Electromyographic Activity of Back Musculature During

Williams' Flexion Exercises

STAN E. BLACKBURN, MS,
and LESLIE GROSS PORTNEY, MS

The purpose of this investigation was to determine the pattern and magnitude
of electromyographic activity recorded from paraspinal musculature at four
different vertebral levels while subjects performed six Williams' flexion exercises
with anterior and posterior pelvic tilt. Bipolar surface electrodes were placed on
the right sides, at C5, T6, L3, and S1, of eight men and eight women. Integrated
electromyographic activity was analyzed at the end range of each exercise. A
significant ( p < .05) interaction effect was found between exercises and type of
tilt at each vertebral level. The difference in electromyographic activity between
the two pelvic positions was most evident in the lumbar and sacral areas, where
electromyographic activity recorded for anterior tilt was greater than for poste­
rior tilt. The results support the following conclusions: 1) pelvic tilt, curl up,
knees to chest, and hamstring stretch performed with posterior tilt minimize the
electromyographic activity in the lumbar and sacral regions that occurs in
conjunction with lengthening of these muscles during posterior pelvic tilt, 2) use
of the standing exercises and anterior tilt positions should be avoided if mini­
mizing electromyographic activity in the lumbar and sacral regions is desired,
and 3) the electromyographic activity of each of the four different vertebral
levels responds independently of every other level during performance of Wil­
liams' flexion exercises.

Key Words: Muscle tonus, Back, Electromyography, Exercise therapy, Physical

therapy.

Williams' flexion exercises are quite popular today
for treating a wide variety of back problems, regard­
less of diagnosis or chief complaint. In many cases
they are used when the disorder's cause or character­
istics are not fully understood by the physician or
physical therapist. Also, physical therapists often
teach these exercises with their own modifications.
Dr. Paul Williams emphasized that the posterior pel­
vic-tilt position was essential to obtain optimum re­
sults. He stressed that any change in the exercise
program should be made only after careful consider­
ation of muscular action, because an exercise that
Mr. Blackburn was a student in the master's degree program in
the Department of Physical Therapy, Sargent College of Allied
Health Professions, Boston University, Boston, MA, when this study
was done. He is now Staff Therapist, Department of Physical Ther-
apy, Massachusetts Rehabilitation Hospital, 125 Nashua St, Boston,
MA 02114 (USA).
Mrs. Portney is Assistant Professor, Department of Physical Ther-
apy, Sargent College of Allied Health Professions, Boston University,
1 University Rd, Boston, MA 02215.
This study was completed in partial fulfillment of the requirements
for Mr. Blackburn's degree of Master of Science in Physical Therapy,
Sargent College of Allied Health Professions.
This article was submitted February 28, 1980, and accepted August
20, 1980.
violates the mechanics of posterior pelvic tilt may be
sufficient to prolong clinical symptoms.1
Williams first developed his exercise program in
1937 for patients with chronic low back pain in
response to his clinical observation that the majority
of patients who experienced low back pain had de­
generative skeletal alterations secondary to interver­
tebral disk lesions.2 These exercises were developed
for men under 50 and women under 40 years of age
who had exaggerated lordosis of the lumbosacral part
of the spine, whose roentgenogram results revealed
narrowing of the posterior margins of the lumbar and
lumbosacral intervertebral disks, and whose symp­
toms were low grade and chronic. The purposes of
these exercises were to reduce pain and provide lower
trunk stability by actively developing the flexor mus­
cles and passively stretching the extensor muscles of
the lumbosacral part of the spine.1,2 No investigation
has studied these two functions or documented what
effect changes in the pelvic position might have on
the functions of these exercises.
Pauly has examined EMG activity during activities
somewhat similar to the Williams' flexion exercises.3
During a toe-touch exercise performed standing, min-

