ARTICLE IN PRESS

Journal of Biomechanics 38 (2005) 18731880

www.elsevier.com/locate/jbiomech
www.JBiomech.com

Intra-abdominal pressure increases stiffness of the lumbar spine

Paul W Hodgesa,b,c,, A.E. Martin Erikssond, Debra Shirleye, Simon C Gandeviab,c
a
Department of Physiotherapy, The University of Queensland, Brisbane, Qld. 4072, Australia
b
Prince of Wales Medical Research Institute, Sydney, Australia
c
University of New South Wales, Sydney, Australia
d
Department of Community Medicine and Rehabilitation, Physiotherapy, University of Umea, Umea, Sweden
e
Department of Physiotherapy, University of Sydney, Sydney, Australia
Accepted 10 August 2004

Abstract

Intra-abdominal pressure (IAP) increases during many tasks and has been argued to increase stability and stiffness of the spine.
Although several studies have shown a relationship between the IAP increase and spinal stability, it has been impossible to
determine whether this augmentation of mechanical support for the spine is due to the increase in IAP or the abdominal muscle
activity which contributes to it. The present study determined whether spinal stiffness increased when IAP increased without
concurrent activity of the abdominal and back extensor muscles. A sustained increase in IAP was evoked by tetanic stimulation of
the phrenic nerves either unilaterally or bilaterally at 20 Hz (for 5 s) via percutaneous electrodes in three subjects. Spinal stiffness was
measured as the force required to displace an indentor over the L4 or L2 spinous process with the subjects lying prone. Stiffness was
measured as the slope of the regression line tted to the linear region of the forcedisplacement curve. Tetanic stimulation of the
diaphragm increased IAP by 2761% of a maximal voluntary pressure increase and increased the stiffness of the spine by 831% of
resting levels. The increase in spinal stiffness was positively correlated with the size of the IAP increase. IAP increased stiffness at L2
and L4 level. The results of this study provide evidence that the stiffness of the lumbar spine is increased when IAP is elevated.
r 2004 Elsevier Ltd. All rights reserved.

Keywords: Intra-abdominal pressure; Spinal stiffness; Diaphragm; Trunk control

1. Introduction forces imposed on the spine in a variety of static and

Intra-abdominal pressure (IAP) is increased during
many tasks that load the spine, such as lifting (Hemborg
et al., 1985) walking, (Grillner et al., 1978), jumping
(Cresswell et al., 1993) and limb movement (Hodges et
al., 1997). It has been argued that this pressure in the
abdominal cavity contributes to the stiffness and
stability of the spine (Bartelink, 1957; Grillner et al.,
1978). In support, several studies have identied a
relationship between the magnitudes of IAP and the
Corresponding author. Department of Physiotherapy, The Uni-
versity of Queensland, Brisbane, Qld. 4072, Australia. Tel.: +61-7-
3365-2008; fax: +61-7-3365-2775
E-mail address: p.hodges@uq.edu.au (P. W Hodges).
dynamic tasks (Cresswell and Thorstensson, 1994;
Grillner et al., 1978; Marras et al., 1985). However,
others have argued that the pressures generated during
functional tasks are insufcient to provide a signicant
increase in spinal stability (McGill and Norman, 1987).
Yet, in a recent study, trunk stabilitymeasured as an
increase in instantaneous trunk stiffness in response to a
sudden load releasewas shown to increase when IAP
was voluntarily elevated by contraction of the abdom-
inal muscles (Cholewicki et al., 1999b). Although these
data are consistent with the proposed mechanical role of
IAP, it is impossible to determine whether it is the IAP
or the abdominal muscle activity associated with its
production that increases the stiffness and stability of
the spine.

