Manual Therapy 20 (2015) 117e123

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

Lateral abdominal muscle size at rest and during abdominal

drawing-in manoeuvre in healthy adolescents
Pawel Linek*, Edward Saulicz, Tomasz Wolny, Andrzej Mysliwiec, Mirosaw Kokosz
Department of Kinesitherapy and Special Methods in Physiotherapy, The Jerzy Kukuczka Academy of Physical Education, Mikolowska 72B, 40-065 Katowice,
Poland

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 21 March 2014
Received in revised form
3 July 2014
Accepted 10 July 2014

Lateral abdominal wall muscles in children and adolescents have not been characterised to date. In the
present report, we examined the reliability of the ultrasound measurement and thickness of the oblique
external muscle (OE), oblique internal muscle (OI) and transverse abdominal muscle (TrA) at rest and
during abdominal drawing-in manoeuvre (ADIM) on both sides of the body in healthy adolescents. We
also determined possible differences between boys and girls and dened any factorsdsuch as body mass,
height and BMIdthat may affect the thickness of the abdominal muscles. B-mode ultrasound was used to
assess OE, OI and TrA on both sides of the body in the supine position. Ultrasound measurements at rest
and during ADIM were reliable in this age group (ICC3,3 > 0.92). OI was always the thickest and TrA the
thinnest muscle on both sides of the body. In this group, an identical pattern of the contribution of the
individual muscles to the structure of the lateral abdominal wall (OI > OE > TrA) was observed. At rest
and during ADIM, no statistically signicant side-to-side differences were demonstrated in either gender.
The body mass constitutes between 30% and <50% of the thickness differences in all muscles under
examination at rest and during ADIM. The structure of lateral abdominal wall in adolescents is similar to
that of adults. During ADIM, the abdominal muscles in adolescents react similarly to those in adults. This
study provided extensive information regarding the structure of the lateral abdominal wall in healthy
adolescents.
2014 Elsevier Ltd. All rights reserved.

Keywords:
Adolescents
Ultrasound
Abdominal wall
Muscle size

1. Introduction
The lateral wall of the abdomen is composed of the transversal
abdominal (TrA) muscle, the abdominal oblique internal (OI)
muscle and the abdominal oblique external (OE) muscle. These
muscles full a specic function and play an important role in the
stabilisation of the spine (Hodges, 1999). In this system, the TrA
muscle is believed to play the most important role, because,
compared with the other abdominal muscles, it is especially t for
segmental spinal stability. Through the tension of the lumbar fascia,
the TrA muscle can also have a lumbar-stiffening effect and, in
healthy populations, it becomes activated prior to performing limb
movements (Hodges, 1999; Barker et al., 2006). However, changes
in the thickness of the abdominal muscles are associated with low
back pain (LBP) in the adult population (Ferreira et al., 2004), but it
has recently been revealed that LBP in adolescents is as frequent a
complaint as LBP in adults (Leboeuf-Yde and Kyvik, 1998; Watson
et al., 2002; Sato et al., 2008). However, we still do not know how
* Corresponding author. Tel.: 48 661 768 601.
E-mail address: linek.zjoterapia@vp.pl (P. Linek).
http://dx.doi.org/10.1016/j.math.2014.07.009
1356-689X/ 2014 Elsevier Ltd. All rights reserved.

these muscles work in adolescents, in whom, like in adults, changes

in the thickness of the abdominal muscles may occur. In a recent
paper, Linek et al. (2014a) reported that, compared with a control
group, adolescents with idiopathic scoliosis have, in the supine
position, distinctly thinner OE, OI and TrA muscles on both sides of
the body. Such variations in the thickness of the abdominal muscles
(especially the TrA muscle) in adolescents with scoliosis may not
ensure proper rotational control of the individual vertebrae of the
spine or stabilisation of the sacroiliac joints. On the other hand,
other studies suggest that the abdominal muscles are essential for
the formation of spinal curvatures in the saggital planes (Lam and
Mehdian, 1999). Studies performed in the adult population have
conrmed that an increase in the TrA muscle thickness in neutral
positions of the spine indicates this role of this muscle in posture
(Reeve and Dilley, 2009). Therefore, it is reasonable to look for
further relationships between the thickness of the abdominal
muscles and body posture and/or LBP in children and adolescents.
However, we believe that, to start with, exhaustive data on the
thickness of these muscles in a healthy population in this age group
need to be provided in order to facilitate subsequent studies in
symptomatic groups.

