together with
stretching exercises and ergonomic advice. Self-motivated aer-
obic exercise and home training using the same exercises
(exercises 2, 3, 59, 11, 15, 16; see exercises later) that were
performed during outpatient visits were strongly encouraged
(5d/wk) during each visit. The self-motivated training was
monitored via exercise diaries. The choice of this rehabilitation
model was based on the pragmatic clinical practice used by
general practitioners for patients with LBP.
Surface Electromyography
Surface electromyographic measurements were made sepa-
rately before and after exercise sessions. After the skin was
cleansed with alcohol, pairs of disposable Ag/AgCl surface
electrodes
a
were attached bilaterally over the following mus-
cles (gs 1A, 1B): rectus abdominis, 3cm lateral from the
umbilicus
29,30
; external oblique, halfway between the anterior
superior iliac spine (ASIS) and the inferior border of the rib
cage at a slightly oblique angle running parallel with the
underlying muscle bers
29,30
; and multidus muscles at L5,
2cm laterally from the midline running through the L5 spinal
process.
22,23
At the L5 level, the electrodes were placed in
parallel with the main direction of the underlying multidus
muscle bers.
31
The interelectrode space between the recording electrodes
was 2cm, and each electrode had an approximately 1.0cm
2
pickup area. The reference electrodes were attached approxi-
mately 9cm laterally from the recording electrode pairs.
Electromyographic Recording and Data Analysis
The ME4000 electromyography system
b
was used to con-
tinuously record bipolar surface activity with 8 channels. The
cables with preampliers were used to ensure good signal
quality. One pair of 10-cm long cables connected the recording
electrodes to the preamplier in each electromyographic chan-
nel. The preamplier was secured in place by attaching it to the
corresponding reference electrode. A single 2.5-m long cable
connected the preamplier to the amplier box. The raw elec-
tromyographic signal was recorded at the sampling rate of
1000Hz and band-pass ltered (high-pass corner frequency,
7Hz; anti-aliasing lter [Butterworth], 500Hz), amplied (dif-
ferential amplier, common mode rejection ratio, 130dB;
gain, 100; noise, 1V), analog-to-digital converted (12-bit),
and stored in a personal computer for later analysis.
For the electromyographic amplitude analysis, we used man-
ually selected artifact-free raw electromyographic sections.
The full-wave rectied electromyographic amplitude was de-
termined by calculating the absolute value of each data point,
and the mean value of the rectied amplitude was dened for
Table 1: Subject Characteristics, ODI Score, and Back Pain
Intensity at Beginning of Rehabilitation and After 3 Months
Parameters At the Beginning After 3 Months P
Age (y) 39.010.1 39.410.4 NS
Height (cm) 173.08.1 173.08.1 NS
Weight (kg) 72.813.3 72.013.0 NS
BMI (kg/m
2
) 24.44.1 24.03.6 NS
ODI 25.310.6 20.813.1 NS
Back pain intensity (VAS) (mm) 26.913.9 32.723.8 NS
NOTE. Values are mean standard deviation (SD).
Abbreviations: BMI, body mass index; NS, not signicant; ODI, Os-
westry Disability Index; VAS, visual analog scale.
824 TRUNK MUSCLE ACTIVITIES IN THERAPEUTIC EXERCISES, Arokoski
Arch Phys Med Rehabil Vol 85, May 2004
100-ms data segments. These data were plotted against time to
assess the average electromyographic amplitude (a mean value
of all data points within the selected areas). In therapeutic
exercises, 3 consecutive repetitions, each of 3- to 5-second data
segments of isometric contractions, and each of 1- to 3-second
data segments of dynamic contractions, were selected for the
assessment of average electromyographic amplitudes.
The electromyographic signals recorded in each exercise
were normalized to the maximal electromyographic amplitude
obtained during the maximal voluntary contraction (MVC).
The MVCs of the back and abdominal muscles were tested
using a Lido active isokinetic rehabilitation system.
c
During
testing, subjects stood on a nonslip material with their pelvis
and thighs xed to 20 of exion via a sturdy metal frame that
stabilized the pelvis and upper thighs posteriorly. Two 5-cm
wide canvas straps were placed anteriorly over the ASIS and
over the thighs. A 15-cm wide supporting harness was tight-
ened around the upper trunk at the level of the scapulae. The
MVCs of back extensor, rectus abdominis, and external oblique
muscles were tested in maximal isometric extension, exion,
and rotation-exion, respectively. Three maximal trunk exion
and extension torque measurements were made, each lasting
approximately 5 seconds. The highest maximal trunk exion
and extension torques (Newton meters) and the corresponding
electromyographic amplitudes (V) were assessed for men and
women. Average electromyographic amplitudes obtained were
normalized to the amplitude at MVC (percentage of maximal
electromyographic amplitude [%EMG
max
]). It was assumed
that all investigated muscles reached their maximal activation
level during either maximal exion or extension. The MVC
and electromyographic measurements were always performed
by the same tester, who was unaware of the results of the rst
test.