0021-9290/$ - see front matter r 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbiomech.2004.08.016
 ARTICLE IN PRESS
1874 P. W Hodges et al. / Journal of Biomechanics 38 (2005) 18731880
Several mechanisms have been proposed for IAP to
augment spinal stability. First, IAP has been argued to
inuence spinal stability via the production of an
extensor moment by exerting a force down on the pelvic
oor and up on the diaphragm (Bartelink, 1957; Keith,
1923; Morris et al., 1961). Although this moment does
not necessarily increase stiffness, antagonist exor and
extensor moments increase trunk stability (Cholewicki
et al., 1999a). Thus, the opposing extension moment
from IAP and exion moment from abdominal muscle
contraction may increase spinal stability and stiffness.
It has been conrmed recently that increased IAPin
the absence of abdominal or erector spinae (ES)
activityproduces a trunk extension moment (Hodges
et al., 2001). In that study, IAP was increased
by stimulation of the phrenic nerve to evoke contraction
of the diaphragm. A second possibility is that increased
stiffness of the abdominal cavity may limit intervertebral
translation and rotation (McGill and Norman, 1987).
Finally, IAP may prevent shortening of the abdom-
inal muscles, thus maintain the hoop-like geometry
of these muscles around the abdominal cavity and
their ability to generate tension (McGill and Norman,
1993). It has not been established whether IAP
alone can increase the stability or stiffness of the
spine.
The aims of the present study were: (1) to identify
whether increased IAP (without concurrent abdominal
or back muscle activity) increases the posteroanterior
stiffness of the spine, and (2) to determine whether any
affect of IAP on spinal stiffness is consistent between
different levels of the lumbar spine.
2. Methods
2.1. Experimental design
We produced an involuntary increase in IAP via a
contraction of the diaphragm evoked by percutaneous
stimulation of one or both phrenic nerves in the neck.
Stiffness of the spine was measured from the forcedis-
placement response to application of a force to a
spinous process of the lumbar spine with the subject
lying prone.
2.2. Subjects
Three healthy volunteer subjects participated in the
experiment. The age, height and weight of the subjects
were 3044 years, 172187 cm, and 5887 kg, respec-
tively. All procedures were approved by the Institutional
Ethics Committee and subjects provided informed
written consent.
2.3. Measurement of spinal stiffness
Lumbar posteroanterior stiffness at L2 and L4 was
measured using a technique similar to that described
previously (Lee and Svensson, 1990). Force was applied
to the spinous process of L4 and L2 (in separate trials)
via a small padded probe using a motor that was servo-
controlled for displacement. The applied force and
linear displacement were analysed over repeated cycles
of displacement (69) at 1 Hz. Stiffness was taken as the
slope of the regression line tted to the forcedisplace-
ment curve between 50 to 110 N for cycles 24. The rst
cycle was rejected from analysis as previous studies have
indicated non-linear changes in stiffness between the
rst and subsequent cycles (Shirley et al., 2002). This
range of force was selected because the forcedisplace-
ment curve is usually linear in this range. Measurement
of posteroanterior stiffness in this manner has good
testretest reliability and is accurate within 1% for
measurement of stiffness of an elastic beam (Lee and
Svensson, 1990).
2.4. Pressure recordings
Gastric (Pga) and oesophageal (Poe) pressures were
measured with a pair of thin-lm strain gauge pressure
transducers (Gaeltec, UK) inserted into the stomach and
oesophagus via the nose. Correct placement of the
transducers was conrmed using a series of manoeuvres
(including a sniff) which produces an opposite change
in Pga and Poe. Pressure data were amplied and
sampled at 100 Hz.
2.5. Electromyography
Chest wall EMG activity was recorded with a pair of
Ag/AgCl electrodes placed in the mid-clavicular line in
the seventh and eighth intercostal space. These electro-
des do not provide selective recordings of diaphragm
EMG, but represent evoked activity of the diaphragm in
addition to any ongoing activity of the diaphragm and
other muscles. EMG of the abdominal and ES muscles
was recorded with surface electrodes placed over the
lateral abdominal wall half-way between the rib cage
and iliac crest and 4 cm lateral to the L2 and L4 spinous
processes, respectively. EMG data were bandpass
ltered between 20 and 1 kHz and sampled at 2 kHz
using Spike2 software and a Power1401 (CED, UK).
2.6. Procedure
Subjects lay prone with the pelvis and thorax
supported on two
5 cm blocks placed above the
xiphoid process and below the anterior superior iliac
spines to leave the abdomen unsupported (Fig. 1). Wide
belts were applied rmly to the abdomen and lower rib
 ARTICLE IN PRESS
P. W Hodges et al. / Journal of Biomechanics 38 (2005) 18731880
Sero-controlled
motor Stimulating electrode
Indentor L2 ES EMG Pressure transducer
L4 ES EMG
Support Belts Support
