[ research report ]

Deydre S. Teyhen, PT, PhD1 • Laura N. Bluemle, PT2 • Jeffery A. Dolbeer, PT3
Sarah E. Baker, PT4 • Joseph M. Molloy, PT, PhD5 • Jackie Whittaker, PT6 • John D. Childs, PT, PhD7

Changes in Lateral Abdominal Muscle

Thickness During the Abdominal
Drawing-in Maneuver in Those
With Lumbopelvic Pain
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L
umbopelvic pain continues global abdominal muscles.2,3,5,13,59 Despite corporate the ADIM in the rehabilitation
to be the most common the widespread use of exercises that in- of patients with lumbopelvic dysfunction,

reason people seek medical

t Study Design: Controlled laboratory study. between groups (P = .522). No differences were
attention in the United
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

States, accounting to 1% of the t Objectives: To determine if changes in
transversus abdominis (TrA) and internal oblique
entire US gross domestic product, (IO) muscle thickness and side-to-side symmetry
despite recent advances in imaging differ in individuals with and without unilateral
lumbopelvic pain while at rest and during the
and surgical technology.1,28,34 abdominal drawing-in maneuver (ADIM).
Altered neuromuscular control t BACKGROUND: Although the ADIM has been
is thought to be a contributing found to produce a symmetrical change in TrA and
IO muscle thickness in healthy subjects, how these
factor to the development of
muscles are activated in those with unilateral lum-
Journal of Orthopaedic & Sports Physical Therapy®
observed for the TrA or IO muscles between the
symptomatic and asymptomatic sides in those
with (TrA, P = .263; IO, P = .172) or without (TrA, P
= .780; IO, P = .635) lumbopelvic pain during the
ADIM. Changes in TrA muscle thickness were greater
than the IO muscle during the ADIM for both groups
(P.001). Specifically, the increases in TrA muscle
thickness in those with and without lumbopelvic
dysfunction were 32.7% and 47.3% greater, respec-
tively, compared to changes in the IO muscle.

chronic lumbopelvic pain.7,23,24,45,52,63 bopelvic pain during the ADIM remains unknown. t Conclusions: Individuals with unilateral
Exercises that preferentially t Methods: Fifteen subjects with lumbopelvic lumbopelvic pain demonstrated a smaller increase
target the transversus abdominis pain and 15 age- and gender-matched control in thickness of the TrA muscle during the ADIM.
subjects were recruited. To investigate a similar This finding provides an element of construct valid-
(TrA) are commonly incorporated subgroup of patients with lumbopelvic pain that ity for the use of the ADIM for assessing TrA muscle
into the rehabilitation has been used in previous research, subjects were thickness in those with unilateral lumbopelvic pain.
required to have unilateral symptoms, a positive However, both groups demonstrated a symmetrical
of patients with lumbopelvic
sacroiliac provocation test, and a positive active
SUPPLEMENTAL pain with the intent to rees- side-to-side change in TrA and IO muscle thickness
straight-leg raise test. Ultrasound images were
VIDEO ONLINE
tablish favorable muscle re- despite the symptomatic group having unilateral
obtained bilaterally at 2 different points during each
symptoms. Further, we detected a preferential
cruitment patterns,62,63 optimize trial of the ADIM: (1) at rest and (2) while maintain-
ing the ADIM. Average percent change in thickness change in TrA muscle thickness during the ADIM
stability, 51,55
and decrease pain.9,47,56,57,64
of the TrA and IO muscles was obtained over 3 trials. in both groups. J Orthop Sports Phys Ther
One of the fundamental exercises used
t Results: The percent change in thickness of the
2009;39(11):791-798. doi:10.2519/jospt.2009.3128
to train the TrA muscle is the abdomi-
TrA was 20.9% less in those with lumbopelvic pain t Key words: internal oblique, lumbar stabiliza-
nal drawing-in maneuver (ADIM)11,49,58,59
compared to the control group (P = .035), while tion exercise, sacroiliac dysfunction, transversus
based on preferential recruitment of the the percent change in IO thickness was equivalent abdominis, ultrasound imaging
TrA with minimal activation of the more