Exercises
The subjects were taught to perform the 18 different exer-
cises by practicing them under the guidance of physiothera-
pists. Subjects had no experience with muscle strength testing
or the therapeutic exercises. The aim of all the exercise studies
was that the subject keep his/her lumbar spine stationary. The
exercises were always performed in the same order (see num-
bered order below). Subjects rested for 2 to 5 minutes between
the exercises. The joint angles of the lower extremities were
controlled with an inclinometer during the exercises. Patients
were able to perform all of the exercises, which were arranged
as follows (see also gs 27).
Exercises While Standing
Exercise 1 (walking on a trampoline). The subject walked
on a trampoline (100 times/min).
Exercise 2 (leg swinging while standing). The subject
stood on 1 leg, with the other leg in 90 of exion, elbows in
90 of exion, and the contralateral hip moved forward to 90
of exion and backward to 10 of extension (76 times/min).
22
Exercise 3 (weights in hands and altering shoulder exion
while standing straight). The subjects stood on the exercise
carpet
d
while holding weights (women, 1kg; men, 2kg) with
slightly exed elbows, moving the weights up and down in the
frontal plane (40 times/min).
23
Exercise 4 (weights in hands and altering shoulder exion
while standing straight on the balance board). The subject
stood on a balance board and held weights (women, 1kg; men,
2kg) with slightly exed elbows, moving the weights up and
down in the frontal plane (40 times/min).
23
Exercise 8 (resisted upper-extremity extension while stand-
ing). The hips and knees were exed about 10 to 20 in the
standing position, legs slightly apart (at the same width as the
pelvis), elbows slightly exed and kept in the horizontal level
while the lumbar spine was kept stationary. The physiothera-
pist resisted upper-extremity isometric extension for 5 sec-
onds.
23
Exercise 9 (resisted upper-extremity exion while stand-
ing). The position was as in exercise 8, but the physiothera-
pist resisted the isometric exion of the upper extremities for 5
seconds.
23
Exercise 10 (resisted upper-extremity adduction while
standing). The position was the same as in exercise 8, but the
physiotherapist resisted the isometric adduction of the right
upper extremity for 5 seconds.
23
Exercises in the Sitting Position
Exercise 5 (weights in hands and altering shoulder exion
while sitting straight). The subject sat with his/her feet on the
oor and held weights (women, 1kg; men, 2kg) with slightly
exed elbows, moving the weights up and down in the frontal
plane while keeping the back straight in the sitting position (40
times/min).
23
Exercise 6 (backward and forward rocking in high sitting).
The subject sat with his/her feet on the oor, upper limbs
crossed over the chest, and back straight; the upper body was
exed and extended from the hips with a movement range
between 45 of exion and 15 of extension while keeping the
back straight (40 times/min).
22
Fig 1. Bipolar surface electromyographic electrode arrangement
(A) over the paraspinal muscles at L5-S1 level and (B) over the
rectus abdominis and externus abdominis muscles.
825 TRUNK MUSCLE ACTIVITIES IN THERAPEUTIC EXERCISES, Arokoski
Arch Phys Med Rehabil Vol 85, May 2004
Exercises in the Prone Position
Exercise 7 (unilateral leg extension with upper body prone
on the board). The subject laid his/her upper body prone on
the board and lifted his/her right leg to the horizontal level for
5 seconds.
23
Exercise 17 (resisted bilateral leg extension while prone).
The subject lay prone, with both knees straight, and lifted both
legs simultaneously a few centimeters from the oor for 5
seconds against resistance.
23
Exercise 18 (bilateral leg extension while prone). The
subject lay prone with both knees straight, and lifted his/her
legs a few centimeters from the oor for 5 seconds.
23
Exercise in the All-Fours Position
Exercise 11 (contralateral arm and leg lift in the all-fours
position). In the all-fours position, the contralateral upper and
lower limbs were lifted to the horizontal plane (40 times/
min).
22,32
Exercises in Supine and in Bridged Position
Exercise 15. Transversus abdominis exercise.
8
Exercise 13 (pushing bent knees against a soft ball in crook
lying). In crook lying with both knees bent, the subject
pushed with his/her knees bilaterally and submaximally against
a soft ball for 3 to 5 seconds while keeping the lumbar spine
stationary.