878 PHYSICAL THERAPY

imal activity was recorded during trunk flexion and
maximal activity during trunk extension from all
paraspinal musculature at all vertebral levels. A uni­
lateral knee lift performed standing resulted in an
immediate recruitment of lumbar musculature, which
diminished toward the end range of the exercise. He
observed an increase in EMG activity of all para­
spinal musculature as subjects squatted from a stand­
ing position and a decrease as subjects returned to the
standing position.
Few studies have dealt with the pelvis' effect on
paraspinal muscle activity. Andersson and associates
found an increase in EMG activity of paraspinal
musculature when examining unsupported sitting as
the anterior pelvic tilt and lumbar lordosis increased.4
Floyd and Silver observed greater lumbar erector
spinae activity in the erect position during the anterior
pelvic tilt than during posterior tilt.5 Klausen hypoth­
esized that increased lumbar erector spinae EMG
activity during anterior tilt played an important role
in performing heavy work safely and efficiently.6
The purpose of this investigation was to determine
the pattern and magnitude of EMG activity recorded
from paraspinal musculature at four different verte­
bral levels while performing six Williams' flexion
exercises with anterior and posterior pelvic tilt. An
understanding of the response of low back muscula­
ture during these exercises as affected by pelvic tilt
will provide clinicians with a basis for their rationale
and evaluation of their clinical benefits. Exercises
using anterior tilt were hypothesized to elicit greater
EMG activity in paraspinal musculature at all four
vertebral levels than exercises performed with poste­
rior tilt.
METHOD
Sixteen subjects, eight men and eight women, vol­
unteered for the study. Criteria for selection included
no history of back injury and familiarity with flexion
exercises of the trunk. All subjects were graduate
students in the Department of Physical Therapy at
Boston University Sargent College of Allied Health
Professions. Ages ranged from 23 to 28, with a mean
age of 24.9 years.
The skin to the right of the spinous processes at
vertebral levels C5, T6, L3, and S1 was washed,
shaved, cleaned with alcohol, and abraded lightly.
Electrode paste* was massaged into the skin. Beck-
man bipolar miniature silver-silver chloride surface
electrodes* were applied longitudinally over these
sites with their centers 1 cm apart on either side of a
point 3 cm lateral to each spinous process (Fig. 1).
Skin resistance was acceptable at less than 20kΩ. A
ground electrode was clipped to the subject's right ear
lobe.
The EMG was recorded on a Grass Model 7D
Polygraph.† Four 7P3 amplifiers† amplified the raw
signal and four 7P10 integrators processed the inte­
grated signal as a cumulative ramp function plotted
against time with an automatic reset at a voltage
equivalent to an accumulated average of 40 EMG
units. The frequency response was half-amplitude at
3 Hz and 20 kHz for the integrators. Chart speed was
10 mm/sec.
To provide a basis for comparison of muscle activ­
ity and to validate the electrode placement, a control
* Beckman Instruments, Inc, 3900 River Rd, Schiller Park, IL
60176.
† Grass Instruments Co, 101 Old Colony Ave, Quincy, MA 02169.

Fig. 1. Electrode place-

ment 3 cm to the right of
spinous processes C5, T6,
L3, and S1

►
Fig. 2. Control contrac-
tion: Active trunk exten-
sion. Resistance was pro-
vided in this position.