Associate Professor, US Army-Baylor University Doctoral Program in Physical Therapy, San Antonio, TX; Director, Center for Physical Therapy Research, San Antonio, TX.
1 

2 
Physical Therapist, William Beaumont Army Medical Center, El Paso, TX. 3 Physical Therapist, Womack Army Medical Center, Fort Bragg, NC. 4 Physical Therapist, Assistant Chief,
Musculoskeletal Clinic, Kimbrough Ambulatory Care Center, Fort George G. Meade, MD. 5 Assistant Chief, Physical Therapy Service, Brooke Army Medical Center, San Antonio,
TX. 6 Physical Therapist, Whittaker Physiotherapy Consulting, White Rock, BC, Canada; PhD Candidate, School of Health Sciences, University of Southampton, Southampton, UK.
7 
Associate Professor and Director of Research, US Army-Baylor University Doctoral Program in Physical Therapy, San Antonio, TX. The protocol of this study was approved by
the Brooke Army and Wilford Hall Medical Center’s Institutional Review Board. The opinions or assertions contained herein are the private views of the authors and are not to be
construed as official or as reflecting the views of the Departments of the Army, Air Force, or Defense. Address correspondence to Deydre Teyhen, Department of Physical Therapy,
US Army Medical Department Center and School, 3150 Stanley Road, Room 1303, ATTN: MCCS-HGE-PT, Fort Sam Houston, TX 78234. E-mail: deydre.teyhen@amedd.army.mil

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 [ research report
limitations in electromyographic mea-
surement techniques26,39,58,59 have pre-
viously impeded researchers’ ability to
readily compare the recruitment of the
TrA and internal oblique (IO) muscles
during the performance of this exercise
in normal and patient cohorts.
Patients with lumbopelvic pain have
been shown to have altered muscle re-
cruitment patterns of the lateral abdomi-
nal muscles, which include the TrA, IO,
and external oblique.7,18,19,23,24,45 Previous
researchers using magnetic resonance
imaging (MRI) and ultrasound imaging
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]
Inclusion and Exclusion Criteria
TABLE 1
for All Subjects
Inclusion criteria for those with unilateral lumbopelvic pain:
A. Unilateral pain over the sacroiliac joint, defined as not proximal to the iliac crests and not distal to the popliteal
fossa24,25,36,41,46
B. A positive active straight-leg raise test44,46
C. Pain for at least the previous 3 months without signs of abating46
D. At least 1 of 6 sacroiliac joint provocation tests are positive31,32
1. Distraction
2. Compression
3. Posterior shear test (thigh-thrust test)
4. Gaenslen's provocation test (right)
5. Gaenslen's provocation test (left)

(USI) have demonstrated a symmetrical

6. Sacral thrust test
change in TrA muscle thickness during
ADIM performance in subjects without
Exclusion criteria for all subjects:
lumbopelvic pain.13,38 Researchers have
A. Known pregnancy or less than 6 months post partum41,46
also demonstrated that those with lum-
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

B. A history of fracture, neoplasm, or previous surgery of the lumbar spine, the pelvic girdle, the hip joint, or the femur41
bopelvic pain have less change in thick-
C. Signs of radiculopathy, as defined by 2 of the 4 neurological signs
ness of the TrA muscle during a lower
1. Diminished sensation to touch in a dermatomal region
extremity task than those without symp-
2. A positive neural tension test
toms.7,17 However, information on chang-
es in muscle thickness during the ADIM 3. Motor weakness not secondary to pain

is limited. Specifically, it is not known if 4. Diminished reflexes43

individuals with unilateral lumbopelvic D. Bilateral sacroiliac pain or a bilaterally positive active straight-leg raise test
symptoms display either a diminished
and/or asymmetric change in muscle Exclusion criteria for the control group:
Journal of Orthopaedic & Sports Physical Therapy®