24,33
Exercise 12 (lifting hips up to a bridged position). The
subject lifted his/her hips up to a bridged position for 5 sec-
onds.
23
Exercise 14 (unilateral knee extension while keeping hips
in a bridged position). The subject kept his/her hips in the
bridged position and extended his/her knee.
23
Exercise in the Side-Lying Position
Exercise 16 (unilateral leg lift against resistance while
lying on 1 side). The subject lay on his/her left side, hips and
knees slightly (1015) exed, with the upper arm supporting
the position. The right lower limb was raised (hip abduction)
submaximally against resistance while the lumbar spine was
kept stationary for 3 to 5 seconds.
24
Statistical Analysis
All values are expressed as mean standard deviation (SD).
The signicance of differences before and after training ses-
sions was evaluated by nonparametric Wilcoxon matched-pairs
signed-rank test. Two-sided signicance was dened as P less
than .05.
RESULTS
The maximal trunk isometric extension and exion forces
and maximal electromyographic amplitudes are listed in table
2. No signicant change was noted in the maximal isometric
trunk extension (at the L5 level) or exion (rectus abdominis
muscle) torques after the exercise period (table 2), but the
maximal trunk rotation exion increased signicantly (35.8%)
(table 2). The corresponding maximal electromyographic am-
plitude of paraspinal muscles at the L5 level, and the rectus and
obliquus externus abdominis muscles were unchanged (table 2).
In general, obliquus externus abdominis and lumbar paraspi-
nal muscle (at the L5 level) %EMG
max
values were higher than
rectus abdominis muscle %EMG
max
values (gs 27). The
lowest muscle %EMG
max
value at the L5 level was detected in
exercises 8 and 15 (5.0%3.1% to 7.9%7.6%), and the
highest values in exercises 12, 14, and 18 (59.6%21.3% to
71.9%40.4%) (gs 4, 6, 7). The lowest levels of rectus
abdominis muscle %EMG
max
values were encountered in ex-
ercises 3, 5, 6, 9, 12 (2.9%2.7% to 3.8%2.6%), and the
highest level was found in exercise 10 (51.3%34.9%) (g 4).
The lowest levels of obliquus externus abdominis muscle
%EMG
max
values were found in exercise 12 (11.0%5.8%)
(g 6). The highest levels of obliquus externus abdominis
muscle %EMG
max
values were detected in exercise 8
(54.2%26.9%) (g 4). The %EMG
max
values did not signif-
icantly change after the exercise period (gs 27).
According to their exercise diaries, none of the patients did
the home exercises 5 to 6 times per week, as had been recom-
mended. Two subjects had exercised less than once a week, 4
Fig 2. Mean standard deviation (SD)
average normalized electromyographic
amplitude (%EMG
max
) (right and left side
combined) (n9) at the beginning and af-
ter 3-month period of follow-up exercises
at the L5 level of erector spinae muscles
and at the rectus abdominis (RA) and
obliquus externus (OE) abdominis mus-
cles during walking or leg swinging: (A)
exercise 1: walking on a trampoline and
(B) exercise 2: leg swinging while stand-
ing.
826 TRUNK MUSCLE ACTIVITIES IN THERAPEUTIC EXERCISES, Arokoski
Arch Phys Med Rehabil Vol 85, May 2004
subjects exercised between 1 to 2.5 times a week, and 3
patients exercised more than 3 times, but not more than 5 times,
a week.
According to VAS, no statistical differences occurred in the
LBP intensity (table 1). Nor did ODI scores signicantly de-
crease during the exercise therapy period (table 1).
DISCUSSION
Trunk muscle electromyographic activities have been inves-
tigated during static and dynamic therapeutic exercises, mostly
in healthy subjects.
22-24,34-42
To our knowledge, this is the rst
study that has evaluated lumbar paraspinal and abdominal
muscle activities during different therapeutic exercises before
and after active physical rehabilitation in patients with LBP.
Simple therapeutic exercises appear to be effective in activat-
ing abdominal as well as lumbar paraspinal muscles in patients
with CLBP.
The mean average normalized electromyographic ampli-
tudes (%EMG
max
) at the L5 level were within 5.0% to 71.9%,
which indicates that the paraspinal muscles were using both
aerobic and anaerobic metabolism.
43
The highest level of lum-
bar paraspinal electromyographic activity was during those
exercises that involved lifting hips up to the bridged position
(exercises 12, 14) and during bilateral leg extension in the
prone position (exercises 17, 18). Our results show that the
lumbar paraspinal muscles are also highly activated in the
standing position (exercises 4, 9). Thus, exercises involving
hyperextension of the back from the prone position are not the
only exercises that can activate the lumbar paraspinal muscles.