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P. Linek et al. / Manual Therapy 20 (2015) 117e123

Functional studies on the abdominal muscles in adults have

been carried out by multiple researchers. In these studies, healthy
(Rankin et al., 2006; Mannion et al., 2008a; Manshadi et al., 2011;
Rho et al., 2013) and LBP populations (Ferreira et al., 2004;
Teyhen et al., 2005; Pulkovski et al., 2011) were investigated and
the activity of the abdominal muscles was assessed using the
abdominal drawing-in manoeuvre (ADIM), which is employed to
evaluate TrA muscle function (Teyhen et al., 2007). ADIM is also the
basic exercise for spine stabilisation and its goal is to restore proper
neuromuscular control (Richardson et al., 2002; Urquhart et al.,
2005a). It has been demonstrated that ADIM is effective in the
treatment of LBP (Rackwitz et al., 2006). In this exercise, the goal
was to isolate the function of the TrA muscle, which depends on
deep sensation, respiratory pattern and capacity of motor learning
(Teyhen et al., 2007). In connection with ADIM, some researchers
have also introduced ratios for better insight into problems with
LBP patients (Teyhen et al., 2005, 2007; Mannion et al., 2008a). For
these reasons, before work could begin on adolescents with LBP, it
was necessary to learn how the abdominal muscles in healthy adolescents respond to ADIM, and to what extent the individual ratios
give similar results to the adult population. Such information will
be used to determine whether the ADIM should be used in further
studies of adolescents.
Electromyography (EMG) is commonly used to evaluate the
activation of the muscles of the lateral wall of the abdomen. Finewire EMG has been successfully used to measure TrA muscle activation during movements of the upper and lower limbs (Hodges
and Richardson, 1997). However, this is an invasive method that
carries the risk of infection; it is also time-consuming and, therefore, difcult to use in studies of larger populations. Surface EMG
also has limitations associated with difculties in determining
precisely which muscle the electric potential is being collected
from. During surface EMG, it is not possible to determine whether
the potential is collected from the TrA or OI muscle (Juker et al.,
1998). However, this distinction is important to determine how
the muscles respond to ADIM; therefore, surface EMG is not
commonly used for studies in this area. Instead, rehabilitative ultrasound imaging (RUSI) is used, which provides the opportunity to
independently observe changes in the thickness of the abdominal
muscles during ADIM. These changes are considered to be an indicator of muscle activity (Kanehisa et al., 1994) because they
correlate with magnetic resonance imagining and EMG results
(Hides et al., 1995; Fischer et al., 2000). RUSI is also a reliable tool
for evaluating abdominal muscles in both adult (Koppenhaver et al.,
2009; Ferreira et al., 2011) and adolescent (Linek et al., 2014b)
populations.
Rankin et al. (2006), Springer et al. (2006), Mannion et al.
(2008b) and Manshadi et al. (2011) have contributed most to the
assessment of the abdominal muscles in the healthy adult population by providing the data to characterise the muscles of the
lateral wall of the abdomen at rest and during ADIM. These reports
also demonstrated relationships between the thickness of the
abdominal muscles and gender, body weight, body mass index
(BMI), height and age. All of this was performed in order to obtain
reference data that could be used to study adults with LBP. Taking
into consideration that there may be differences between the
adolescent and adult populations, the relationships between the
thickness of the abdominal muscles (at rest, during ADIM and obtained ratios) and sex, body mass, height and BMI were investigated in this work. It were also tested to obtain information about
whether or not, and if so, to what degree, the variables mentioned
above should be controlled mathematically in the subsequent
studies in the adolescent population. To summarise, the introduction of certain baseline data concerning abdominal muscles in
children and adolescents will ll an important information gap.