thickness during the ADIM.
USI is a noninvasive tool with well-
established reliability30,37,54,58 and valid-
ity for assessing muscle thickness.13,27,33
A. A history of low back, sacroiliac, pelvic, hip, or thigh pain in the previous year resulting in lost work, inability to perform
recreational activities, or symptoms that required medical attention10
B. A history of congenital lumbar or pelvic anomalies25
C. An inability to perform or a positive active straight-leg raise test25,46

USI has been recently used to measure

muscular geometry and indirectly in-
fer the extent of muscle activation via
changes in muscle thickness.7,20,29,40 Spe-
cifically, USI has shown promise as a tool
to study the TrA and IO muscles by as-
sessing changes in muscle thickness dur-
ing specific tasks.59,60,61 Recent evidence
suggests that USI is able to differentiate
during the ADIM. A secondary purpose lumbopelvic pain was based on having
was to determine if a side-to-side differ- at least 1 positive sacroiliac provocation
ence might exist in subjects with unilat- test31,32,61 (Table 1, ONLINE VIDEO) and a posi-
eral lumbopelvic pain. tive active straight-leg raise test.41,42 The
active straight-leg raise test is judged to
Methods be positive when, in supine, the patient
flexes the hip by lifting the lower extrem-
Subjects ity, with the knee fully extended off the

the changes in thickness of the deep ab-
dominal muscles,20,40 which can provide
valuable insight into potential lateral ab-
dominal motor control deficits in patients
with lumbopelvic pain.
The primary purpose of this study
was to use USI to investigate and deter-
mine if changes in thickness of the TrA
and IO muscles differ between a specific
subgroup of individuals with unilateral
lumbopelvic pain and those without pain,
T
hese data represent a secondary
analysis from a larger study investi-
gating the changes in muscle thick-
ness of the lateral abdominal muscles
during the active straight-leg raise test.61
We recruited 30 individuals, aged 18 to
50 years, to participate in this study, 15
subjects with unilateral lumbopelvic pain
and 15 age- and gender-matched control
subjects. To facilitate comparisons with
prior publications, determination of
table 5 cm, and experiences unilateral
pain, discomfort, or a feeling of heaviness
relative to that experienced when the op-
posite lower extremity is lifted.44,46 Con-
trol subjects were required to be within
2 years of age and of the same gender as
their matched subjects with lumbopelvic
pain and to not have any of the exclu-
sion criteria (Table 1). All subjects were
Department of Defense healthcare ben-
eficiaries, including active-duty military,

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TABLE 2 Demographic Descriptive Data*

Lumbopelvic Pain Group (n = 15) Control Group (n = 15) P Value

Age (y) 38.3  8.6 (24-49) 36.7  8.8 (24-50) .84
Gender (n, % female) 7 (46.7%) 7 (46.7%) 1.00
BMI (kg/m2) 26.7  4.1 (20.2-32.8) 27.2  3.7 (21.5-30.5) .56
FABQ-W (0-42) 14.1  9.3 (0-29) NA NA
ODI (0%-100%) 22.7  11.9 (9-50) NA NA
Sacroiliac positive provocation tests (1-6)† 2.9  0.7 (1-4) NA NA
FIGURE 1. Bilateral images of the lateral abdominal
Abbreviations: BMI, Body mass index; FABQ-W, Fear Avoidance Beliefs Questionnaire work subscale;
muscles were obtained by having 2 pairs of raters ODI, Modified Oswestry Disability Index.
situated on each side of the supine patient in the * Data are mean  SD (range), except for gender.
hook-lying posture. †
Number of positive tests out of 6.
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not involved in the USI assessment. Sub-
jects then were instructed and performed
the ADIM, while the lateral abdominal
muscles were monitored by USI.
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tive to the 2 adjacent fascial lines, in the
center of the muscle belly, was used to
ensure standardized placement for the
measurement of thickness of the TrA and

Prior to assessment of the lateral ab- IO muscles.