These results are in accord with our earlier observations in
Fig 3. Mean SD average normalized elec-
tromyographic amplitude (%EMG
max
) (right
and left side combined) (n9) at the begin-
ning and after 3-month period of follow-up
exercises at the L5 level of erector spinae
muscles and at the rectus abdominis and
obliquus externus abdominis muscles while
sitting or standing: (A) exercise 6: backward
and forward rocking in high sitting position;
(B) exercise 5: weights in hands and altering
shoulder exion while sitting upright; (C) ex-
ercise 3: weights in hands and altering shoul-
der exion while standing straight; and (D)
exercise 4: weights in hands and altering
shoulder exion while standing straight on
the balance board.
827 TRUNK MUSCLE ACTIVITIES IN THERAPEUTIC EXERCISES, Arokoski
Arch Phys Med Rehabil Vol 85, May 2004
healthy subjects.
23
It was also shown that holding additional
weights, or the additional load produced by unbalanced limb
movements, can increase trunk muscle activity, as has been
shown with healthy subjects.
22,23
It has been suggested that deep local stabilizing lumbar
multidus muscles should be contracted independently of the
global muscles, that is, the obliquus externus and internus and
rectus abdominis muscles.
8
The obliquus externus muscles are
apparently also activated during many exercises (exercises 17,
10, 11, 13, 16) simultaneously with the paraspinal muscles at
the L5 level. Thus, it is also concluded that it is difcult to
contract the lumbar paraspinal muscles (ie, local stabilizing
muscles) independently from the obliquus externus muscles
(ie, global stabilizing muscles) in these stabilization exercises.
However, in general, the activity in the abdominal muscles
(especially the rectus abdominis muscle) was lower than in the
paraspinal muscles, which indicates that loading was mostly
targeted to the paraspinal muscles. We have reported similar
ndings in healthy subjects.
23
Lumbar paraspinal electromyography has been used to esti-
mate back extensor force generation and spinal compression
during lifting activities,
44
because electromyographic activity is
related to the load acting on the lumbar disks.
45
Thus, the high
activation level of the lumbar paraspinal muscles may lead to
unfavorable forces impinging on the spine.
32,46
Second, it has
also been suggested that back muscle contractions as low as
25% of MVC can provide maximal joint stiffness
47
and that
between 30% and 40% of MVC is needed to improve muscle
performance.
8
Thus, the therapeutic exercises, in which the
mean %EMG
max
values of lumbar paraspinal muscles were
clearly above 40% (exercise 4, 9, 12, 14, 17, 18), may not be
suitable for exercising the paraspinal muscle for back pain
patients, because they could increase the risk of back injury.
The lowest muscle %EMG
max
values at the L5 level were
detected in resisted upper-extremity extension in the standing
position (exercise 6) and during abdominal contraction while
supine (exercise 15). Such exercises as 13 and 16, in which
prolonged tonic holding of lumbar paraspinal muscles is re-
quired, appear adequate to activate the lumbar paraspinal mus-
cles in the reeducation phase and exercise progressions in the
stabilization exercise program. Walking exercises (exercises 1,
2), exercises in the sitting position (exercises 5, 6), in the
standing position (exercises 3, 10), while prone (exercise 7),
and in the all-fours position (exercise 11) should be used later
in the rehabilitation process, when more intensive muscle load-
ing can be tolerated.
Fig 4. Mean SD average
normalized electromyographic
amplitude (%EMG
max
) (right
and left side combined) (n9)
at the beginning and after
3-month period of follow-up
exercises at the L5 level of
erector spinae muscles and at
the rectus abdominis and
obliquus externus abdominis
muscles while standing: (A)
exercise 8: resisted upper-ex-
tremity extension while stand-
ing; (B) exercise 9: resisted up-
per-extremity exion while
standing; and (C) exercise 10:
resisted upper-extremity ad-
duction while standing.
Fig 5. Mean SD average normalized elec-
tromyographic amplitude (%EMG
max
) (right
and left side combined) (n9) at the begin-
ning and after 3-month period of follow-up
exercises at the L5 level of erector spinae
muscles and at the rectus abdominis and
obliquus externus abdominis muscles while
prone or on the all-fours position: (A) exercise
7: unilateral leg extension while upper body
prone on the board; and (B) exercise 11: con-
tralateral arm and leg lift in the all-fours po-
sition.
828 TRUNK MUSCLE ACTIVITIES IN THERAPEUTIC EXERCISES, Arokoski
Arch Phys Med Rehabil Vol 85, May 2004
Dynamic measurements have indicated pathologically low
muscle activities and asymmetries in active movements in back
pain patients.