Such studies may also contribute to a better understanding of the

structure of the lateral abdominal wall at rest and during ADIM in
adults and could be used as baseline data to compare children and
adolescents that are experiencing some disturbances in body
posture and LBP. Therefore, the primary aim of this report was to
assess the reliability of the RUSI measurement and the thickness of
the OE, OI and TrA muscles at rest and during ADIM on both sides of
the body in healthy adolescents. The secondary aim was to determine possible differences between boys and girls in the maturation
period and to dene any factorsdsuch as body mass, height and
BMIdthat may affect the thickness of the abdominal muscles
studied in this age group.
2. Methods
2.1. Participants
Elementary and middle school students between 10 and 16
years of age were enrolled. During preliminary selection, all individuals that revealed external signs of scoliosis or other postural
defects during screening were excluded. The Adams' test was performed and body rotation was tested using a scoliometer. The intrarater reliability of axial trunk rotation measured by the scoliometer
was very good and excellent for the upper, medium and lower
thorax and lumbar segments, respectively (Bonagamba et al., 2010).
The scoliometer is widely used in screening to evaluate body
rotation and scoliosis, and is often used in clinical studies of children with scoliosis (Bunnell, 1984; Korovessis et al., 2005). During
the measurements, all subjects were barefoot. Boys were evaluated
shirtless, but girls were assessed wearing swimsuits that allowed
viewing of the entire back. Female participants also had their hair
tied. Before examination, the spinous process of each thoracic and
lumbar vertebrae of the spine, from T1 to L5, was identied by
palpation and was marked with a dermographic pen. The scoliometer is able to analyse, in degrees, the asymmetry and axial
rotation of the spine, with the patient positioned with the trunk in
anterior exion (Adams' test). The examiner positioned the centre
of the device on the mark, regarding the spinous process of each
vertebra with the scoliometer perpendicular to the axial axis of the
spine, and measured the axial trunk rotation. Based on this examination, only the subjects with no body rotation angle detected
were included.
Moreover, based on an interview performed, with the participation of at least one parent, the following children were excluded:
a) those who had previously had any surgical procedure performed
in the chest, the abdominal cavity, the pelvic girdle and/or the
spine; b) those with a chronic cardiovascular/respiratory system; c)
those who had experienced an illness and/or trauma associated
with prolonged (>14 days) hospitalisation or immobilisation during a period of 2 years prior to the study; d) those who experienced
pain in the spine, pelvic girdle or lower limbs during the 3 months
preceding the study; and e) those who took any medications that
may affect the function of the nervous and muscular systems
within the 1 year preceding the study.
The study conformed to the standards set by the Declaration of
Helsinki and was approved by the local medical ethics committee.
All participants and their parents received verbal and written information about all procedures and gave their signed and informed
consent to participate.
2.2. Ultrasound scanning procedure
The scanning procedures were performed by one investigator
(PL). The entire procedure, the sequence of measurements and the
instructions were identical for of the participants of the study.

P. Linek et al. / Manual Therapy 20 (2015) 117e123

A real-time ultrasound B-scanner (MINDRAY DP-6600 Digital

Ultrasonic Diagnostic Imaging System; Medical Corp. Redmont,
USA) with a 60 mm-wide 75L38 EA linear-array transducer (5.0/7.5/
10 MHz) was used to obtain images of the abdominal muscles. The
penetration depth was 5.39 cm at a sampling frequency of 7.5 MHz.
The transducer was always placed on the anterolateral wall of the
abdomen, between the iliac crest and the costal margin, perpendicular to the longitudinal axis of the body, and nally adjusted to
ensure that the fascial borders of the three muscles (TrA, OI, OE)
appeared parallel on the screen. Any participant with an unclear
ultrasound image of the abdominal muscle (mainly those that were
obese) were not include in the study.
Measurements of the thickness of the OE, OI and TrA muscles (at
rest) were made in the supine position. The knees of the examined
individuals were extended and the upper limbs were placed along
the sides of the trunk (Fig. 1). The thickness of the muscles at rest
was stored at the end of normal expiration. The thickness of the
muscles at ADIM was measured in the same position, after giving
the same instructions to each person examined. The instructions
included an explanation of the manoeuvre that was required of
them (Hides et al., 2004). Next, all participants had the opportunity
to perform one trial, without the RUSI control, in order to check
whether the exercise was properly performed but not for feedback.
At rest and during ADIM, three consecutive measurements were
performed alternately for each side, always starting with the right
side. Therefore, each person had to perform the ADIM six times. To
assess the reliability, the second series (exactly the same as the
rst) of the measurements was performed after 6e8 days.
2.3. Data processing
Based on anthropometric parameters, the BMI of each participant was calculated as body mass [kg]/height [m2]. The mean of
three measurements of the OE, OI and TrA muscles, obtained from
the RUSI, was used for the analysis of the measurements performed
separately for the right side and left side of the body, both in the
resting position and during ADIM. For these data, some proposed
indices (Teyhen et al., 2005, 2007; Mannion et al., 2008a) were
calculated using the following equations: (1) contraction
ratio muscle thickness during ADIM/muscle thickness at rest; (2)
TrA preferential activation ratio (TrA during ADIM/(OE OI TrA
during ADIM)) e (TrA at rest/(OE OI TrA at rest)); (3) relative
thickness at rest (100  OE or OI or TrA at rest)/(OE OI TrA at
rest); (4) relative thickness during ADIM (100  OE or OI or TrA
during ADIM)/(OE OI TrA during ADIM); (5)

119

difference muscle during ADIM e muscle at rest; (6) sum OE, OI,
TrA at rest OE OI TrA at rest; (7) sum OE, OI, TrA during
ADIM OE OI TrA during ADIM; and to determine the percentage difference in the thickness of the muscles between sides,
the following formula was used (8) muscle thickness
difference [(right side  left side)/(right side)]  100.
Calculations using each equation were performed for each side
of the body, for boys and girls, separately. For equations numbered
(1), (3), (4), (5) and (8), the parameters were calculated for the OE,
OI and TrA muscles, separately.