FIGURE 2. Ultrasound image of the lateral abdominal
muscles: transversus abdominis (TrA), internal
oblique (IO), and external oblique (EO) muscles.
family members, and retirees. Subjects
Journal of Orthopaedic & Sports Physical Therapy®
dominal muscles during the ADIM, sub-
jects were provided with a standardized
overview and a review of the testing pro-
cedures. Without any visual cues, subjects
were instructed to “gently draw in your
lower abdomen,” to achieve abdominal
hollowing after tidal expiration while in
the supine hook-lying position.58
To minimize bias, pairs of investiga-
tors were used to collect the ultrasound
images; 1 investigator in each pair was
designated as the recorder, and the other
investigator was designated as the im-
ager. The imager was responsible for
positioning the transducer for optimal
visualization and standardization of the

provided written, informed consent and
signed Health Insurance Portability and
Accountability Act privacy forms ap-
proved by the Brooke Army and Wilford
Hall Medical Center’s Institutional Re-
view Board prior to participation.
Procedure
Potential subjects with unilateral lum-
bopelvic pain were screened with a phys-
ical examination, including the active
straight-leg raise and sacroiliac provoca-
tion tests. Eligible consenting subjects
completed an additional physical ex-
amination, history, demographic ques-
tionnaire, and self-report measures: the
Modified Oswestry Low Back Pain Dis-
ability Questionnaire (Oswestry),6,8 the
Numerical Pain Rating Scale (NPRS), and
the Fear-Avoidance Beliefs Questionnaire
(FABQ).4,65 These self-report measures
were collected for descriptive purposes.
To help minimize bias, the researcher
performing the physical examination was
USI was used to measure changes in
muscle thickness. Bilateral ultrasound
images were obtained after tidal expi-
ration at rest and immediately upon
performing the ADIM. Simultaneous im-
ages were obtained by using 2 ultrasound
units (Sonosite TITAN; Sonosite, Inc,
Bothell, WA), with 5-MHz curvilinear
arrays (Figure 1).20,54,58,59 Each transducer
was placed on the anterolateral aspect of
the abdominal wall, just superior to the
iliac crest, perpendicular to the body’s
axillary line,53 and oriented to capture
as much of the length of the TrA as pos-
sible, while including its lateral insertion
with the thoracolumbar fascia.59
All images were saved, and measure-
ments were performed off-line with
Image-Pro Plus Software, Version 4.5
(Image Processing Solutions, Inc, Silver
Spring, MD). Thickness measurements
were taken from the outer border of the
hyperechoic fascia line of each muscle
(Figure 2).59 A perpendicular line rela-
musculature. The recorder verified prop-
er exercise performance. The pairs con-
sisted of physical therapy students who
were provided training sessions in the
measurement procedures by 2 investiga-
tors experienced in the use of USI in the
assessment of anterolateral abdominal
musculature. Both investigators were re-
quired to agree on the specific placement
of the on-screen caliper prior to saving
the image. Although the researchers ob-
taining the USI were kept separate from
the physical examination process, blind-
ing of those with and without unilateral
lumbopelvic pain was not possible based
on the potential pain response during the
USI assessment of the active straight-leg
raise test.61
Once the students were trained, pilot
data from 10 individuals were used to de-
termine interrater reliability. Reliability
for these researchers was assessed us-
ing the intraclass correlation coefficient
(ICC2,3), standard error of measure-