Volume 61 / Number 6, June 1981 879

Fig. 3. Williams' flexion exercises performed with anterior and posterior pelvic tilt. A) Exercise 1: Pelvic tilt. B)
Exercise 2: Curl up. C) Exercise 3: Knees to chest. D) Exercise 4: Hamstring stretch. E) Exercise 5: Thigh Stretch. F,
Exercise 6: Squat.
contraction was recorded with each subject. The con-
trol contraction, adapted from Pauly, was one he
described as producing maximal EMG activity in the
paraspinal muscles and as representing 100 percent
muscle activity at each vertebral level.3 The subject
was positioned prone on a plinth with arms extended
at his sides, hips maintained in a neutral position, and
knees extended by hanging the feet over the end of
the plinth. The ankles and hips were stabilized by
straps. The subject actively extended his trunk with
his head facing forward until his full range of trunk
extension was reached (Fig. 2). A control contraction
was performed for three seconds by applying maximal
manual resistance to the back of the head and upper
thoracic trunk in the midline.
Following the performance of the control exercise,
each subject was taught to perform an anterior and a
posterior pelvic tilt as described by Cailliet.7 To per-
form an anterior pelvic tilt, the subject was taught to
move the anterior superior iliac spines (ASIS) anterior
to the symphysis pubis in the sagittal plane. To per-
form a posterior pelvic tilt, the subject was taught to
move the ASIS posterior to the symphysis pubis in
880
the sagittal plane. The subject was then instructed to
palpate his symphysis pubis and ASIS to allow him
to visualize and palpate the pelvis' movement. He
then practiced the motion several times until both he
and the experimenter felt confident he could perform
each tilt effectively during the exercises.
Each subject performed six Williams' flexion ex-
ercises2 in random order, and he repeated six trials of
each exercise, three using anterior tilt followed by
three using posterior tilt. Each subject was introduced
to each exercise just prior to testing for that exercise.
The experimenter first demonstrated the exercise,
after which the subject practiced once before any data
were recorded. The subject was instructed to perform
the appropriate tilt, begin the exercise, hold at the
end range for three seconds, and return slowly to the
starting position.
The six exercises were
1. Pelvic tilt. The subject was positioned supine with
knees flexed, feet flat on the surface, and heels close
to the buttocks. The hands rested just above the
umbilicus as anterior and posterior tilt were per-
formed (Fig. 3A).
PHYSICAL THERAPY
2. Curl up. The subject was positioned as in Exercise right knee remained fully extended. This exercise
1 with the arms folded across the chest and feet differed from the exact position that Williams found
stabilized by straps. The subject raised his trunk off most effective for stretching hip flexor muscles with
the mat slowly by tucking the chin into the chest until lumbosacral flexion, a position similar to a sprinter's
both scapulae just cleared the surface (Fig. 3B). starting position. However, Williams indicated that
this exercise could be performed in different posi-
3. Knees to chest. The subject was positioned as in
tions.2 The upright position was chosen to observe
Exercise 1 with hands clasped around both knees.
better the effects of the pelvic tilt on paraspinal
The grip on the knees was maintained as both knees
activity.
were brought toward the chest. The head remained
flat on the surface to avoid any rocking motion (Fig. 6. Squat. The subject stood with both feet parallel,
3C). about shoulder's width apart. Attempting to maintain
the trunk as perpendicular as possible to the floor,
4. Hamstring stretch. The subject was positioned in eyes focused ahead, and feet flat on the floor, the
long sitting with toes directed toward the ceiling and subject slowly lowered his body by flexing his knees
knees fully extended. The subject slowly lowered the (Fig. 3F).
trunk forward over the legs, keeping knees extended, For those exercises performed supine, two plinths
arms outstretched over the legs, and eyes focused were placed side by side, separated by 4 in (10.2 cm)
ahead (Fig. 3D). so as not to displace the electrodes. The subject was
5. Thigh stretch. The subject stood with the left foot positioned so that electrodes were located in the space
about 2 ft (61 cm) in front of the right. The exact between the plinths. For those exercises performed
distance varied according to each subject's comfort. standing, the subject was allowed to grasp the plinth
While attempting to maintain the trunk as perpendic- for balance but not for bearing weight. During re-
ular as possible to the floor, the subject slowly brought cording, the experimenter carefully observed the po-
the trunk anteriorly over the left leg by flexing the sition of the pelvis to correct any deviation from the
left knee and plantar flexing the right ankle (Fig. 3E). appropriate tilt and to determine the end range of the
The left foot remained flat on the ground and the exercise.
TABLE
2 X 6 ANOVA Comparing the Effect of Exercise and Pelvic Tilt on EMG Activity at Four Vertebral Levels
Vertebral Level Source df MS F
Cervical Subjects 15 .710
Exercise 5 .018 1.38
Error 75 .013
Tilt 1 .551 23.21 a
Error 15 .024
Exercise X Tilt 5 .033 2.72b
Error 75 .012
Thoracic Subjects 15 .111
Exercise 5 .297 6.22 a
Error 75 .046
Tilt 1 .039 0.57
Error 15 .069
Exercise X Tilt 5 .135 2.5 b
Error 75 .054
Lumbar Subjects 15 .440 21.58 a
Exercise 5 .239 21.58 a
Error 75 .011
Tilt 1 .208 19.36 a
Error 15 .017
Exercise X Tilt 5 .095 13.60 a
Error 75 .007
Sacral Subjects 15 .445
Exercise 5 .148 18.64 a
Error 75 .008
Tilt 1 .064 7.39 b
Error 15 .009
Exercise X Tilt 5 .028 4.18 b
Error 75 .007
a
p<.01.
b
p < .05.