48,49
Also patients with LBP have failed to in-
crease their paraspinal activity level during the Valsalva ma-
neuvre or sit-up test.
50
Thus, we hypothesized that the thera-
peutic exercises would produce lower trunk muscle activity in
patients with CLBP when compared with healthy subjects who
had no current or past back pain problems. The mean maximal
trunk exion and extension torques in healthy women and men
was 78 and 134Nm in exion and between 151 and 237Nm in
extension, respectively.
23
Thus, the mean maximal trunk
torques in this study show that trunk muscle strength is de-
Fig 6. Mean SD average normalized elec-
tromyographic amplitude (%EMG
max
) (right
and left side combined) (n9) at the begin-
ning and after 3-month period of follow-up
exercises at the L5 level of erector spinae
muscles and at the rectus abdominis and
obliquus externus abdominis muscles while
prone or supine or in the bridged position: (A)
exercise 15: abdominal contraction while su-
pine; (B) exercise 13: pushing bent knees
against a soft ball in crook lying; (C) exercise
12: lifting hips up to the bridged position; and
(D) exercise 14: unilateral knee extension
while keeping hips in the bridged position.
Fig 7. Mean SD average
normalized electromyo-
graphic amplitude (%EMG
max
)
(right and left side combined)
(n9) at the beginning and af-
ter 3-month period of fol-
low-up exercises at the L5
level of erector spinae mus-
cles and at the rectus abdomi-
nis and obliquus externus ab-
dominis muscles while lying
on 1 side or prone: (A) exercise
16: unilateral leg lift against
resistance while lying on 1
side; (B) exercise 17: resisted
bilateral leg extension while
prone; and (C) exercise 18: bi-
lateral leg extension while
prone.
829 TRUNK MUSCLE ACTIVITIES IN THERAPEUTIC EXERCISES, Arokoski
Arch Phys Med Rehabil Vol 85, May 2004
creased in patients with LBP, as has been shown earlier.
51,52
Similarly, the mean maximal trunk electromyographic ampli-
tudes during the MVC test were lower in patients with LBP
than in healthy subjects.
23
It is possible that the average elec-
tromyographic amplitudes obtained during the therapeutic ex-
ercises were also lower in patients with LBP, but when these
values were normalized to the electromyographic amplitude at
MVC (%EMG
max
), no clear difference could be detected be-
tween the groups.
We also hypothesized that learning might be a factor asso-
ciated with increased muscle strength and electromyographic
activity in MVC tests and during the exercises. However, the
mean maximal trunk torques and electromyographic ampli-
tudes, as well as the %EMG
max
values of separate therapeutic
exercises, did not differ signicantly after 3 months of fol-
low-up from the results at the beginning of the study. This
indicates that the patients with LBP performed therapeutic
exercises in the same manner during the rehabilitation period.
Exercise therapy is a widely used treatment for LBP. Al-
though exercise-based rehabilitation programs can reduce LBP
intensity, alleviate functional disability, and improve back ex-
tension strength and endurance,
53-56
there is no consensus on
the effectiveness of exercise therapy compared with inactive
treatments for CLBP.
19,20
There is also insufcient clinical
knowledge about targeting the load during therapeutic exer-
cises. The theory behind the use of spine stabilization exercises
for patients with spine dysfunction stresses the importance of
the deep local stabilizing muscles, especially the multidus and
transversus abdominis muscles.
8
Stabilization exercises are
benecial for patients with symptomatic spondylolysis or spon-
dylolisthesis,
55
and long-term results suggest that specic ex-
ercise therapy in addition to medical management and resump-
tion of normal activity may be more effective in reducing LBP
recurrences than medical management and normal activity
alone.
57
However, stabilization exercises have no effect on the
cross-sectional area of multidus muscles; intensive lumbar
resistance training is necessary to restore the size of multidus
muscles in patients with CLBP.
58
In this study, there were no changes in the perceptional
subjective pain detected by VAS or ODI after rehabilitation.
This was unexpected because the results of earlier studies
suggest that active physical rehabilitation programs are effec-
tive in alleviating LBP and can reduce functional disability,
although some studies
19,20
agree with our present results. One
possible explanation is that in our rehabilitation program, the
patients with LBP visited the outpatient clinic only 4 to 6 times
and for exercise under the guidance of a physiotherapist during
the 3-month period. The remainder of the exercise sessions
depended on the patients own motivation to perform the
exercises at home. It has been shown that the reduction of pain
and disability during active physical rehabilitation is strongly
dependent on a decrease in psychologic distress and fear avoid-
ance.