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 [ research report
ment (SEM), and minimal detectable
change (MDC), and has been previously
reported.61 These values are consistent
with previous reports using the same
measurement technique to assess the
ADIM.30,37,58
Data Analysis
TrA and IO muscle thickness values while
contracted were normalized based on
the resting-thickness values. TrA percent
change was equal to (TrA active – TrA
rest)/TrA rest  100. IO percent change
was equal to (IO active – IO rest)/IO rest
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]
Descriptive Statistics for Muscle Thickness
TABLE 3
at Rest and During ADIM
Symptomatic Side* Asymptomatic Side* P Value†
Lumbopelvic pain group (n = 15)
TrA .263
Rest 3.8  0.8 4.1  1.0
ADIM 6.1  2.7 6.5  2.6
Percent change (%)‡ 44.6  23.8 48.9  23.7
IO .172
Rest 8.2  2.5 7.9  2.5
ADIM 9.9  4.5 9.6  5.2
Percent change (%)‡ 11.8  10.2 8.4  11.4
Control group (n = 15)

 100. These percentages were calculat- TrA .780

ed to assess the relative change in muscle
thickness.
Separate 2-tailed independent t tests
were performed on the percent change
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Rest 4.1  0.9 4.3  1.3
ADIM 6.8  2.1 7.1  2.2
Percent change (%)‡ 65.4  27.6 67.1  31.5
IO .635

in muscle thickness of the TrA and IO
muscles to determine whether different
changes in muscle thickness during the
ADIM existed between subjects with
and without lumbopelvic pain. Separate
pairwise t tests were used to determine
if a difference in TrA and IO percent
change occurred between symptomatic
and asymptomatic side in individuals
Journal of Orthopaedic & Sports Physical Therapy®
Rest 7.9  3.1 8.6  3.2
ADIM 9.1  3.4 9.9  4.1
Percent change (%)‡ 18.1  36.1 13.3  15.1
Abbreviations: ADIM, abdominal drawing-in maneuver; IO, internal oblique; TrA, transversus
abdominis
* Values are mean  SD mm.
†
Statistical significance for side-to-side difference in percent change in muscle thickness for the lum-
bopelvic pain group and the control group.
‡
Percent change in muscle thickness from rest to during the ADIM.

with lumbopelvic pain and symmetry in

the control subjects. Descriptive statistics
were calculated to summarize the data
related to TrA and IO muscle thickness
values at rest and while contracted. The
Absolute Side-to-Side Percent Difference
TABLE 4
in Resting Muscle Thickness*
Muscle Lumbopelvic Pain Group (n = 15) Control Group (n = 15) P Value

alpha-level was a priori set to .05 for each TrA 18.8  9.6 (5.9-37.1) 14.0  11.6 (2.0-42.5) .237

analysis. All statistical analyses were con- IO 11.5  12.6 (1.0-43.1) 10.2  8.7 (0.7-33.3) .758

ducted using SPSS, Version 12.0 (SPSS, Abbreviations: IO, internal oblique; TrA, transversus abdominis.
* Values are mean  SD (range).
Inc, Chicago, IL).

Results and the percent change in thickness are the lateral abdominal muscle wall for
provided in Table 3. the TrA and IO muscles between groups

T
hirty subjects were enrolled
in this study: 15 subjects with uni-
lateral lumbopelvic pain and 15
age- and gender-matched control sub-
jects (TABLE 2). The subjects with uni-
lateral lumbopelvic pain had moderate
disability (mean  SD Oswestry Disabil-
ity Index score, 22.7%  11.9%) and low
fear-avoidance beliefs (mean  SD work
subscale score, 14.1  9.3). Muscle thick-
ness for the TrA and IO muscles for each
side of the body at rest and during ADIM,
There was no significant difference in
percent change of muscle thickness be-
tween symptomatic and asymptomatic
sides in those with lumbopelvic pain
in either the TrA (P = .263) or IO (P =
.172) muscles. Similar nonsignificant
side-to-side differences were noted in
the control group for the TrA (P = .780)
and IO (P = .635) muscles. Additionally
there were no differences noted in the
group mean percent difference in rest-
ing muscle thickness between sides of
(Table 4). While these differences were
not significant, individual asymmetries
were evident, with mean values for the
different muscles ranging from 10.2% to
18.8%. Because there was no significant
side-to-side difference in either group,
the remainder of the results and discus-
sion will be based only on symptomatic-
side data.
The control group demonstrated a
20.9% greater percent change in TrA
thickness during the ADIM (P = .03).

