Lumbar spine stabilization using a Pressure Biofeedback Unit on Muscle Activity and Lateral Pelvic Tilt During Hip Abduction in a sidelying position. Results: Significantly decreased electromyographic activity in the quadratus lumborum (PHA, 60.39%Ti15.62% of maximum voluntary isometric contraction [MVIC]; HALS, 27.90%Ti13.03% of MVIC).
Descrição original:
Título original
Effects of Lumbar Stabilization Using a Pressure Biofeedback Unit on Muscle Activity and Lateral Pelvic Tilt During Hip Abduction in Sidelying
Lumbar spine stabilization using a Pressure Biofeedback Unit on Muscle Activity and Lateral Pelvic Tilt During Hip Abduction in a sidelying position. Results: Significantly decreased electromyographic activity in the quadratus lumborum (PHA, 60.39%Ti15.62% of maximum voluntary isometric contraction [MVIC]; HALS, 27.90%Ti13.03% of MVIC).
Lumbar spine stabilization using a Pressure Biofeedback Unit on Muscle Activity and Lateral Pelvic Tilt During Hip Abduction in a sidelying position. Results: Significantly decreased electromyographic activity in the quadratus lumborum (PHA, 60.39%Ti15.62% of maximum voluntary isometric contraction [MVIC]; HALS, 27.90%Ti13.03% of MVIC).
Effects of Lumbar Stabilization Using a Pressure Biofeedback
Unit on Muscle Activity and Lateral Pelvic Tilt During Hip Abduction in Sidelying Heon-Seock Cynn, PT, MA, Jae-Seop Oh, PT, MSc, Oh-Yun Kwon, PT, PhD, Chung-Hwi Yi, PT, PhD ABSTRACT. Cynn H-S, Oh J-S, Kwon O-Y, Yi C-H. Ef- fects of lumbar stabilization using a pressure biofeedback unit on muscle activity and lateral pelvic tilt during hip abduction in sidelying. Arch Phys Med Rehabil 2006;87:1454-8. Objective: To assess the effects of lumbar spine stabiliza- tion using a pressure biofeedback unit on the electromyo- graphic activity and angle of lateral pelvic tilt during hip abduction in a sidelying position. Design: Comparative, repeated-measures study. Setting: University research laboratory. Participants: Eighteen able-bodied volunteers (9 men, 9 women) with no history of pathology. Intervention: Subjects were instructed to perform hip abduc- tion in a sidelying position in both the preferred hip abduction (PHA) and hip abduction with lumbar stabilization (HALS). A pressure biofeedback unit was used for lumbar stabilization. Main Outcome Measures: Surface electromyography was recorded from the quadratus lumborum, gluteus medius, inter- nal oblique, external oblique, rectus abdominis, and multidus muscles. Kinematic data for lateral pelvic tilt angle were mea- sured using a motion analysis system. Dependent variables were examined with 2 (PHA vs HALS) 2 (men vs women) analysis of variance. Results: Signicantly decreased electromyographic activ- ity in the quadratus lumborum (PHA, 60.39%15.62% of maximum voluntary isometric contraction [MVIC]; HALS, 27.90%13.03% of MVIC) and signicantly increased elec- tromyographic activity in the gluteus medius (PHA, 25.03% 10.25% of MVIC; HALS, 46.06%21.20% of MVIC) and in- ternal oblique (PHA, 24.25%18.10% of MVIC; HALS, 44.22%20.89% of MVIC) were found when the lumbar spine was stabilized. Lateral pelvic tilt angle (PHA, 13.864.66; HALS, 5.554.16) was decreased signicantly when the lumbar spine was stabilized. In women the electromyographic activity (percentage of MVIC) in gluteus medius, external oblique, and rectus abdominis was signicantly higher than that observed in men. Conclusions: With lumbar stabilization, the gluteus medius and internal oblique activity was increased signicantly, and the quadratus lumborum activity was decreased signicantly, causing reduced lateral pelvic tilt in a sidelying position. These results suggest that hip abduction with lumbar stabilization is useful in excluding substitution by the quadratus lumborum. Key Words: Electromyography; Muscle; Rehabilitation; Spine. 2006 by the American Congress of Rehabilitation Med- icine and the American Academy of Physical Medicine and Rehabilitation D URING THE PAST DECADE, in the eld of physical therapy, the concept of lumbar stabilization has emerged to prevent musculoskeletal injuries, to rehabilitate, and to im- prove performance. Lumbar stabilization refers to internal sta- bilization achieved by the isometric contraction of abdominal and lumbar muscles to maintain stability. 