An Investigation of the Core Muscles Involved

in the Back Bridge Test:

A Pilot Study
Cassandra Baar, Jason Ciaramittaro, Sharon Whalen, Amy Wicks
Advisor: Dr. Katharine Conable
October 19, 2012

Abstract
Objective: to determine any correlation between the back bridge with leg extension
(BBLE) test and specific muscle weaknesses. The BBLE is a functional screening test widely used
in physical rehabilitation to evaluate the strength of the multifidus muscle.
Subjects: 29 healthy men and women, median age 24, with no known pathology or
structural imbalances preventing performance of the BBLE. We measured an average of 3 hip
drops bilaterally and tested the rectus abdominis, abdominal obliques, quadratus lumborum,
psoas, gluteus medius, gluteus maximum, hamstring and multifidus bilaterally. Testing was
repeated twice within one week. The examiners performing muscle tests were blind to the hip
drop data. No intervention was done
Results: The average mean hip drop was 0.89 and 0.93, right and left respectively. The
average standard deviation was 0.51 and 0.67.
There was moderate agreement between bilateral drops of 1.5 or greater and the Left
Abdominal Oblique with Kappas of 0.40 and 0.52 right and left respectively. The Right Gluteus
Medius also demonstrated a moderate agreement with the contralateral hip drop with a Kappa
of 0.46 with the left hip drop. There was fair agreement between the Left Quadratus
Lumborum and the contralateral right hip drop with a Kappa of 0.25.
Conclusion: The BBLE functional screen reflects a more complex group of muscle
weaknesses than the multifidi alone. The hip drop test is highly variable day to day suggesting
hip drop as determined by the BBLE screen may be a more transient occurrence and better
treated by immediate protocols than rehabilitation.

Introduction
The back bridge with leg extension (BBLE) test is widely used as a functional screen to
assess the strength of the multifidus muscle. The multifidus muscle is a deep stabilizer of the
lumbar spine and the BBLE screen is performed in order to identify muscle weakness so that
appropriate rehabilitative core training programs can be designed and implemented. Yu Okubo
et als study used electromyographic analysis to demonstrate that the multifidus muscle is
more active than other muscles during the back BBLE test (1).

This study employed manual muscle testing to examine the muscle inhibition patterns
associated with hip drop during the back bridge with leg extension test. The authors
hypothesize that a failure of the BBLE test suggests a weakness of multiple muscles of the core
and pelvis working synergistically and not the multifidus alone.

Manual muscle testing (MMT) was used to evaluate the strength of the pelvic stabilizer
muscles. The muscles examined were tested bilaterally and are as follows: quadratus
lumborum, multifidus, oblique abdominals, rectus abdominals, psoas, gluteus medius, gluteus
maximus, and hamstring. A future study can then evaluate treatment of the muscles most
frequently found weak on the results of the BBLE test.

Materials and Methods

The authors, four trimester nine student interns from Logan College of Chiropractic,
examined 34 chiropractic student volunteers. Twenty-nine subjects completed the study. There
were nine male participants and 20 female participants, with a mean age of 24.8 (SD 1.75).
All subjects were screened for major injuries or physical conditions that would have prevented
them from participation in the study, per the Inclusion/Exclusion criteria form. No subject
volunteers were excluded based on these criteria. The study was approved by the Institutional
Review Board of Logan College of Chiropractic.
A standard metal yardstick was attached vertically, via a metal clamp, to a flat adjusting
table. A standard goniometer was used to measure the degree of knee flexion during the back
bridge.
Subjects reported for three visits. At each visit, each subject performed the back bridge
three consecutive times bilaterally, and then underwent manual muscle testing via Applied
Kinesiology procedures.

Estimation of Hip Drop

After each subject read the Informed Consent form and consented to participation, they
completed an Inclusion/Exclusion Criteria form. Once they were included in the study, testing
began. Subjects were instructed to locate their anterior-superior iliac spines (ASIS) bilaterally,
so that a round sticker could be positioned for visual observation during the back bridge test.
The examiners verified the location of the ASIS prior to application of the stickers. Subjects
were instructed to lie on their backs, and the yardstick apparatus was positioned along the flat
table so as to align it with the subjects hips. The examiner then instructed the subject to raise
his/her pelvis from the table. The examiner verified the angle of the knee to be at 90 or
positioned the subjects knees to be at 90, then recorded the position of the sticker in relation
to the yardstick. Finally, the examiner instructed the subject to extend their knee; the examiner
recorded the apparent hip drop (or 0 for no notable drop) on the log. The patient was
instructed to return to a neutral position and rest. Two consecutive measurements were taken
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on the ipsilateral side; the patient was then instructed to perform the same maneuvers on the
contralateral side while the examiner recorded the findings. The average of the three bridges
on each side was used for data analysis.