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02 Teyhen.indd 794 10/15/09 4:28:49 PM

 100
90
80
TrA
Percent Change in Thickness (%)
70
60
50
40
30
20
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10
0 ential changes in TrA thickness in both
Lumbopelvic pain group
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
FIGURE 3. Illustration of mean percent change and standard deviation in thickness for the transverse abdominis
(TrA) and internal oblique (IO) during the abdominal drawing-in maneuver for those with and without unilateral
lumbopelvic pain.
Subjects with lumbopelvic pain demon-
strated a mean  SD change of 44.6% 
23.8%, while the control group demon-
strated a 65.5%  27.7% change (Figure
Journal of Orthopaedic & Sports Physical Therapy®
3). There was no significant difference
in the amount of change in IO thick-
ness between those with lumbopelvic
pain (11.9%  10.3%) and those in
the control group (18.2%  36.1%) (P
= .52). During the ADIM, both groups
demonstrated greater percent change
in muscle thickness of the TrA muscle
compared to the IO muscle (P.001).
In those with lumbopelvic pain, the TrA
muscle demonstrated a 32.7% greater
increase in thickness compared to the
IO muscle. In the control group, the
percent change in TrA muscle thickness
was 47.3% greater than the IO muscle
thickness change.
Discussion
A
lthough motor control exer-
cises have been found to be effective
in the treatment of those with low
back pain, the exact mechanism through
which this form of exercise influences pain
journal of orthopaedic & sports physical therapy | volume 39 | number 11 | november 2009 |
02 Teyhen.indd 795
IO
Control group
and function remains unclear.35 Subjects
in this study with unilateral lumbopelvic
pain demonstrated a diminished ability
to thicken the TrA muscle without any
deficits noted in the ability to thicken the
IO muscle during the ADIM compared
to age- and gender-matched control sub-
jects without lumbopelvic pain. Specifi-
cally, subjects with unilateral lumbopelvic
pain had a 20.9% decrease in the ability
to thicken the TrA compared to healthy
controls without any associated changes
in the ability to thicken the IO muscle
during the ADIM. These findings are
consistent with previous research that
has identified a diminished or delayed
activation of the TrA in those with lum-
bopelvic pain.7,12,21,22,59 These findings may
indicate that individuals with a history of
lumbopelvic pain also have a diminished
ability to preferentially contract the TrA
muscle compared to the IO muscle dur-
ing the ADIM. These changes during the
volitional task of the ADIM may help
explain additional altered motor control
patterns46 associated with the positive ac-
tive straight-leg raise test, as displayed by
subjects with unilateral lumbopelvic pain
who enrolled in this study.
Although the change in muscle thick-
ness of the TrA muscle during the ADIM
was diminished by 20.9% in those with
unilateral lumbopelvic pain, both those
with and without lumbopelvic pain
preferentially thickened the TrA muscle
compared to the IO muscle during the
ADIM. In those with lumbopelvic pain
the TrA thickened 45% to 49% on aver-
age, while the IO thickened only 8% to
12%. In those without lumbopelvic pain,
the TrA thickened 65% to 67%, while
the IO thickened only 13% to 18% on
average. These findings clearly demon-
strate that the ADIM results in prefer-
those with and without lumbopelvic
pain and, in conjunction with previous
research,7,12,17,54,59,61 provide an element
of construct validity for the ADIM as a
motor control exercise that preferentially
targets the TrA muscle.
The individuals without lumbopelvic
pain were able to preferentially thicken
the TrA muscle better than those with
unilateral lumbopelvic pain. This sug-
gests the need to examine alternative
methods to help facilitate the TrA muscle
in those with lumbopelvic pain. The rela-
tive difference of change in TrA thickness
between the groups was 20.9%, which
corresponds to a difference in absolute
magnitude of less than 0.5 mm. What
remains unclear is whether this change