Volume 61 / Number 6, June 1981 881

 Each exercise, including the control contraction,
was held at the end range for three seconds. This end
range was indicated on the EMG record by a man­
ually operated event marker. The slope of the inte­
grated signal was obtained for the three-second hold
at the end range. This value represented the rate of
accumulation of electrical activity for that period of
time. The values for each vertebral level were then
converted to percentages of the control contraction.
Statistical analysis was performed in two parts.
Initially, a multivariate analysis of variance and co-
variance (MANOVA) examined the interaction of
vertebral level with repeated measures of exercise,
pelvic tilt, and trials. Based on the results of this
analysis, the mean of the three trials for each exercise
was taken. Each vertebral level's response was then
analyzed by a separate 2 x 6 analysis of variance
(ANOVA), using tilt and exercise as repeated mea­
sures and the mean of the three trials. A Scheffé
comparison was then implemented to locate the
source of all significant differences at the .05 level.
RESULTS
The MANOVA showed significant (p < .05) main
effects of exercise (F= 119, df = 1,15), type of pelvic
tilt (F = 4.27, df =5,75), and vertebral level (F =
31.68, df = 5,45) with a significant (p <.05) interac­
tion effect between these three variables (F = 4.66, df
= 15,225). A significant difference was not found
between trials, thereby confirming measurement re­
liability (F = 1.19, df = 2,30). Because the MANOVA
showed that each vertebral level responded indepen­
dently of the other levels and because there was no
significant difference between trials, each vertebral
level was then analyzed by a separate ANOVA using
the mean of the three trials followed by a Scheffé
comparison as described above. The ANOVA dem­
onstrated a significant interaction effect between tilt
and exercise at all vertebral levels (Table).
The relative pattern of activity exhibited during the
exercises was similar between cervical and thoracic
levels and between lumbar and sacral levels. In most
cases, the EMG activity was greater during an exercise
performed with anterior tilt than with posterior tilt
(Fig. 4).
The patterns of activity recorded at the cervical
and thoracic levels between anterior and posterior
pelvic tilt were not consistent (Fig. 4). At the cervical
level, Exercise 4 (hamstring stretch) with posterior tilt
produced significantly greater EMG activity than did
Exercise 1 (pelvic tilt) with posterior tilt and anterior
tilt. At the thoracic level, only Exercise 3 (knees to
chest) with anterior tilt produced significantly greater
EMG activity than did Exercise 2 (curl up) and
Exercise 4 (hamstring stretch), both with posterior
tilt.
882
At the lumbar level, posterior tilt produced signifi­
cantly less EMG activity than did anterior tilt during
Exercise 1 (pelvic tilt), Exercise 3 (knees to chest),
and Exercise 6 (squat). No significant differences
were found between exercises performed with poste­
rior tilt. When the anterior tilt was performed, Exer­
cise 1 (pelvic tilt), Exercise 3 (knees to chest), and
Exercise 6 (squat) had significantly greater EMG
activity than Exercise 2 (curl up), Exercise 4 (ham­
string stretch), or Exercise 5 (thigh stretch). Exercise
5 (thigh stretch) had significantly greater EMG activ­
ity than either Exercise 4 (hamstring stretch) or Ex­
ercise 6 (squat).
At the sacral level, only Exercise 1 (pelvic tilt)
showed a significant difference between anterior and
posterior tilt. All exercises performed with a posterior
tilt resulted in low amounts of EMG activity. Only
Exercise 5 (thigh stretch) demanded slightly higher
EMG activity, but it was only significantly greater
than Exercise 1 (pelvic tilt). When the anterior tilt
was performed, Exercise 5 (thigh stretch) required
significantly higher EMG activity than did Exercise
2 (curl up) and Exercise 4 (hamstring stretch), and
Exercise 6 (squat) was significantly greater in EMG
activity than was Exercise 4 (hamstring stretch).
DISCUSSION
The data showed a general trend that the anterior
pelvic tilt produced greater EMG activity than pos­
terior tilt at all vertebral levels. This trend agrees with
the findings of Asmussen and Klausen8 and Floyd
and Silver.5 The effect of varying the pelvis' position
was most evident at the lumbar and sacral levels.
Exercise 1 (pelvic tilt) alone showed a large difference
between posterior and anterior tilt at both the lumbar
and sacral areas. This observation would be expected
because the trunk and head were supported by the
plinth and so the low back extensor muscles were
primarily responsible for producing the anterior tilt­
ing motion.5 The activity at the cervical and thoracic
levels during either tilt was, consequently, minimal,
and many subjects exhibited no activity at these
higher levels during this exercise.
Exercise 2 (curl up) and Exercise 4 (hamstring
stretch) with anterior tilt produced minimal activity
at both lumbar and sacral levels. These exercises
required trunk flexion at the end range, making main­
tenance of the anterior tilt position difficult. Thus,
the end range positions during both anterior and
posterior tilt were probably very similar, explaining
why similar measurements for both tilts were ob­
served during these exercises. In addition, many sub­
jects stated that these two exercises were the most
difficult to perform. This difficulty may have impeded
their ability to maintain either anterior or posterior
pelvic tilt. Had the pelvic excursion been measured at
PHYSICAL THERAPY
Fig. 4. Mean EMG activity (percentage of control) during six Williams' flexion exercises while performing anterior and
posterior pelvic tilt.