2.4. Data analysis

An intraclass correlation coefcient (ICC) was calculated to
assess intra-rater reliability (ICC3,k) of each muscle thickness
measurement (Shrout and Fleiss, 1979).
In addition, the standard
p
error of measurement SEM SD  1  ICC
p and the smallest
detectable differences SDD 1:96  SEM  2 were calculated
for each measurement.
Differences in demographic data between boys and girls were
examined using an independent sample t-test. This test was also
used to compare the thickness of the muscles and other parameters
described in the data processing section between the right and left
sides of the body, separately for boys and girls. An independent ttest was also used to compare boys and girls. The results are presented as the mean and 95% condence interval (CI). The order of
the relative muscle thicknesses was based on the mean and CI
values.
Forward conditional multiple regression analyses were used to
identify the unique factors that predicted muscle thickness at rest
and during ADIM as well as the other parameters included in the
data processing section. In each case, gender, body mass, body
height and BMI were entered as possible predictors for selection in
the regression model. For all analyses, the threshold of the p value
considered as signicant was set at <0.05.

3. Results
3.1. Participants
Seventy-one subjects including 39 boys and 32 girls between 10
and 16 years of age, were randomly included in the study. Full
characteristics of the population studied are presented in Table 1.

Fig. 1. Ultrasound scanning of the lateral abdominal muscles.

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P. Linek et al. / Manual Therapy 20 (2015) 117e123

Table 1
Descriptive statistics. Values represent mean (95% condence interval), unless
indicated otherwise.
Boys (n 39)
Age (years)
Height (cm)
Body mass
(kg)
BMI
Handednessa

Girls (n 32)

Differences boys
minus girls

12.7 (12.2e13.3)
12.6 (12.2e13.1)
0.09 (0.62e0.81)
161.4 (157.4e165.3) 154.8 (151.8e157.8) 6.56* (1.51e11.62)
50.9 (46.7e55.1)
46.5 (42.1e50.9)
4.41 (1.63e10.4)
19.2 (18.4e20.1)
34 (87.2%) right
5 (12.8) left

19.1 (17.8e20.4)
32 (100%) right

0.12 (134e1.58)
NOT

BMI, body mass index, NOT, analysis not performed.

p < 0.01, (value in bold).
a
Enquired about with a single question: with which hand do you write?

3.3. Absolute muscle thickness

Table 3 shows the mean muscle thickness at rest and during ADIM
for the right and left abdominal muscles, for boys and girls separately.
At rest, the OI muscle was always the thickest and the TrA muscle was
the thinnest on both sides of the body, independent of gender. During
ADIM, in boys and girls, the OI muscle remained the thickest, but the
TrA muscle was thicker than the OE muscle (Table 3; the mean value
and 95% CI). At rest, the thickness of the OI muscle on both sides of the
body and the OE muscle on the left in boys' bodies was signicantly
greater than in girls. During ADIM, only the OI muscle remained
signicantly thicker in boys. The combined OE, OI and TrA muscle
thickness during ADIM was also signicantly greater in boys (Table 4).
3.4. Relative muscle thickness

Table 2
Estimates of intra-rater reliability.
Muscle state

OE
Rest
ADIM
OI
Rest
ADIM
TrA
Rest
ADIM

Average of three repeated measures (n 71)a

ICC3,3

SEM (mm)

SDD (mm)

ICC3,3

SEM (mm)

SDD (mm)

0.97
0.96

0.22
0.24

0.64
0.66

0.97
0.95

0.26
0.25

0.71
0.68

0.97
0.97

0.35
0.38

0.98
1.05

0.97
0.97

0.32
0.36

0.88
0.99

0.96
0.93

0.20
0.40

0.56
1.17

0.95
0.94

0.21
0.36

0.59
1.01

For both genders, there was an identical pattern in the percentage contribution of the individual muscles to the structure of
the lateral abdominal wall at rest and during ADIM, on both sides of
the body (OI > OE > TrA) (Table 3; the mean value and 95% CI).
At rest, a signicantly higher percentage contribution of the OI
muscle on the right side of the body and a signicantly smaller
percentage contribution of the TrA muscle on the left side of the
body were noted. In ADIM, in girls, the percentage contribution of
the TrA muscle is increased and that of the OI muscle is decreased
on both sides of the body compared with boys (Table 4).
3.5. Ratio

TrA, transversus abdominis; OI, internal oblique abdominis; OE, external oblique
abdominis ADIM, abdominal draw in manoeuvre; ICC, intraclass correlation coefcient; SEM, standard error of the measurement; SDD, the smallest detectable
differences.
a
First, shown results for right side, next for the left side of the body muscle.

The ratios as well as the difference in the OE muscle thickness

between ADIM and rest were signicantly different in boys when
the thickness of this muscle was greater on the right side of the
body (Table 3).

3.2. Reliability study

3.6. Side-to-side differences

The intra-rater ICC3,3 value for the average of three repeated

measures (n 71) was greater than 0.95 for all of the abdominal
muscles examined at rest on both sides of the body. During ADIM,
the ICC level was slightly reduced (Table 2).