1 It has also been referred to in the literature as core strengthening, motor control training, and dynamic stabilization. 2 Panjabi 3 theorized that spine stability is dependent on 3 subsystems: passive (spinal col- umn), active (spinal muscles), and control (neural control) subsystems. Panjabi 4 also dened a neutral zone as being a midrange position with minimal resistance to displacement owing to minimal tension in the passive subsystem. In this midrange position, deep intersegmental muscle contraction should be provided to control excessive motion and to com- pensate for instability because passive restraints cannot control the spinal movement. Two deep muscles, the transversus ab- dominis and lumbar multidus, are important for this spinal segment stabilization. It was also suggested that cocontraction of these deep muscles must be performed without involvement of the rectus abdominis or external oblique muscles, which are overactive in patients with low back pain. 5 A pressure biofeedback unit, a originally developed for as- sessing the ability of abdominal muscles to actively stabilize the lumbar spine, has been used to examine lumbar stabiliza- tion in various studies. 6-10 It is a reliable and valid clinical instrument for assessing deep abdominal muscle function, and has been used to develop a method for the careful monitoring of lumbar stabilization. 11,12 The pressure biofeedback unit con- sists of an inatable cushion connected to a pressure gauge and an ination device. When the pressure biofeedback unit is placed and inated, the subject is required to maintain the desired pressure and a constant lumbar position during lower- extremity movement under external loads. Changes in the pressure during hip movement reect an inability to maintain isometric contraction of the abdominal muscles, resulting in uncontrolled movement and instability of the lumbar spine. According to Janda, 13 hip abduction has failed if hip exion, hip external rotation, or lateral pelvic tilt is observed before 40 of abduction is achieved. Lateral pelvic tilt can occur when the quadratus lumborum substitutes for a weakened gluteus medi- us. 14 The lateral portion of the quadratus lumborum originates on the lateral iliumand inserts into the 12th rib without attachment to any vertebrae and produces primarily a lateral bending moment, whereas the medial portion of the muscle provides segmental stability through its segmental attachments. 5 Substitution by the lateral portion of the quadratus lumborum leads to pelvic obliquity From the Department of Rehabilitation Therapy, Graduate School, Yonsei Univer- sity, Wonju, South Korea. 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 or upon any organization with which the authors are associated. Reprint requests to Oh-Yun Kwon, PT, PhD, Dept of Rehabilitation Therapy, Graduate School, Yonsei University, 234 Maji-li, Hungob-myon, Wonju, Kang- won-do 222-710, Republic of Korea, e-mail: kwonoy@yonsei.ac.kr. 0003-9993/06/8711-10804$32.00/0 doi:10.1016/j.apmr.2006.08.327 1454 Arch Phys Med Rehabil Vol 87, November 2006 (lateral pelvic tilt), and the lumbar spine undergoes lateral exion resulting in lateral instability and impaired movement. 15 Although many studies assessing lumbar stabilization have been conducted with subjects in the supine position, 7,10 no studies on lumbar stabilization with subjects in the sidelying position were found in the literature. In addition, we know of no study conrming the effect of lumbar stabilization on the selective recruitment of the gluteus medius and the inhibition of the quadratus lumborum in the sidelying position. Given that hip abduction in the sidelying position is the appropriate move- ment for testing the range of motion and strength of the gluteus medius and is commonly prescribed as an exercise, investigat- ing the role of lumbar stabilization during sidelying will pro- vide the clinician with useful information for designing and implementing exercise protocols. Based on published reports and clinical experience, we hy- pothesized that increased gluteus medius activity and reduced quadratus lumborum activity would result in decreased ipsilat- eral lateral tilt during hip abduction in the sidelying position while the