Volume 61 / Number 6, June 1981 883

the end range, this problem would have been recog­
nized. Differences in EMG activity between the two
tilts may have also been apparent at the beginning
and the end of the exercise, but these were not mea­
sured.
Exercise 1 (pelvic tilt), Exercise 3 (knees to chest),
Exercise 5 (thigh stretch), and Exercise 6 (squat)
performed with an anterior tilt were found to be the
most demanding exercises in terms of EMG activity
in the lumbar and sacral areas. The high EMG activ­
ity observed during Exercise 5 (thigh stretch) and
Exercise 6 (squat) with an anterior tilt might be the
result of a combination of the standing position and
active maintenance of the anterior tilt position. In
addition, these were the only two exercises performed
standing. Many investigators have documented bursts
of EMG activity in paraspinal musculature during
standing, attributing the activity to forward and lat­
eral displacement of the center of gravity.5, 8-13 As-
mussen and Klausen concluded that, of the 75 percent
of the cases studied, the erector spinae muscles were
primarily responsible for maintaining erect posture.8
The high activity observed in Exercise 1 (pelvic tilt)
and Exercise 3 (knees to chest) during anterior tilt
was probably caused by the observed greater excur­
sion of the pelvis during these exercises than during
all other exercises. The stabilization of the head, neck,
and upper trunk during the performance of these
exercises and the ease with which subjects reportedly
performed them may have facilitated isolated motion
of the pelvis during anterior tilt and produced a more
forceful contraction of the low back extensor muscles.
The idea that isolated pelvic motion was facilitated
during these two exercises is also supported by the
fact that the lowest percentage of EMG activity re­
corded during posterior pelvic tilt was at the lumbar
and sacral levels. As previously discussed, Exercise 2
(curl up) and Exercise 4 (hamstring stretch) were
found to be the most difficult for the subjects to
perform; Exercise 5 (thigh stretch) and Exercise 6
(squat) were performed standing, making isolated
performance of the pelvic tilts difficult. This argument
would have had statistical support had the excursion
of the pelvis been measured.
Our findings support the concept that, to minimize
EMG activity in the low back musculature, the Wil­
liams' flexion exercises should be done with a poste­
rior pelvic tilt and in a supine position with the upper
trunk stabilized. Our data suggest that the anterior
pelvic tilt and standing position should be avoided
when minimizing EMG activity in the lumbar and
sacral regions is desired. Although this evidence is
not unexpected, it is important to remember that
these exercises should probably be avoided if the
patient has difficulty maintaining the appropriate
pelvic position.
The EMG activity recorded from the cervical and
thoracic areas was not as predictable as was the EMG
884
activity recorded from the lumbar and sacral areas.
This finding suggests that the alternate positions (an­
terior tilt and posterior tilt) of the pelvis had less
effect on the cervical and thoracic areas than on the
lumbar and sacral regions. Clinicians often explain to
their patients that the posterior pelvic tilt position will
produce a stretching effect in all four vertebral regions
from the pelvis to the neck. Our results do not support
this generalization.
One explanation for the variability of the EMG
response in the cervical region has been put forth by
Pauly.3 He attributes this variability to the changing
center of gravity of the head relative to the trunk. The
different exercises, pelvic positions, and starting po­
sitions certainly would place different demands on
the head, neck, and upper trunk to maintain the
upright position of the head and neck. Another con­
tributing factor is the relatively large number of small
muscles that cross the cervical region at different
depths. The EMG activity monitored at this level
must be considered to be a summation of all these