59
In this study, this effect was minimized by reducing
outpatient visits. In these visits, patients not only did the
exercises, but were also motivated and helped to realize that
completing them could be done without fear of pain. The
second explanation would be that, despite the strong encour-
agement to perform the exercises at home, the evidence from
the exercise diaries indicated that most of the patients exercised
insufciently on their own.
CONCLUSIONS
In this study with a small group of patients with CLBP,
active physical rehabilitation had no effect on the abdominal
and back muscle activities of therapeutic exercises commonly
used in the treatment of CLBP. Patients were able to perform
these therapeutic exercises with abdominal and back extensor
muscle activities similar to those we found in healthy subjects
in our earlier studies. Furthermore, 3 months of active rehabil-
itation, which included 4 to 6 outpatient visits and additional
self-motivated unsupervised home training, failed to decrease
their LBP intensity and functional disability, although this
model is widely used for outpatient therapy of LBP.
Acknowledgment: We thank Lea Kroger, PT, for technical help.
References
1. Callaghan JP, McGill SM. Muscle activity and low back loads
under external shear and compressive loading. Spine 1995;20:
992-8.
2. Kaigle AM, Holm SH, Hansson TH. Experimental instability in
the lumbar spine. Spine 1995;20:421-30.
3. McGill SM. The biomechanics of low back injury: implications on
current practice in industry and the clinic. J Biomech 1997;30:
465-75.
4. Gardner-Morse MG, Stokes IA. The effects of abdominal muscle
coactivation on lumbar spine stability. Spine 1998;23:86-91; dis-
cussion 91-2.
5. Crisco JJ, Panjabi MM, Yamamoto I, Oxland TR. Euler stability
of the human ligamentous lumbar spine. Part II: Experiment. Clin
Biomech 1992;7:27-32.
6. Wilke HJ, Wolf S, Claes LE, Arand M, Wiesend A. Stability
increase of the lumbar spine with different muscle groups. A
biomechanical in vitro study. Spine 1995;20:192-8.
7. Panjabi M, Abumi K, Duranceau J, Oxland T. Spinal stability and
intersegmental muscle forces. A biomechanical model. Spine
1989;14:194-200.
8. Richardson C, Jull G, Hodges P, Hides J. Therapeutic exercises
for spinal segmental stabilization in low back pain. London:
Churchill Livingstone; 1999.
9. Magnusson ML, Aleksiev A, Wilder DG, et al. European Spine
Societythe AcroMed Prize for Spinal Research 1995. Unex-
pected load and asymmetric posture as etiologic factors in low
back pain. Eur Spine J 1996;5:23-35.
Table 2: Maximal Trunk Flexion and Extension Torques and Electromyographic Amplitudes
at Beginning of Rehabilitation and After 3 Months
Parameters At the Beginning After 3 Months P
Trunk extension (Nm) 147.375.9 170.172.3 NS
Trunk exion (rectus abdominis) (Nm) 72.037.9 93.542.5 NS
Trunk rotation-exion (obliquus externus) (Nm) 52.926.5 82.465.8 .05
Multidus at L5, trunk extension EMG amplitude* (V) 112.971.8 127.795.4 NS
Rectus abdominis, trunk exion EMG amplitude* (V) 143.792.7 179.2101.4 NS
Obliquus externus abdominis, trunk exion EMG amplitude* (V) 92.772.3 104.764.8 NS
NOTE. Values are mean SD.
Abbreviation: EMG, electromyographic.
*Pooled data (right- and left-sided data averaged).
830 TRUNK MUSCLE ACTIVITIES IN THERAPEUTIC EXERCISES, Arokoski
Arch Phys Med Rehabil Vol 85, May 2004
10. Wilder DG, Aleksiev AR, Magnusson ML, Pope MH, Spratt KF,
Goel VK. Muscular response to sudden load. A tool to evaluate
fatigue and rehabilitation. Spine 1996;21:2628-39.
11. Hodges PW, Richardson CA. Altered trunk muscle recruitment in
people with low back pain with upper limb movement at different
speeds. Arch Phys Med Rehabil 1999;80:1005-12.
12. Leinonen V, Kankaanpaa M, Luukkonen M, Hanninen O, Airaksi-
nen O, Taimela S. Disc herniation-related back pain impairs
feed-forward control of paraspinal muscles. Spine 2001;26:E367-
72.
13. Parkkola R, Alanen A, Kalimo H, Lillsunde I, Komu M, Kormano
M. MR relaxation times and ber type predominance of the psoas
and multidus muscle. An autopsy study. Acta Radiol 1993;34:
16-9.