Figure 1: Estimating Hip Drop

Manual Muscle Tests

After estimation of hip drop via the back bridge maneuver, each subject underwent
manual muscle testing via standard Applied Kinesiology procedures. Examiners performing the
manual muscle tests were blinded to the results of the hip drop measurements. Each subject
was tested for rectus abdominis, abdominal obliques, quadratus lumborum, psoas, gluteus
medius, gluteus maximus, hamstring and multifidus, bilaterally. Muscles were graded as
strong/facilitated when they received +5/5 and weak/inhibited when they received +4/5.
Data analysis was performed using Microsoft Excel. Daily average hip drop and overall
was analyzed for each subject. Additionally, kappa values were obtained for each manual
muscle test in relation to significant hip drop values.

Figure 1: Hip Drop Measurement and Manual Muscle Testing

Results
Kappa was calculated to quantitatively measure the agreement between the two sets of
observers: the two examiners who measured the hip drops and the two examiners who
evaluated specific muscles on each participant. Using the following table as a guide, Kappa
values of 0.21 or greater were deemed clinically significant and as indication that the muscle
being tested was consistently inhibited or weak with a positive hip drop during the test. Kappa
values less than .21 were also significant in that they demonstrate less than fair agreement and
suggest that the muscle being tested was not consistently inhibited or strong during the test.

Kappa Agreement
<0
Less than chance agreement
0.010.20
Slight agreement
0.21 0.40
Fair agreement
0.410.60
Moderate agreement
0.610.80
Substantial agreement
0.810.99
Almost perfect agreement

Hip drops of less than 1 inch, greater than or equal to 1 inch and greater than or equal
to 1.5 inches were evaluated for correlation to the muscle tests performed. Only when the hip
drops were greater than or equal to 1.5 inches were any statistically relevant Kappa values
achieved.
Table 1: Kappa: Agreement between muscle tested and Hip Drop >=1.5
Pos=
Drop>=1.5

Hip Drops >= 1.5

Muscle Tested

Right

Rectus Abdom

Right

Abdominal Oblique
Quadratus Lumborum
Psoas

Right

-0.122
0.007

-0.108
-0.176

Left

0.405

0.526

Right

0.089

-0.124

Left

0.254

0.060

Right
Right

0.106
-0.059
-0.140

-0.076
-0.085
0.076

Left

0.114

0.463

Right

0.137
0.156
0.070
0.007

0.041
0.096
-0.147
0.160

Right

0.151

-0.051

Left

0.058

0.113

Left
Glut Medius
Glut Max

Left
Hamstring

Right
Left

Multifidi

Left

With Hip Drops of 1.5 or more, the Left Abdominal Oblique had moderate agreement
with both the left and right hip drop, Kappa 0.40 and 0.52 respectively. The Right left Gluteus
Medius also demonstrated moderate agreement with the contralateral or left hip drop, Kappa
0.46, but not the right. The Left Gluteus Medius did not agree with either right or left hip drop.
The Left Quadratus Lumborum demonstrated a fair agreement with the contralateral or right
hip drop, Kappa 0.25, but not the left and the Right Quadratus Lumborm did not agree with
either.

Discussion
Core stability greatly effects the movements of the pelvis, hips, low back and many
other areas. The hip musculature transfers forces from the lower extremity toward the spine.
Weak or inhibited hip muscles have been associated with pelvis, hip, and thigh pathology
(3,5,6). The aim of the study was to determine whether there was agreement between a
positive hip drop test and specific muscle weakness or inhibition. While the BBLE screening is
commonly accepted to check the stability of the multifidus muscle, the hypothesis of this study
was that failure of the screen or a measurable hip drop is a weakness of synergistic muscles of
the core and pelvis.

The results of the study revealed a fair to moderate kappa agreement of three muscles
being inhibited with a positive hip drop. The muscles involved were the bilateral abdominal
obliques which showed a moderate agreement, contralateral gluteus medius which also
showed a moderate agreement and the contralateral quadratus lumborum showed a fair kappa
agreement. The multifidus had only a slight kappa agreement with Kappas ranging from 0 to
.15. While the hypothesis of our study was that synergistic muscles of the core and pelvis
would be inhibited, the study revealed bilateral abdominal obliques were the most consistently
inhibited muscles with a positive hip drop test.