lumbar spine is stabilized with a pressure biofeed- back unit. The aims of this study were to assess the effect of lumbar stabilization using a pressure biofeedback unit on the electromyographic activity and angle of lateral pelvic tilt and to investigate the difference of muscle activation between men and women during hip abduction in the sidelying position. METHODS Participants We recruited 18 able-bodied young subjects (9 men, 9 women) from university students who volunteered to participate in this study. Subjects characteristics are shown in table 1. The exclu- sion criteria were past or present neurologic, musculoskeletal, or cardiopulmonary diseases that could interfere with hip ab- duction. Each subject signed informed consent approved by the university institutional review board before entering the study. Surface Electromyographic Recording and Data Analysis We collected electromyographic data using a data acquisi- tion system (Biopac MP100WSW b ) and a Bagnoli electromyo- graphy system. c The skin was cleansed with rubbing alcohol, and disposable Ag-AgCl surface electrodes were positioned at an interelectrode distance of 2cm. The reference electrode was attached to the styloid process of the ulna on the dominant upper extremity. Electromyographic data were collected for the following muscles on the same side as the dominant lower ex- tremity: quadratus lumborum (4cm lateral from the vertebral ridge or belly of the erector spinae muscle, and at a slightly oblique angle at half the distance between the 12th rib and the iliac crest), gluteus medius (parallel to the muscle bers, over the proximal one third of the distance between the iliac crest and the greater trochanter), external oblique (on the inferior edge of the 8th rib, superolateral to the costal margin), internal oblique (in the horizontal plane, 2cm medial to the anterior superior iliac spine), rectus abdominis (2cm lateral to the umbricus), 16,17 and multidus (parallel to the muscle bers, 2cm lateral to the midline running through the L5 spinal process). 18 We amplied and digitized the electromyographic signals with AcqKnowledge software (version 3.7.2). b Bandpass (20450Hz) and bandstop lters (60Hz) were used. The raw data were pro- cessed into the root mean square (RMS) and were converted to ASCII les for analysis. For normalization, the mean RMS of 3 trials of maximal voluntary isometric contraction (MVIC) was calculated for each muscle. The manual muscle testing position was used, as described by Kendall et al. 19 The electromyo- graphic signals collected during hip abduction were expressed as a percentage of the calculated mean RMS of the MVIC (% MVIC). Kinematic Study of Lateral Pelvic Tilt We used a 3-dimensional ultrasonic motion analysis system (CMS-HS d ) to measure the lateral pelvic tilt during hip abduc- tion in sidelying. One triplet bearing 3 active markers that emit an ultrasonic signal was secured to the pelvis on the side of the lower extremity to be lifted. Three markers were positioned to face the measuring sensor by a fastening belt passing around at the level of anterior superior iliac spines. The measuring sensor consisting of 3 microphones was positioned in front of the subject to record the ultrasonic signal from the markers. The measuring plane was set and aligned according the markers. The angle of the lateral pelvic tilt measured before hip abduc- tion was calibrated to 0 as a reference position, and the relative angle of the lateral pelvic tilt during hip abduction was calculated from this reference position. 20,21 The sampling rate was 20Hz. After data collection angular displacements for lateral pelvic tilt were low-pass ltered with a cutoff frequency of 8Hz. The kinematic data were analyzed by the Windata soft- ware (version 2.19). d The mean angle of 3 trials was deter- mined for comparison. Procedure Each subject was required to assume a sidelying position with the nondominant lower extremity contacting a rm mat- tress. The upper trunk, pelvis, and dominant lower extremity were aligned in a straight line. The nondominant lower extrem- ity could be exed at both the hip and knee joints for comfort and stability. While sidelying, the subject was asked to perform hip abduction with the dominant lower extremity in