Abdominal Chest wall
EMG EMG
Fig. 1. Experimental set-up showing subject position and measure-
ment equipment. Belts around the abdomen and rib cage maximised
the pressure increase from phrenic stimulation. Supports under the
pelvis and rib cage prevented contact between the abdomen and
support.
cage to restrict displacement of the abdominal contents
and thus maximise the increase in IAP produced by
evoked contraction of the diaphragm. The diaphragm
was electrically stimulated either bilaterally or unilat-
erally using wire electrodes inserted adjacent to the
phrenic nerves at the level of the cricoid cartilage and
posterior to the sternocleidomastoid muscles (Gandevia
and McKenzie, 1986; Sarnoff et al., 1951). Prior to
insertion, the sites for electrode insertion (i.e. minimal
concurrent activation of surrounding neck muscles and
the brachial plexus) were identied using a small-probe
electrode. Two to three insertions were required to
achieve optimal placement of the wire electrodes.
Surface electrodes were placed just below the clavicle
to act as anodes. Electrical stimuli were delivered from a
constant voltage source with a rectangular pulse (1 ms)
at a frequency of 20 Hz for 810 s. Stimulation of the
diaphragm was conrmed by the latency of the
compound muscle action potential from the stimulus
onset. Stimulation intensity was set to achieve the
maximal increase in IAP within the tolerance of the
subject. Long trains of stimuli were required to ensure
that the IAP increase was maintained tonically without
the movement of the spine, which would interfere with
the measurement of the spinal stiffness.
Measurements of spinal stiffness were made with the
probe of the stiffness device placed over the spinous
process of L4 and L2, in different trials. When the probe
(1.5  2 cm) was placed over L4, the device was angled
4.51 caudally and 11.51 rostrally for application of force
at L2. Control measurements of stiffness were made rst
with 69 cycles of force application with the breath held
at the end of a normal expiration. For stimulation trials,
phrenic stimulation was initiated at the same time as the
onset of force application and sustained for the 69
cycles. Trials were conducted with the stimulation
intensity at the maximum tolerable level and several
increments below this intensity. In some trials, stimuli
were applied to the phrenic nerve unilaterally due to
1875
suboptimal placement of the wire on one side. Subjects
were encouraged to remain relaxed throughout the
procedure and received verbal feedback of the EMG
activity of the abdominal and ES muscles. Additional
Head control and stimulation trials were conducted without
support
the belt around the abdomen. An identical procedure
was used at the L2 and L4 levels. At the completion of
the trial, subjects maximally contracted the abdominal
Anode muscles in a Valsalva manoeuvre against a closed glottis
to generate maximal IAP. Data from this trial were used
for normalization of the EMG and IAP values.
2.7. Data analysis
Stiffness was calculated for the second to fourth cycle
of force application. Root-mean-square (RMS) EMG
amplitude was measured at rest and during the
application of force to the spinous processes. In the
trials with phrenic nerve stimulation cross-talk from
the diaphragm was recorded in both the abdominal and
ES EMG electrodes. However, the amplitude of EMG
for each muscle could be measured for the period
between the end of the evoked diaphragm compound
muscle action potential and the subsequent stimulus
(
20 ms). EMG data were recorded in this manner for
ve randomly selected stimulation trials and were
averaged. EMG data are presented as an increase in
EMG above baseline. Pearsons correlation coefcient
was calculated to determine the strength of relationship
between the increase in IAP and spinal stiffness.
3. Results
When the diaphragm was electrically stimulated via
one or both phrenic nerves, IAP increased by
1.85.9 kPa, which resulted in pressures equivalent to
2761% of the pressure increase during a maximum
voluntary pressurisation of the abdominal cavity with
the glottis closed (Fig. 2). The maximum IAP achieved
for each subject is presented in Table 1. When IAP was
increased in this manner, the stiffness of the spine
assessed by posteroanterior pressure applied to the L4
spinous processes, increased by 831%. That is, a larger
force was required to displace the spinous process of L4,
an identical distance as in the control trial (Fig. 3).
Stiffness increased in all trials for all subjects. Fig. 4
shows the relationship between the pressure increase and
the resultant increase in spinal stiffness at L4 for each
subject. The changes in pressure and stiffness were
signicantly correlated for individual subjects
(R2 0:4320:91; all Po0:05; Fig. 4).
The EMG activity of the ES at L2 and L4 occurred
with each loading cycle during control and stimulation
trials. There was no activity of the abdominal muscles.
During the stimulation trials the ES EMG increase was
 ARTICLE IN PRESS
1876 P. W Hodges et al. / Journal of Biomechanics 38 (2005) 18731880