According to Wadsworth et al, manual muscle testing (MMT) is both reliable and highly
valuable (7). In fact, she and her team demonstrated that, statistically, MMT and Cybex testing
were not significantly different (7) and, Imai et al., demonstrated that both MMT and
dynamometer muscle testing are equally reliable testing methods (3). Therefore, the testers
decided to use MMT in this study. To help increase the inter-examiner reliability, the two
testers practiced the MMT prior to testing the subjects so their techniques were as similar as
possible.
The multifidus had only slight Kappa agreement. The examiners hypothesize that the
MMT used for the multifidus may include other muscles and therefore may not fully isolate the
multifidus, leading to false negatives, which could account for the low Kappa value.

A limitation of the study is that the group tested was relatively young healthy individuals
and does not account for persons of older age. Persons of older age may have different
inhibited muscles correlating to the back bridge test with leg extension. It is also possible that
persons of older age may not be able to balance enough to extend the leg while performing the
back bridge. This would need to be evaluated further.

The hip drop measurement data collected in this study exhibited a high average mean
standard deviation: 0.51 and 0.67, right and left respectively. This suggests that the
measurement technique was not adequately precise. It also suggests that the phenomenon of
hip drop maybe more variable on a daily basis than expected. We were also unable to find any
standards in the literature suggesting what measured drop may be significant for developing
strength and rehabilitative treatment protocols.

Some authors suggest that the hip drop test should be performed on an unstable
surface, in order to obtain the maximal activation of the trunk musculature. For instance, the
subjects feet on a balance trainer during the back bridge exercise to initiate maximal trunk
activation (3). However, due to the lack of a balance trainer availability and possible injury to
subjects in this study, the hip drop test was performed on a stable flat surface.

Conclusion:
The BBLE is often used as a functional screen to assess the strength of the multifidus
muscle. The Kappa values from our study suggest that the multifidus alone may not be the
primary inhibited muscle when this test fails. Instead, the hip drop may be more strongly
associated with the inhibition of the abdominal obliques. Further study is warranted to assess
this finding.

Possible future study designs could include a broader population in age and fitness level
and a more accurate method of measuring hip drop parameters to clearly define a significant
hip drop.

Permissions
Informed Consent was obtained from each participant in writing.

Conflict of Interests
The authors deny any conflict of interest that may have unduly influenced them or may
have compromised the integrity of the data collected.

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References
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Okubo, Ur, Kaneoka, Koji, Imai, Atsushi, et. al., Electromyographic Analysis of
Transversus Abdominis and Lumbar Multifidus Using Wire Electrodes During Lumbar
Stabilization Exercises., Journal of Orthopaedic & Sports Physical Therapy., November
2010., 40(11). 743-750.

2.

Lin HT, Hsu AT, Chang JH, Chien CS, Chang GL; Comparison of EMG Activity
Between Maximal Manual Muscle Testing and Cybex Maximal Isometric Testing of the
Quadriceps Femoris., J Formos Med Assoc. 2008 Feb;107(2):175-80.

3.

Imai, Atsusi, Kaneoka, Koji, Okubo, Yu, et al., Trunk Muscle Activity during Lumbar
Stabilization Exercises on Both a Stable and Unstable Surface, J Orthop Sports Phys
Ther 2010;40(6):369-375.

4.

Sderman, Kerstin; Lindstrm, Britta, The Relevance of Using Isokinetic Measures to

Evaluate Strength, Advances in Physiotherapy 2010, 12 (4), 194 -200.

5.

Colston, Marisa, Core Stability, Part 2: The Core-Extremity Link, International Journal
of Athletic Therapy & Training March 2012, (17)2, 10-15

6.

Colston, Marisa A., Core Stability , Part 1: Overview of the Concept, International
Journal of Athletic Therapy & Training January 2012, (17)1, 8-13

7.

Carolyn T Wadsworth, Ruth Krishnan, Mary Sear, Jean Harrold and David H Nielsen;
Intrarater Reliability of Manual Muscle Testing and Hand-held Dynametric Muscle
Testing, Physical Therapy, September 1987 (67)9, 1342-1347.

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