in thickness reflects a clinically impor-
tant difference. Previous researchers
have demonstrated improved function
and decreased pain for those with lum-
bopelvic pain35,55-57,62,63 when the ADIM
was utilized as part of the motor con-
trol exercise program. Therefore, the
20.9% reduction in TrA muscle thick-
ness change during the ADIM in those
with lumbopelvic pain may either nor-
malize with training, or the deficit may
not be sufficiently large to interfere with
the outcome in response to a motor con-
trol exercise program that integrates the
ADIM. Nonetheless, this study design
precludes our making conclusions about
the clinical efficacy of these exercises or
795
10/15/09 4:28:51 PM
 [ research report
their diagnostic accuracy.
Despite the unilateral nature of the
symptoms in those with lumbopelvic pain,
the mean thickness values for all subjects
demonstrated symmetrical muscle thick-
ness of the lateral abdominal muscles
during rest and during the ADIM. These
mean muscle thickness values are in
agreement with data from prior publica-
tions.37,38,48 However, similar to prior re-
ports,38,48 individual side-to-side muscle
asymmetries were evident, with side-to-
side absolute percent differences ranging
up to 43%. Rankin et al48 have suggested
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the use of relative muscle thickness values
instead of absolute values to address the
within-subject asymmetries noted in ab-
dominal muscle thickness. Although indi-
vidual variation did exist, the symmetrical
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
change in muscle thickness in the lateral
abdominal muscles during the ADIM
supports the anatomical and neuromus-
cular control of these muscles.58
The lack of a statistically significant
side-to-side difference in lateral ab-
dominal muscle thickness in those with
lumbopelvic pain differs from the side-
to-side asymmetry noted in the lumbar
Journal of Orthopaedic & Sports Physical Therapy®
multifidus muscle in those with unilat-
eral lumbopelvic pain.16 The symmetrical
thickening of these muscles during the
ADIM is in agreement with prior find-
ings that have assessed the characteristics
of the lateral abdominal muscles during
the ADIM in those with and without
lumbopelvic pain.12,13,50 Therefore, un-
like the treatment of those with lumbar
multifidus atrophy, in which improved
symmetry of the lumbar multifidus with
motor control exercise training was asso-
ciated with a decreased rate of occurrence
of lumbopelvic pain,14,15 it is unknown if
similar strategies for the lateral abdomi-
nal muscles would be effective. Addition-
ally, future researchers should address if
different exercise prescription strategies
are required for the lateral abdominal
muscles compared to the lumbar multi-
fidus muscle. For example, lumbar mul-
tifidus motor control exercises may need
to be more segmental and side specific,
whereas the lateral abdominal muscles
796 | november 2009 | volume 39 | number 11 | journal of orthopaedic & sports physical therapy
02 Teyhen.indd 796
may respond to a more generalized train-
ing approach.
To help control for differences in
muscle thickness based on age and gen-
der,48,54 subjects in the control group
were age- and gender-matched. Addi-
tionally, there were no differences be-
tween the groups based on body mass
index. Despite the fact that we controlled
for these possible confounding variables,
we did not find a significant difference
in percent change of the IO muscle dur-
ing the ADIM between groups. Based
on a between-group IO percent change
difference of approximately 20%, with
a standard deviation of approximately
23%, the study would have been ad-
equately powered (75%) to detect a dif-
ference. Also, although we did not detect
a significant side-to-side difference for
either muscle, the observed effect sizes
for both muscles were not clinically
meaningful and within measurement
error. Therefore, it provides additional
support to the lack of any meaningful
asymmetry in these muscles across sub-
jects in both groups.
A limitation of this study was that