Stimulus Stimulus

200 mV
(R) Chest
wall EMG (R) Chest
wall EMG

500 mV
(L) Chest
wall EMG

Pga

Pga

0.5 kPa
Pdi

5 kPa
Poe

(B) 50 ms
19.34 100
Pdi Nmm-1
80

N
60
40

140 N
0 2 4
Force 140
mm

N
Force 0
Disp 8 mm 8

mm
Disp 0
(A) 1s (C)

Fig. 2. (A) Representative raw data showing sustained increase in gastric (Pga), oesophageal (Poe) and transdiaphragmatic (Pdi) pressures as a result
of tetanic stimulation of the diaphragm at 20 Hz. The lower two traces show the force and displacement data for two cycles. The section identied
with dotted lines is expanded in panel B. (B) Compound muscle action potentials recorded with the chest wall EMG electrode on the right and
corresponding changes in Pga and Pdi. (C) Method for measurement of posteroanterior stiffness of the spine. Stiffness was measured as the slope of
the regression line tted to the linear region of the force-displacement curve.

Table 1 amplitude recorded with the belts in situ and with the
Maximum absolute gastric pressure (Pga) and ES EMG amplitude same stimulation intensity), and stiffness was increased
during the stimulation trials as a proportion of the amplitude during by 1329%. Thus, the presence of the belts cannot
the control trial for L2 and L4
explain the size of the increase in stiffness recorded
Subjects Maximum Pga ES at L2 ES at L4 during the evoked diaphragm contraction.
(kPa) (proportion (proportion When the procedure was repeated with stiffness
control) control) measured at L2 the results were similar to those at L4.
S1 8.4 0.85 0.66 When IAP was increased by phrenic nerve stimulation
S2 5.1 0.94 0.85 the force required to displace the device applied to the
S3 7.8 1.17 1.05 spinous process of L2 increased. The relationship
between the increase in IAP and stiffness were correlated
for the individual subjects (r=0.590.97; Fig. 4). When
the stiffness was normalised to that recorded for the
less than or slightly more than the increase in EMG control trial the slope of the regression line was steeper
recorded during the control trials (Table 1). In one for the measurements at the L2 level than at L4
subject, an additional trial was conducted with a (Table 2). This suggests that a similar increase in IAP
voluntary increase in ES EMG matched to the increase would produce a larger increase in stiffness at the L2
in the control trials and thus exceeded the levels level than at L4. Similar to the L4 trials there was only a
occurring during the stimulation trials. Instruction was small increase ES EMG and no activity of the
given to ensure that the IAP was not elevated in this abdominal muscles during the L2 trials (Table 1).
trial. When EMG activity was increased in this way, the
stiffness increased by 16% of the control value and thus,
less than the stiffness increase of 2229% in the 4. Discussion
stimulation trials. To conrm that the stiffness increase
was not related to the application of the belts to the The results of this study provide evidence that
abdomen and rib cage, a pair of control and stimulation increased IAP augments stiffness of the spine. These
trials was conducted with the belts removed. In this data are consistent with the hypothesis that modulation
condition, the IAP increase was less (5963% of the IAP of IAP during functional tasks contributes to the
 ARTICLE IN PRESS
P. W Hodges et al. / Journal of Biomechanics 38 (2005) 18731880 1877

Phrenic stimulation
Control
15

mm
Disp
0
125

N
Force 0

4 kPa
Pdi

4 kPa
Pga

Stim
(A) 1s

100 18.32 18.63 18.62

Force (N)

80

60 14.50 14.28 14.33

40
0 2 4 0 2 4 0 2 4
(B) Displacement (mm)

Fig. 3. (A) Representative raw data from a single subject showing force application in a control trial and during phrenic stimulation. During
stimulation the gastric and transdiaphragmatic pressures are elevated. There is an additional increase in pressure with force application. (B)
Forcedisplacement curves generated from the second to fourth trial for control (lled circles) and stimulation trials (open circles). Note the increase
in slope of the regression line (i.e. posteroanterior stiffness) with phrenic stimulation.