both the preferred condition and the stabilized-lumbar condition, in random order. An inclinometer was used to determine when the hip was in 35 of abduction. A bar was placed at this level and provided feedback to the subject as they were instructed to abduct their hip until the side of their knee touched the bar and to hold the position for 5 seconds. The electromyographic signal was recorded during this 5-second period. In the stabi- lized-lumbar condition, the pressure biofeedback unit was placed between the rm mattress and the subjects lumbar spine in the sidelying position. The elastic bag was inated until the lumbar curve was straight, at which point the target pressure was determined. The spinous processes in lumbar region were palpated and a rigid ruler was used to visually establish that the lumbar curve was straight. Subjects were instructed to use the visual feedback provided by the analog gauge of the pressure biofeedback unit in order to maintain the determined target pressure during hip abduction. A researcher monitored the pressure uctuations. Pressure changes of 5mmHg from the target pressure were allowed to accommo- date changes induced by breathing. Prior to testing all subjects were familiarized with the standard position and movement and with the use of the pressure biofeed- back unit and felt comfortable at the time of data collection. Table 1: Subject Characteristics Parameters Subjects (N18) Age (y) 23.53.5 Weight (kg) 59.35.1 Height (cm) 167.74.3 NOTE. Values are mean standard deviation (SD). 1455 LUMBAR STABILIZATION DURING HIP ABDUCTION, Cynn Arch Phys Med Rehabil Vol 87, November 2006 Statistical Analysis The data are expressed as the mean standard deviation (SD). A 22 analysis of variance with 1 within-subject factor (condition) and 1 between-factor (sex) was used to determine the main effects and their interaction in each muscle with the signicance level set at P equal to or less than .05. RESULTS The electromyographic activity and the angle of lateral pel- vic tilt during preferred hip abduction (PHA) and hip abduction with lumbar stabilization (HALS) is shown in table 2. There were signicant main effects for condition (PHA vs HALS) in quadratus lumborum (F 1,16 54.51, P.000), gluteus medius (F 1,16 46.29, P.000), internal oblique (F 1,16 23.92, P.000), and for angle of the lateral pelvic tilt (F 1,16 73.79, P.000). There were signicant main effects for sex in gluteus medius (F 1,16 4.98, P.040), external oblique (F 1,16 20.10, P.000), and rectus abdominis (F 1,16 14.25, P.002). There were also signicant condition by sex interactions in gluteus medius (F 1,16 7.30, P.016), external oblique (F 1,16 11.55, P .004), and multidus (F 1,16 10.37, P.005). With lumbar spine stabilization, the electromyographic activity was de- creased signicantly in the quadratus lumborum and increased signicantly in the gluteus medius and internal oblique. The angle of lateral pelvic tilt was decreased signicantly with lumbar spine stabilization. In women the electromyographic activity in gluteus medius, external oblique, and rectus abdo- minis was higher than that observed in men. DISCUSSION Lumbar stabilization can be achieved by the cocontraction of the transversus abdominis and lumbar multidus. When the transversus abdominis contracts, the intra-abdominal pressure (IAP) increases, and the tension of the thoracolumbar fascia increases. Consequently, stabilization of the spine is main- tained by the IAP in the abdominal cavity and the stiffness of the lumbar spine. 22 Furthermore, the activation of the transver- sus abdominis is independent of the direction of limb move- ment and is continuous throughout lower limb movement, 23,24 suggesting a stabilizing function of the abdominal pressure. Panjabi 4 determined that the lumbar multidus acts as a stabi- lizer in the lumbar spine because it is a deep, segmentally attached muscle. The role of the multidus as a segmental stabilizer has been also demonstrated previously. 