muscles. Exercise 2 (curl up) and Exercise 4 (ham­
string stretch) with both tilts produced large amounts
of EMG activity in the cervical area. This finding
might be explained by the difficulty of the exercises'
resulting in a strain of the upper trunk and neck
musculature to maintain the isometric trunk and neck
flexion at the end range. This strain may have been
the result of neck musculature cocontraction as evi­
denced by the increased cervical neck extensor muscle
EMG activity.
In the thoracic region, the electrodes recorded para­
spinal activity just lateral to T6. Electromyographic
activity was probably also recorded from the rhom­
boid muscles and the middle and lower portions of
the trapezius muscle. In all exercises except Exercise
1 (pelvic tilt), some upper extremity movement or
support was required. Based on dissection and meth­
odology of previous research,6, 9, 11 the electrodes had
been located appropriately to record paraspinal activ­
ity in the thoracic area. However, the contribution of
the scapular musculature to the EMG output must be
considered substantial. Although surface electrodes
have been used to record paraspinal activity,8, 10, 13, 14
several experimenters have used indwelling electrodes
to record from deeper paraspinal musculature3, 9, 11, 15
and others have used both.4, 5, 12, 16 Interpretation of
the present findings suggests that the specificity of
indwelling electrodes would be more appropriate in
determining electrical output from a specific muscle
at each vertebral level.
Patients with low back pain have been observed to
respond differently than normal subjects to trunk
flexion, in that their erector spinae muscles do not
relax as the trunk moves into full flexion, suggesting
that splinting may occur in an effort to prevent further
injury or pain.17 The occurrence of splinting strongly
suggests the need to repeat this study of Williams'
PHYSICAL THERAPY
flexion exercises with subjects who complain of low
back pain and whose problems would be appropri-
ately treated with this exercise program. Because these
exercises were developed for specific purposes, further
study might compare their effects on patients with
various back problems and on other muscle groups
involved in performing Williams' flexion exercises,
including the abdominal, hipflexor,and hip extensor
muscles. Also, because many clinicians are teaching
back extension and rotation exercises for many pa-
tients with low back pain, further study is needed to
determine the efficacy of these exercises. This study
did not show that the EMG recorded during posterior
pelvic tilt was less than at rest or with the pelvis
maintained in a neutral position. Further study could
examine these variables and would require an instru-
ment capable of measuring the excursion of the pelvis.
CONCLUSIONS
We have presented evidence that supports the fol- in preparing the photographs, and Barbara Myers,
lowing conclusions: 1) Exercise 1 (pelvic tilt), Exercise PhD, for her assistance with the statistical analyses.
2 (curl up), Exercise 3 (knees to chest), and Exercise
4 (hamstring stretch), performed with posterior tilt,
minimize the EMG activity in the lumbar and sacral
regions that occurs in conjunction with lengthening
of these muscles during posterior pelvic tilt, 2) use of
the standing and anterior tilt positions should be
avoided if minimizing EMG activity in the lumbar
and sacral regions is desired, and 3) all four vertebral
levels of paraspinal muscles perform independently
of each other during Williams'flexionexercises. This
study supports the use of Williams' flexion exercises
to minimize paraspinal activity by adhering to the
mechanics of posterior pelvic tilt.
Acknowledgments. The authors would like to thank
the staff of the Instructional Resource Center at Sar-
gent College of Allied Health Professions, Boston
University, for their expertise in organizing and pre-
paring the figures, Larry Greenberg for his assistance

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