At rest and during ADIM, no statistically signicant side-to-side

differences were demonstrated between the two genders. At rest,
in boys, the mean percentage difference was 1.06, 4.17 and 1.83%
for the OE, OI and TrA muscles, respectively. In girls, it was 5.44, 2.3

Table 3
Mean (95% condence interval) values for abdominal muscle thickness at rest and during abdominal hollowing in both genders.
Boys (n 39)

Dependent variable

Thickness at rest (mm)

Thickness during hollowing (mm)

Contraction ratio

Relative thickness at rest (% of total TrA. OI. OE)

Relative thickness during hollowing (% of total TrA. OI. OE)

Difference (muscle during hollowing e muscle at rest) [mm]

TrA preferential activation ratio

Sum OE. OI. TrA at rest (mm)
Sum OE. OI. TrA during hollowing (mm)

OE
OI
TrA
OE
OI
TrA
OE
OI
TrA
OE
OI
TrA
OE
OI
TrA
OE
OI
TrA

Girls (n 32)

Right side

Left side

Right side

Left side

4.64 (4.25e5.03)
8.01 (7.38e8.63)
3.66 (3.40e3.92)
4.58 (4.22e4.95)
8.96 (8.11e9.82)
5.28 (4.77e5.79)
1.01 (0.95e1.06)
1.11 (1.06e1.17)
1.44 (1.34e1.54)
28.4 (26.9e29.9)
48.9 (47.5e50.3)
22.7 (21.6e23.7)
24.8 (23.2e26.5)
47.1 (45.7e48.5)
28.0 (26.6e29.4)
0.05 (0.28e0.18)
0.96 (0.54e1.37)
1.61 (1.24e1.99)
0.053 (0.041e0.066)
16.3 (15.2e17.4)
18.8 (17.4e20.3)

4.56 (4.09e5.04)
7.60 (6.90e8.29)
3.71 (3.43e3.98)
4.01 (3.66e4.37)
8.28 (7.40e9.15)
5.24 (4.72e5.77)
0.90 (0.86e0.94)
1.08 (1.03e1.14)
1.42 (1.31e1.52)
28.6 (26.9e30.3)
47.7 (46.1e49.3)
23.7 (22.5e24.9)
23.5 (21.7e25.2)
46.7 (45.3e48.1)
29.8 (28.4e31.2)
0.55 (0.81e(0.29)
0.67 (0.25e1.10)
1.53 (1.15e1.92)
0.061 (0.047e0.074)
15.8 (14.6e17.1)
17.5 (16.0e19.1)

4.12 (3.69e4.54)
6.34 (5.76e6.93)
3.34 (2.92e3.76)
4.07 (3.68e4.45)
6.76 (6.24e7.28)
4.86 (4.45e5.28)
0.99 (0.95e1.04)
1.08 (1.03e1.12)
1.54 (1.38e1.68)
29.9 (28.5e31.2)
46.1 (44.8e47.3)
23.9 (22.9e24.9)
25.8 (24.5e27.2)
43.1 (41.8e44.4)
30.9 (29.6e32.3)
0.04 (0.22e0.13)
0.42 (0.14e0.69)
1.52 (1.13e1.91)
0.070 (0.053e0.086)
13.8 (12.4e15.1)
15.7 (14.5e16.8)

3.87 (3.45e4.28)
6.07 (5.59e6.54)
3.36 (3.03e3.70)
3.61 (3.29e3.93)
6.40 (5.94e6.86)
4.75 (4.30e5.19)
0.96 (0.89e1.01)
1.06 (1.02e1.10)
1.45 (1.32e1.58)
28.8 (27.5e30.2)
45.8 (44.5e47.2)
25.2 (24.3e26.2)
24.4 (23.2e25.6)
43.5 (42.2e44.8)
32.1 (30.6e33.5)
0.25 (0.49e(0.01)
0.33 (0.07e0.59)
1.38 (0.99e1.78)
0.068 (0.052e0.084)
13.3 (12.2e14.4)
14.8 (13.7e15.8)

TrA, transversus abdominis; OI, internal oblique abdominis; OE, external oblique abdominis.
For explanations of the dependent variables, see method section in the text.