25-27 We found signicantly increased internal oblique activi- ties with lumbar stabilization. The internal oblique was thought to enhance the stability of the spine in previous studies, 23,28,29 and this is consistent with our results, suggesting that increased internal oblique muscle activity contributed to lumbar stabilization. In this study, however, the activity of the external oblique, rectus abdominis, and multidus did not show signicant changes with the use of a pressure biofeedback unit. Lumbar stabilization during hip abduction in sidelying does not seem to affect the activity of these muscles. Unlike the internal oblique muscle, the external oblique and rectus abdominis do not blend at the lateral raphe of the thoracolumbar fascia, 1 so that the external oblique does not contribute to lumbar stabili- zation. The rectus abdominis runs longitudinally from pubic crest and symphysis to costal cartilages and sternum. Thus, this muscle could have led to sagittal plane stabilization with the multidus that runs relatively longitudinally. Our ndings are consistent with those of Arokoski et al 18 who reported that it was difcult to contract the paraspinal muscles independently from the external oblique during stabilization exercise in the sidelying position. In addition, Jull et al 7 found no RMS amplitude difference in rectus abdominis and the lumbar erec- tor spinae with abdominal setting action during leg lifting in supine position. In women a higher percentage of MVIC in gluteus medius, external oblique, and rectus abdominis was observed. This higher percentage of MVIC in women is thought to result from the need to maintain lumbopelvic stability required during hip abduction in sidelying position. The sex-dependent differences exist affecting the lumbopelvic stability between men and women, even though we did not measure the differences. First, less skeletal muscle mass, thickness of lateral abdominal mus- cles, and physiologic cross-sectional area of abdominal region in women were reported from the previous studies. 30-32 As mus- cle mass increases, so does amount of titin. Passive muscle stiffness will increase as amount of titin increases, because titin contribute to passive muscle stiffness. 15 Thus, passive muscle stiffness in women will be lower than that in men. This lower passive stiffness can result in less lumbopelvic stability while assuming hip abduction in sidelying position. Second, the wider pelvic size in women, 31 as an anthropometric difference, may be one of the causes inducing lower lumbopelvic stability in women. The center of gravity in sidelying position in women would be positioned relatively higher than men secondary to the wider pelvis, possibly threatening the lumbopelvic stability of maintaining hip abduction in sidelying position. For these possible reasons, it is presumed that the higher percentage of MVIC in gluteus medius, external oblique, and rectus abdomi- nis was required in women to overcome the lower lumbopelvic stability during hip abduction in sidelying position. Further Table 2: Electromyographic Activity in Muscles and Angle of Lateral Pelvic Tilt During Preferred Hip Abduction and Hip Abduction With Lumbar Stabilization Parameters PHA HALS Muscle activity (% MVIC) Quadratus lumborum Men 56.0821.46 32.2315.34 Women 64.709.78 23.5710.72 All 60.3915.62 27.9013.03 Gluteus medius Men 22.3710.67 36.9818.05 Women 27.739.83 55.1424.35 All 25.0310.25 46.0621.20 Internal oblique Men 20.2617.34 31.1525.70 Women 28.2418.86 57.2916.08 All 24.2518.10 44.2220.89 External oblique Men 19.938.24 16.9412.54 Women 39.6719.74 50.0834.04 All 29.8013.99 33.5123.29 Rectus abdominis Men 14.537.60 12.579.18 Women 30.9722.82 32.9326.96 All 22.7515.21 22.7518.07 Multidus Men 41.1916.51 25.4215.20 Women 43.2923.97 40.8224.75 All 42.2420.74 33.1219.99 Angle of lateral pelvic tilt (deg) Men 11.994.15 4.363.14 Women 15.734.58 6.734.87 All 13.864.66 5.554.16 NOTE. Values are mean SD. 1456 LUMBAR STABILIZATION DURING HIP ABDUCTION, Cynn Arch Phys Med Rehabil Vol 87, November 2006 studies should address the relation between the neuromuscular control in the lumbopelvic region during hip abduction in sidely- ing position and the sex-specic differences. Janda 13 also identied an abnormal recruitment sequence for hip abduction in symptomatic subjects compared with non- symptomatic subjects. In patients with low back pain, gluteus medius activity was delayed, whereas gluteus medius activity was observed before the ipsilateral quadratus lumborum in normal subjects. The recruitment imbalance between the glu- teus medius and quadratus lumborum can induce movement impairment. For this reason, the gluteus medius and quadratus lumborum should be closely monitored for lumbar stability and joint support. 