14. Ng JK, Richardson CA, Kippers V, Parnianpour M. Relationship
between muscle ber composition and functional capacity of back
muscles in healthy subjects and patients with back pain. J Orthop
Sports Phys Ther 1998;27:389-402.
15. Mannion AF. Fibre type characteristics and function of the human
paraspinal muscles: normal values and changes in association with
low back pain. J Electromyography Kinesiol 1999;9:363-77.
16. Mannion AF, Kaser L, Weber E, Rhyner A, Dvorak J, Muntener
M. Inuence of age and duration of symptoms on bre type
distribution and size of the back muscles in chronic low back pain
patients. Eur Spine J 2000;9:273-81.
17. Kaser L, Mannion AF, Rhyner A, Weber E, Dvorak J, Muntener
M. Active therapy for chronic low back pain: part 2. Effects on
paraspinal muscle cross-sectional area, ber type size, and distri-
bution. Spine 2001;26:909-19.
18. Mannion AF, Taimela S, Muntener M, Dvorak J. Active therapy
for chronic low back pain: part 1. Effects on back muscle activa-
tion, fatigability, and strength. Spine 2001;26:897-908.
19. van Tulder MW, Koes BW, Bouter LM. Conservative treatment of
acute and chronic nonspecic low back pain: a systematic review
of randomized controlled trials of the most common interventions.
Spine 1997;22:2128-56.
20. van Tulder MW, Malmivaara A, Esmail R, Koes BW. Exercise
therapy for low back pain. Cochrane Database Syst Rev 2000;(2):
CD000335.
21. Mannion AF, Muntener M, Taimela S, Dvorak J. Comparison of
three active therapies for chronic low back pain: results of a
randomized clinical trial with one-year follow-up. Rheumatology
(Oxford) 2001;40:772-8.
22. Arokoski JP, Kankaanpaa M, Valta T, et al. Back and hip extensor
muscle function during therapeutic exercises. Arch Phys Med
Rehabil 1999;80:842-50.
23. Arokoski JP, Valta T, Airaksinen O, Kankaanpaa M. Back and
abdominal muscle function during stabilization exercises. Arch
Phys Med Rehabil 2001;82:1089-98.
24. Arokoski JPA, Valta T, Kankaanpaa M, Airaksinen O. Activation
of paraspinal and abdominal muscles during manually assisted and
non-assisted therapeutic exercises. Am J Phys Med Rehabil 2002;
81:326-35.
25. Danneels LA, Coorevits PL, Cools AM, et al. Differences in
electromyographic activity in the multidus muscle and the ilio-
costalis lumborum between healthy subjects and patients with
sub-acute and chronic low back pain. Eur Spine J 2002;11:13-9.
26. Alexiev AR. Some differences of the electromyographic erector
spinae activity between normal subjects and low back pain pa-
tients during the generation of isometric trunk torque. Electro-
myogr Clin Neurophysiol 1994;34:495-9.
27. Ng JK, Richardson CA, Parnianpour M, Kippers V. Fatigue-
related changes in torque output and electromyographic parame-
ters of trunk muscles during isometric axial rotation exertion: an
investigation in patients with back pain and in healthy subjects.
Spine 2002;27:637-46.
28. Fairbank JC, Couper J, Davies JB, OBrien JP. The Oswestry low
back pain disability questionnaire. Physiotherapy 1980;66:271-3.
29. Cram JR, Kasman GS, Holtz J. Introduction to surface electro-
myography. Gaithersburg: Aspen; 1998. p 223-383.
30. Cresswell AG, Grundstrom H, Thorstensson A. Observations on
intra-abdominal pressure and patterns of abdominal intra-muscu-
lar activity in man. Acta Physiol Scand 1992;144:409-18.
31. Biedermann HJ, DeFoa JL, Forrest WJ. Muscle bre directions of
iliocostalis and multidus: male-female differences. J Anat 1991;
179:163-7.
32. McGill SM. Low back exercises: evidence for improving exercise
regimens. Phys Ther 1998;78:754-65.
33. Norris CM. Spinal stabilization: an exercise program to enhance
lumbar stabilization. Physiotherapy 1995;81:138-45.
34. Blackburn SE, Portney LG. Electromyographic activity of back
musculature during Williams exion exercises. Phys Ther 1981;
61:878-85.
35. Bankoff AD, Furlani J. Electromyographic study of the rectus
abdominis and external oblique muscles during exercises. Elec-
tromyogr Clin Neurophysiol 1984;24:501-10.
36. Richardson C, Toppenberg R, Jull G. An initial evaluation of eight
abdominal exercises for their ability to provide stabilization for
the lumbar spine. Aust J Phys 1990;36:6-11.