P. Linek et al. / Manual Therapy 20 (2015) 117e123

121

Table 4
Mean differences (95% condence interval)a of variables between sides and gender.
Dependent variable

Thickness at rest
(mm)
Thickness during
hollowing (mm)
Contraction ratio

Relative thickness at
rest (% of total TrA. OI. OE)
Relative thickness during
hollowing (% of total TrA. OI. OE)
Difference (muscle during
hollowing e muscle at
rest) [mm]
TrA preferential activation ratio
Sum OE. OI. TrA at rest (mm)
Sum OE. OI. TrA during hollowing
(mm)

Differences between sides

OE
OI
TrA
OE
OI
TrA
OE
OI
TrA
OE
OI
TrA
OE
OI
TrA
OE
OI
TrA

Differences between genders

Right side minus left side (boys)

Right side minus left side (girls)

Boys minus girls

(right side)

Boys minus girls

(left side)

0.07 (0.53e0.68)
0.41 (0.51e1.33)
0.05 (0.42e0.33)
0.57* (0.07e1.07)
0.68 (0.51e1.89)
0.03 (0.68e0.76)
0.10y (0.03e0.17)
0.02 (0.04e0.10)
0.02 (0.11e0.17)
0.15 (2.41e2.10)
1.18 (0.92e3.28)
1.03 (2.60e0.55)
1.38 (0.97e3.73)
0.41 (1.50e2.32)
1.78 (3.74e0.16)
0.49y (0.15e0.84)
0.28 (0.31e0.87)
0.08 (0.44e0.61)
0.007 (0.02e0.01)
0.43 (1.18e2.06)
1.30 (0.74e3.34)

0.25 (0.33e0.84)
0.27 (0.46e1.01)
0.02 (0.55e0.50)
0.46 (0.03e0.95)
0.36 (0.31e1.04)
0.11 (0.48e0.71)
0.04 (0.02e0.11)
0.01 (0.04e0.07)
0.08 (0.11e0.28)
1.03 (0.88e2.93)
0.25 (1.54e2.05)
1.28 (2.64e0.08)
1.45 (0.28e3.19)
0.37 (2.16e1.43)
1.08 (3.00e0.83)
0.20 (0.08e0.49)
0.08 (0.28e0.46)
0.13 (0.41e0.68)
0.001 (0.02e0.02)
0.51 (1.21e2.22)
0.93 (0.62e2.48)

0.52 (0.04e1.09)
1.66z (0.80e2.52)
0.32 (0.14e0.79)
0.51 (0.005e1.03)
2.20z (1.16e3.24)
0.42 (0.25e1.08)
0.007 (0.06e0.07)
0.03 (0.03e0.10)
0.09 (0.27e0.08)
1.46 (3.53e0.61)
2.76y (0.88e4.63)
1.30 (2.76e0.16)
1.02 (3.15e1.10)
3.99z (2.09e5.90)
2.98y (4.90e(1.05)
0.008 (0.30e0.29)
0.53* (0.02e1.06)
0.09 (0.44e0.63)
0.01 (0.03e0.003)
2.51y (0.85e4.17)
3.14y (1.27e5.00)

0.69* (0.06e1.34)
1.53z (0.66e2.40)
0.34 (0.07e0.77)
0.40 (0.07e0.88)
1.87z (0.84e2.91)
0.49 (0.20e1.19)
0.05 (0.12e0.01)
0.02 (0.04e0.09)
0.03 (0.19e0.12)
0.28 (2.49e1.92)
1.83 (0.28e3.96)
1.55* (3.11e(0.005)
0.94 (3.12e1.22)
3.22y (1.35e5.10)
2.28* (4.27e(0.28)
0.30 (0.65e0.05)
0.34 (0.17e0.86)
0.15 (0.39e0.69)
0.007 (0.02e0.01)
2.57y (0.88e4.27)
2.77y (0.86e4.67)

TrA, transversus abdominis; OI, internal oblique abdominis; OE, external oblique abdominis.
p < 0.04, yp < 0.004, zp < 0.0007 (values in bold).
a
Based on mean values presented in Table 2; for explanations of the dependent variables, see text.

and 3.26% for the OE, OI and TrA muscles, respectively. In ADIM,
the differences obtained were 11.3, 6.7 and 0.44% in boys and 10.1,
3.9 and 1.51% in girls for the OE, OI and TrA muscles, respectively.
3.7. Predictors of thickness change
In the multiple regression analysis, basic variables (gender,
height, body mass and BMI) were studied, which affect and explain,
to the greatest degree, the variability in the thickness of the
abdominal muscles at rest and during ADIM. Owing to the lack of
signicant differences between the right and left sides of the body
(in either gender) for the OI and TrA muscles, a regression analysis
was conducted using the mean value of both measurements on the
right and left sides of the body. In the case of the OE muscle, there
were signicant differences in the 'contraction ratio', 'thickness
during ADIM' and 'difference' in boys and, therefore, in these cases,
the regression analysis was performed separately for the right side
and left side of the body.
As shown in Table 5, the body mass explains between >30% and
<50% of the variance in muscle thickness of all muscles under examination (at rest and during ADIM). Body mass explains (>50%)
the variability of the overall thickness (the sum of the OE, OI and
TrA muscles) of all the muscles of the lateral wall of the abdomen at
rest and during ADIM. The contraction ratio of the OE and OI
muscles is explained in <10% by body mass (OE) and height and
BMI (OI), respectively; no signicant predictor was determined for
the TrA muscle in this case. The difference in the OI and TrA muscle
thickness (thickness during hollowing e thickness at rest) depends,
to the largest extent on the body weight, which explains the variability of the difference parameter for these muscles in 18 and 13%,
respectively (Table 5).
4. Discussion
In this report, the results of studies concerning the thickness of
the abdominal muscles of healthy adolescents between 10 and 16
years of age at rest and during ADIM are presented. This is the rst