15 Clinicians often report overactivity and trigger points for the quadratus lumborum with gluteus medius insuf- ciency in patients with back pain. 14 In addition, increased tension in the quadratus lumborum was implicated in pelvic upward movement and rotational malalignment. 33 Care should be taken to prevent an overactive quadratus lumborum from substituting for the gluteus medius. Our results conrm the hypothesis that lumbar stabilization during hip abduction in sidelying can reduce quadratus lum- borum activity and ipsilateral pelvic tilt and can recruit the gluteus medius and internal oblique. Previous studies have recommended a treatment protocol that included relaxation to decrease the activity of the quadratus lumborum and exercise to facilitate the recruitment of the gluteus medius. 5,14 The lumbar stabilization method used here could stabilize the pelvis and recruit the gluteus medius muscle without substitution by the quadratus lumborum. Therefore, we suggest that lumbar stabi- lization during sidelying is useful in treatment protocols de- signed to prevent motor control dysfunction by reducing quad- ratus lumborum activity and strengthening the gluteus medius. Our study showed that lumbar stabilization using a pressure biofeedback unit signicantly increased gluteus medius and internal oblique activity, while decreasing quadratus lumborum activity and ipsilateral pelvic tilt in hip abduction during side- lying. We used surface electromyography to investigate muscle activity and assumed that the detected signal represented each muscle in its entirety; however, there are potential signal al- terations caused by muscle movements below the surface elec- trode or cross-talk from adjacent muscles. We established the predetermined hip abduction at 35 of verticality to assure hip abduction in the frontal plane and to prevent possible hip or pelvis movement in other planes that might affect the targeted muscle activities. Our results cannot be generalized to other populations because all the subjects participating in the study were young and able-bodied. Therefore, the benets of lumbar stabilization used in this study should be conrmed in other populations. The activity of the transversus abdominis was not measured in our study. Therefore, further studies are warranted to assess deep muscle activity during hip abduction training while sidelying with lumbar stabilization and to determine the direct benet and selective muscle facilitation associated with lumbar stabilization. CONCLUSIONS This study showed that the activity of the gluteus medius and internal oblique increased signicantly, the activities of the quadratus lumborum decreased signicantly, and the lateral pelvic tilt was reduced signicantly during sidelying with lum- bar stabilization achieved using a pressure biofeedback unit. Therefore, hip abduction with lumbar stabilization during side- lying can be recommended as a more effective method for excluding unwanted substitution by the quadratus lumborum and to facilitate gluteus medius muscle activity. References 1. Kisner C, Colby LA. Therapeutic exercise: foundations and tech- niques. 4th ed. Philadelphia: FA Davis; 2002. 2. Akuthota V, Nadler SF. Core strengthening. Arch Phys Med Rehabil 2004;85(3 Suppl 1):S86-92. 3. Panjabi M. The stabilizing system of the spine. Part I, function, dysfunction, adaptation, and enhancement. J Spinal Disord 1992; 5:383-9. 4. Panjabi M. The stabilizing system of the spine. Part II, neutral zone and instability hypothesis. J Spinal Disord 1992;5:390-7. 5. Richardson C, Jull G, Hodges P, Hides J. Therapeutic exercise for spinal segmental stabilization in low back pain. London: Churchill Livingstone; 1999. 6. Herrington L, Davies R. The inuence of Pilates training on the ability to contract the transversus abdominis muscle in asymptom- atic individuals. J Bodywork Mov Ther 2005;9:52-7. 7. Jull G, Richardson C, Toppenberg R, Comerford M, Bui B. Towards a measurement of active muscle control for lumbar stabilization. Aust J Phys 1993;39:187-93. 