37. Moffroid MT, Haugh LD, Haig AJ, Henry SM, Pope MH. Endur-
ance training of trunk extensor muscles. Phys Ther 1993;73:10-7.
38. Ng J, Richardson C. EMG study of erector spinae and multidus
in two isometric back extension exercises. Aust J Phys 1994;40:
115-21.
39. Sarti MA, Monfort M, Fuster MA, Villaplana LA. Muscle activity
in upper and lower rectus abdominus during abdominal exercises.
Arch Phys Med Rehabil 1996;77:1293-7.
40. Vezina MJ, Hubley-Kozey CL. Muscle activation in therapeutic
exercises to improve trunk stability. Arch Phys Med Rehabil
2000;81:1370-9.
41. Souza GM, Baker LL, Powers CM. Electromyographic activity of
selected trunk muscles during dynamic spine stabilization exer-
cises. Arch Phys Med Rehabil 2001;82:1551-7.
42. Plamondon A, Serresse O, Boyd K, Ladouceur D, Desjardins P.
Estimated moments at L5/S1 level and muscular activation of
back extensors for six prone back extension exercises in healthy
individuals. Scand J Med Sci Sports 2002;12:81-9.
43. strand PO, Rodahl K. Textbook of work physiology. Physiolog-
ical bases of exercise. 3rd ed. New York: McGraw-Hill; 1991.
44. Dolan P, Adams J. The relationship between EMG activity and
extensor moment generation in the erector spinae muscles during
bending and lifting activities. J Biomech 1993;26:513-22.
45. O

rtengren R, Andersson GB, Nachemson A. Studies of relation-

ships between lumbar disc pressure, myoelectric back activity, and
intra-abdominal (intra-gastric) pressure. Spine 1981;6:98-103.
46. Callaghan JP, Gunning JL, McGill SM. The relationship between
lumbar spine load and muscle activity during extensor exercises.
Phys Ther 1998;78:8-18.
47. Cresswell AG, Oddsson L, Thorstensson A. The inuence of
sudden perturbations on trunk muscle activity and intra-abdominal
pressure while standing. Exp Brain Res 1994;98:336-41.
48. Hoyt WH, Hunt HH, De Pauw MA, et al. Electromyographic
assessment of chronic low back pain syndrome. J Am Ostepath
Assoc 1981;80:57-9.
49. Cram R, Steger J. EMG scanning in diagnosis of chronic pain.
Biofeedback Self Regular 1983;8:229-41.
50. Soderberg GL, Barr JO. Muscular function in chronic low back
dysfunction. Spine 1983;8:79-85.
51. Smidt G, Herring T, Amundsen L, Rogers M, Russell A, Lehmann
T. Assessment of abdominal and back extensor function. A quan-
titative approach and results for chronic low-back patients. Spine
1983;8:211-9.
52. Mayer TG, Smith SS, Keeley J, Mooney V. Quantication of
lumbar function. Part 2: Sagittal plane trunk strength in chronic
low-back pain patients. Spine 1985;10:765-72.
53. Manniche C, Lundberg E, Christensen I, Bentzen L, Hesselse G.
Intensive dynamic back exercises for chronic low back pain: a
clinical trial. Pain 1991;47:53-63.
54. Taimela S, Harkapaa K. Strength, mobility, their changes, and
pain reduction in active functional restoration for chronic low
back disorders. J Spinal Disord 1996;9:306-12.
55. OSullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation
of specic stabilizing exercise in the treatment of chronic low
back pain with radiologic diagnosis of spondylolysis or spon-
dylolisthesis. Spine 1997;22:2959-67.
831 TRUNK MUSCLE ACTIVITIES IN THERAPEUTIC EXERCISES, Arokoski
Arch Phys Med Rehabil Vol 85, May 2004
56. Kankaanpaa M, Taimela S, Airaksinen O, Hanninen O. The ef-
cacy of active rehabilitation in chronic low back pain. Effect on
pain intensity, self-experienced disability, and lumbar fatigability.
Spine 1999;24:1034-42.
57. Hides JA, Jull GA, Richardson CA. Long-term effects of specic
stabilizing exercises for rst-episode low back pain. Spine 2001;
26:243-8.
58. Danneels LA, Vanderstraeten GG, Cambier DC, et al. Effects of
three different training modalities on the cross sectional area of the
lumbar multidus muscle in patients with chronic low back pain.
Br J Sports Med 2001;35:186-91.
59. Mannion AF, Junge A, Taimela S, Muntener M, Lorenzo K,
Dvorak J. Active therapy for chronic low back pain: part 3.
Factors inuencing self-rated disability and its change following
therapy. Spine 2001;26:920-9.
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