report to evaluate the abdominal muscles using RUSI in this age

group. The reliability analysis shows that the use of RUSI in this age
group is highly reliable. The use of three consecutive measurements guarantees an ICC of more than 0.93 at rest and during ADIM,
which is consistent with the results of studies performed in adults
(Rankin et al., 2006; Mew, 2009).
In the adolescent population studied, the mean thicknesses
obtained at rest were 4.3, 6.99 and 3.51 mm for the OE, OI and TrA
muscles, respectively. In reports where the mean age was higher
than 35, the mean thickness of the muscles under examination was
6.4 mm for the OE muscle, 8.02 mm for the OI muscle and 4.3 mm
for the TrA muscle (Rankin et al., 2006; Mannion et al., 2008b;
Pulkovski et al., 2011), whereas, in the report by Manshadi et al.
(2011), in which the mean age of the subjects was 27, the mean
thicknesses of the muscles were 3.8, 5.4, and 2.68 mm for the OE, OI
and TrA muscles, respectively. This is interesting, because in children and adolescents between 10 and 16 years of age, one would
expect a lower abdominal muscles thickness compared with adults.
However, the mean thicknesses of the muscles in the studies by
Manshadi et al. (2011) were lower compared with the muscles
presented in the current report. In the studies by Rankin et al.
(2006), the participants were moderately active, whereas in the
study by Manshadi et al. (2011), the subjects stated that they did
not do any physical activity. In our report, no assessment of the
participants was performed in terms of physical activity. The
impact of physical activity on the thickness of the muscles was
conrmed by the studies of cricket players (Hides et al., 2006), but
it is also possible that the physical activity level is more important
than the age of the population examined. This statement should be
further studied. Moreover, it was demonstrated that during ADIM
the mean muscle thickness values in those studied in this investigation were lower than that in the report of Mannion et al. (2008b),
and they were higher than those reported by Manshadi et al. (2011).
Here things seem logical, as a lower thickness at rest would reect a
lower thickness during ADIM. The present report also shows that, at
rest, the OI muscle is the thickest and the TrA muscle is the thinnest
in both genders, similar to adult populations (Mannion et al.,

122

P. Linek et al. / Manual Therapy 20 (2015) 117e123

Table 5
Multiple regression analyses showing the unique factors predicting muscle thickness at rest and during ADIM. Gender, body mass, body height and BMI were entered
as possible predictors for selection in the regression model.
Dependent variable entered in regression Signicant
models
predictor
Thickness at rest (mm)

OE
OI
TrA
OE right side
OE left side
OI
TrA
OE right side
OE left side
OI

Body
Body
Body
Thickness during
Body
ADIM (mm)
Body
Body
Body
Contraction ratio
e
Body
Body
BMI
TrA
e
Difference (muscle during OE right side e
Body
hollowing e muscle at OE left side
rest) [mm]
OI
Body
TrA
Body
TrA preferential activation ratio
e
Sum OE. OI. TrA at rest (mm)
Body
Sum OE. OI. TrA during hollowing (mm) Body

Beta
R-squared
coefcient

0.651z
0.667z
0.545z
0.600y
0.580y
0.700z
0.558z
e
mass
0.278*
height 0.298*
0.251*
e
e
mass
0.368y
height 0.435y
height 0.376*
e
mass
0.727z
mass
0.743z
mass
mass
mass
mass
mass
mass
mass

0.42
0.49
0.30
0.36
0.33
0.49
0.31
e
0.08
0.09
0.07
e
e
0.13
0.18
0.14
e
0.53
0.55

TrA, transversus abdominis; OI, internal oblique abdominis; OE, external oblique
abdominis.
BMI, body mass index; e, lack signicant predictors.
For explanations of the dependent variables, see method section in the text.
*
p < 0.05, yp < 0.01, zp < 0.00001.