8. Mills JD, Taunton JE, Mills WA. The effect of a 10-week training regimen on lumbo-pelvic stability and athletic performance in female athletes: a randomized-controlled trial. Phys Ther Sport 2005;6:60-6. 9. Richardson C, Jull G, Toppenberg R, Comerford M. Techniques for active lumbar stabilization for spinal protection: a pilot study. Aust J Phys 1992;38:105-12. 10. Wohlfart D, Jull G, Richardson C. The relationship between dynamic and static function of the abdominal muscles. Aust J Phys 1993;39:9-13. 11. Cairns M, Harrison K, Wright C. Pressure biofeedback: a useful tool in the quantication of abdominal muscular dysfunction? Physiotherapy 2000;86:127-38. 12. Richardson CA, Jull GA. Muscle control-pain control. What ex- ercises would you prescribe? Man Ther 1995;1:2-10. 13. Janda V. Evaluation of muscle imbalance. In: Liebenson C, editor. Rehabilitation of the spine: a practitioners manual. Baltimore: Williams & Wilkins; 1996. p 97-112. 14. Chaitow L. Muscle energy techniques. London: Churchill Living- stone; 1996. 15. Sahrmann S. Diagnosis and treatment of movement impairment syndrome. St. Louis: Mosby; 2002. 16. Cram JR, Kasman GS, Holtz J. Introduction to surface electro- myography. Gaithersburg: Aspen; 1998. 17. Vera-Garcia FJ, Grenier SC, McGill SM. Abdominal muscle response during curl-ups on both stable and labile surfaces. Phys Ther 2000;80:564-9. 18. Arokoski JP, Valta T, Kankaanpaa M, Airaksinen O. Activation of lumbar paraspinal and abdominal muscles during therapeutic ex- ercises in chronic low back pain patients. Arch Phys Med Rehabil 2004;85:823-32. 19. Kendall FP, McCreary EK, Provance PG. Muscles: testing and function with posture and pain. 5th ed. Baltimore: Williams & Wilkins; 2005. 20. Knoll Z, Kiss RM, Kocsis L. Gait adaptation in ACL decient patients before and after anterior cruciate ligament reconstruction surgery. J Electromyogr Kinesiol 2004;14:287-94. 21. Vogt L, Banzer W. Measurement of lumbar spine kinematics in incline treadmill walking. Gait Posture 1999;9:18-23. 22. Ebenbichler GR, Oddsson LIE, Kollmitzer J, Erim Z. Sensory- motor control of the lower back: implications for rehabilitation. Med Sci Sports Exerc 2001;33:1889-98. 23. Cresswell AG, Grundstrom A, Thorstensson A. Observations on intra-abdominal pressure and patterns of abdominal intra- muscular activity in man. Acta Physiol Scand 1992;144:409-18. 1457 LUMBAR STABILIZATION DURING HIP ABDUCTION, Cynn Arch Phys Med Rehabil Vol 87, November 2006 24. Hodges PW, Richardson CA. Contraction of the abdominal mus- cles associated with movement of the lower limb. Phys Ther 1997;77:132-43. 25. Kaigle AM, Holm SH, Hansson TH. Experimental instability in the lumbar spine. Spine 1995;20:421-30. 26. McGill SM. Kinetic potential of the lumbar trunk musculature about three orthogonal orthopaedic axes in extreme postures. Spine 1991;16:809-15. 27. Wilke HJ, Wolf S, Claes LE, Arand M, Wiesend A. Stability increase of the lumbar spine with different muscle group: a bio- mechanical in vitro study. Spine 1995;20:192-8. 28. Tesh KM, ShawDunn J, Evans JH. The abdominal muscles and vertebral stability. Spine 1987;12:501-8. 29. Macintosh JE, Bogduk N, Gracovetsky S. The biomechanics of the thoracolumbar fascia. Clin Biomech 1987;2:7-83. 30. Janssen I, Heymseld SB, Wang Z, Ross R. Skeletal muscle mass and distribution in 468 men and women aged 18-88 yr. J Appl Physiol 2000;89;81-8. 31. Marras WS, Jorgensen MJ, Granata KP, Wiand B. Female and male trunk geometry: size and prediction of the spine loading trunk muscles derived from MRI. Clin Biomech (Bristol, Avon) 2001;16:38-46. 32. Springer BA, Mielcarek BJ, Neseld TK, Teyhen DS. Rela- tionships among lateral abdominal muscles, gender, body mass index, and hand dominance. J Orthop Sports Phys Ther 2006; 36:289-97. 33. Schamberger W. The malalignment syndrome: implication for medicine and sports. London: Churchill Livingstone; 2002. Suppliers a. Chattanooga Group, 4717 Adams Rd, Hixson, TN 37343. b. Biopac Systems Inc, 42 Aero Camino, Goleta, CA 93117. c. Delsys Inc, 650 Beacon St, Boston, MA 02215. d. Zebris Medizintechnik GmbH, D-88305 Isny im Allgu, Max- Eyth-Weg 42, D-88316 Isny im Allgu, Germany. 1458 LUMBAR STABILIZATION DURING HIP ABDUCTION, Cynn Arch Phys Med Rehabil Vol 87, November 2006