the inclusion criteria for the subjects
with lumbopelvic pain included being
positive on at least 1 of 6 sacroiliac pain
provocation tests. Previous research has
shown that a cluster of at least 3 of 6 pos-
itive provocative tests has a sensitivity of
0.94 and specificity of 0.78 for diagnos-
ing lumbopelvic pain over the sacroiliac
region. 31,32 By only requiring 1 of the 6
sacroiliac pain provocation tests be posi-
tive for inclusion, the symptomatic sub-
jects represented a more heterogeneous
group than would have been ideal. How-
ever, 13 of the 15 subjects in the symp-
tomatic lumbopelvic group were positive
on at least 3 provocative tests. Further,
as our sample size was relatively low,
the results may not be generalizable to
a wide spectrum of patients with lum-
bopelvic pain.
Future research should further in-
vestigate muscle function in individuals
with lumbopelvic pain when perform-
ing other exercises currently being used
]
clinically for restoration of motor control
in the lumbopelvic region. Knowledge of
which exercises are potentially more ef-
fective at activating specific muscles may
assist clinicians in establishing more ap-
propriate and effective rehabilitation
programs. Further, a better understand-
ing of the behavior of the lateral abdom-
inal muscles during specific exercises
may ultimately prove beneficial in terms
of decreased incidence or recurrence of
lumbopelvic pain.
Conclusion
T
he percent change in thickness
of the TrA muscle during the ADIM
was significantly lower (20.9% less)
in those with lumbopelvic pain compared
to those in a control group, while changes
in IO thickness were equivalent between
groups. Despite the selection of subjects
with unilateral lumbopelvic pain, chang-
es in TrA and IO muscle thickness during
ADIM were bilaterally symmetrical. Dur-
ing the ADIM, the TrA muscle was pref-
erentially thickened over the IO muscle
in subjects with and without lumbopel-
vic pain. The results of this study provide
an element of construct validity for the
ADIM in its use for assessing muscle
function of the TrA and IO muscles in
subjects with unilateral lumbopelvic pain.
Further research is needed to investigate
lateral abdominal wall muscle function of
individuals with lumbopelvic pain during
other commonly used rehabilitation exer-
cises aimed at restoring motor control in
the lumbopelvic region. t
KEY POINTS
Findings: The ADIM resulted in prefer-
ential changes in TrA muscle thickness
compared to changes in IO muscle
thickness in those with and without uni-
lateral lumbopelvic pain. However, indi-
viduals with unilateral lumbopelvic pain
demonstrated a smaller increase (20.9%
less) in thickness of the TrA muscle dur-
ing the ADIM. The side-to-side changes
in thickness of the TrA and IO muscles
during the ADIM were symmetrical,
10/15/09 4:28:51 PM
 despite the unilateral symptoms in those
with lumbopelvic pain.
Implications: These findings add to the
construct validity for the ADIM and its
use for assessing muscle function of the
TrA and IO muscles for those with uni-
lateral lumbopelvic pain.
Caution: As the sample size was relative-
ly low, the results may not be generaliz-
able to a wide spectrum of patients with
lumbopelvic pain.
ACKNOWLEDGEMENTS: In memoriam, the au-
thors would like to acknowledge Captain Anna
Downloaded from www.jospt.org at on March 9, 2017. For personal use only. No other uses without permission.
Kelly, United States Air Force, who assisted
in the development of the methods and data
collection during this study. Additionally, the
authors would like to thank the following per-
sonnel for assistance in data collection: Jared
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Williamson, Nathan Carlson, Sean Suttles,
Shane O’Laughlin, and Stephen Goffar.
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leg-raise test. Spine. 2002;27:E1-8. on specific stabilizing exercises for pelvic girdle
47. O'Sullivan PB, Phyty GD, Twomey LT, Allison GT. pain after pregnancy: a two-year follow-up of a www.jospt.org

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