2008b; Manshadi et al., 2011). During ADIM, the OI muscle

remained the thickest muscle, and the OE muscle became the
thinnest muscle in the population examined. In the report by
Mannion et al. (2008b), irrespective of the measurement conditions
(rest or during ADIM), the OI and TrA muscles remained the
thickest and the thinnest, respectively. These differences can be
explained by the use of a different methodology in above-cited
experiment.
In the adolescent population examined, no differences in the
thickness of the OI and TrA muscles, between the right and left
sides, at rest and during ADIM, were demonstrated, which is
consistent with other studies (Mannion et al., 2008b; Rho et al.,
2013). A signicantly greater thickness of the OI muscle at rest
and during ADIM was noted in boys compared with girls, which is
consistent with the reports of Rho et al. (2013) and Rankin et al.
(2006). According to Mannion et al. (2008b), body mass is an
important predictor of the muscle thickness at rest and during
ADIM. Our study also conrms this, because body mass explained
more than 50% of the differences in the thickness of the abdominal
muscles at rest and during ADIM. Thus, a very strong correlation
exists between body mass and muscle thickness, which is as high in
adolescents as it is in adults. However, as opposed to the work by
Rho et al. (2013) and Rankin et al. (2006), no differences between
genders were demonstrated for the TrA muscle thickness. In the
mentioned studies, the men were taller, heavier and had higher
BMI values, but, in this report, the boys were only taller than girls.
This can explain the lack of such differences in TrA muscle thickness
between genders in the younger population.
These studies also suggest that there is a different strategy of
muscle activation in girls, because the contribution of the TrA
muscle to the structure of the lateral abdominal wall in girls is
greater (Kulas et al., 2006). However, with regards to the TrA
contraction ratio and TrA preferential activation ratio, no signicant
differences between the genders were observed. These results are
consistent with the studies of adults (Springer et al., 2006; Mannion
et al., 2008b).
With regards to the contraction ratio during ADIM, some differences exist among the studies of adult populations. In the

reports of Critchley and Coutts (2002), Hides et al. (2006), Mannion

et al. (2008b), Kiesel et al. (2008) and Manshadi et al. (2011), the
TrA contraction ratio was approximately 1.51, whereas, in other
studies this index was distinctly higher, that is, 1.8 (Springer et al.,
2006) or 2.2 in subjects with LBP (Teyhen et al., 2005). In this
report, the contraction ratio was also approximately 1.5 and, similar
to the report of Mannion et al. (2008b), did not depend on body
mass. Based on such results, the contraction ratio during ADIM can
be a valid indicator that can be used to compare symptomatic
young population (scoliosis, etc.). Moreover, the suggestion that
only the TrA muscle is activated during ADIM (Jull and Richardson,
2000) has not been conrmed. In the current report, activation of
the TrA and OI muscles occurred during ADIM; this is consistent
with studies in adults (Hides et al., 2006; Mannion et al., 2008b;
Manshadi et al., 2011). Therefore, it is likely that the TrA and OI
muscles do not act independently (Urquhart et al., 2005b), and
their co-activation provides evidence that the functions of the two
muscles are also superimposed in adolescence.
It should be emphasised that correct performance of ADIM requires smooth generation of tonic, low-load, isometric abdominal
contraction. In order to make a valid comparison of the ultrasound
measuring techniques for the muscle architecture when relaxed
and during ADIM, the level of muscle activity should be known, as
RUSI is only sensitive to muscle contraction up to about 30% of the
maximal voluntary contraction (Hodges et al., 2003). In this work,
the maximal voluntary contraction was not measured (similar to
other works in this eld; Rankin et al., 2006; Mannion et al.,
2008b), because obtaining intramuscular abdominal EMG data in
large numbers of subjects (especially young adolescents) is very
difcult. Hence, it needs to be acknowledged that these reference
data cannot accurately indicate whether or not changes in muscle
thicknesses were observed during correct or incorrect performance
of the ADIM. Another limitation of this study is the fact that some of
the reported signicant differences (Table 4) are smaller than the
SDD reported in Table 2; therefore, they could be attributed to
measurement error.
5. Conclusions
The results of the present study provide extensive information
about the structure of the lateral wall of the abdomen in healthy
adolescent boys and girls between the ages of 10 and 16, which
enables comparisons among different clinical groups in order to
assess any abnormalities. In adolescents of 10e16 years old, the
structure of the lateral abdominal wall is similar to that of adults. At
rest and during ADIM, the percentage contribution to the structure
of the lateral abdominal wall follows the order OI, OE and TrA
muscle, from the highest to the lowest. In this age group, the
thickness of the lateral abdominal wall in boys was greater than in
girls. Body mass was the best predictor of the muscle thickness.
Body mass should be taken into account as a confounder in
comparing subjects with pain and other abnormalities characteristic of adolescence. During ADIM, the abdominal muscles in adolescents react similarly to those in adults.
Ethics approval
Local Ethics Committee, The Jerzy Kukuczka Academy of Physical Education in Katowice Ethics Committee approved this study.
Participants gave written informed consent before data collection
began.
Source(s) of support
Own source.

P. Linek et al. / Manual Therapy 20 (2015) 117e123

Competing interests
Nil.
Conict of interest statement
All authors declare no conicts of interest.
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