20
R2= 0.91 R2= 0.43 R2= 0.72
18
Stiffness (Nmm-1)

16

14

12

10
(A) 2.5 4.5 6.5 8.5 2.5 4.5 6.5 8.5 2.5 4.5 6.5 8.5

20 34
R2= 0.86 R2= 0.59 R2= 0.97
18 30

16 26

14 22

12 18

10 14
0.5 2.5 4.5 6.5 8.5 0.5 2.5 4.5 6.5 8.5 0.5 2.5 4.5 6.5 8.5
(B) Pga (kPa)

Fig. 4. Relationship between Pga and spinal stiffness for each subject with the indentor placed over the (A) L4 and (B) L2 spinous process. The
correlation coefcient is shown in the upper left corner. Note the strong relationship between parameters for all subjects.
 ARTICLE IN PRESS
1878 P. W Hodges et al. / Journal of Biomechanics 38 (2005) 18731880
Table 2
Regression slope for relationship between IAP and posteroanterior
stiffness normalized to stiffness in non-stimulation trial L2 and L4
Subjects L4 L2
S1 1.02 0.89
S2 1.02 0.94
S3 2.60 0.30
mechanical stability of the spine. As pressure was
increased involuntarily by electrical stimulation of the
diaphragm, these data conrm that IAP without overt
activity of the abdominal or back muscles, has a
mechanical effect on the spine.
4.1. Methodological factors
A limited number of subjects participated in the
present study due to the discomfort associated with
strong tetanic electrical stimulation and the percuta-
neous stimulation of the phrenic nerves. Wire stimula-
tion electrodes were used to isolate the stimulus to the
phrenic nerve and minimise stimulation of neck muscles
or the brachial plexus. Less selective stimulation greatly
increased the discomfort associated with the procedure
and limited the intensity of stimulation that could be
used. Despite the discomfort, there was no or little
increase in ES or abdominal muscle EMG activity
between the stimulation and control trials. We acknowl-
edge other muscles that were not recorded, such as the
deep paraspinal muscles, may inuence stiffness. In
addition, stress in the abdominal wall is necessary to
produce IAP, thus passive tension of the abdominal
muscles is not excluded in this model. Although the
number of subjects was small, the results were consistent
and all showed a positive relationship between the
amplitude of IAP and the increase in spinal stiffness.
Recent data using a porcine model have conrmed these
ndings (Hodges et al., 2003, unpublished observations).
The only result that varied considerably between
subjects was the difference in stiffness between L2 and
L4 which was greater for subject 3. The reason for this
difference is unclear and could not be explained by
differences in muscle activity or stimulation intensity.
The measure of posteroanterior stiffness of the spine
is a composite measure and is inuenced by stiffness of
the entire spine and its supporting structures, for
instance soft tissue compression, extension of the spine,
anterior rotation of the pelvis, deformation and rigid-
body displacement of the ribcage and anterior shear of
the target vertebra all occur in response to the poster-
oanterior pressure (Lee et al., 1995). However, the
stiffness of the segments at which the force is applied
will contribute signicantly to the overall measurement.
In the present study, motion of the rib cage was
restricted by application of a rm belt to reduce further
compression and ensure that the rib position was
consistent between test conditions. Furthermore, the
abdomen was unsupported to reduce the effect of the
compliance of the abdominal contents on stiffness.
Measurement of an increase in stiffness in trials without
application of the belts (but with lesser increase in IAP)
conrm that the effect was not simply due to the
mechanical effects of the belts. Despite the limitations of
this measure of spinal stiffness, it does provide a non-
invasive technique to evaluate spinal stiffness, at least in
one direction. A further consideration is that although
the data indicate that posteroanterior stiffness of the
spine is increased by the increase in IAP, it was not
possible to quantify its contribution to overall stability
of the spine; this requires further investigation.
4.2. Spinal stiffness is increased by intra-abdominal
pressure
Although several previous biomechanical and in vivo
studies predicted that IAP has a limited inuence on
mechanical stability of the spine and production of an
extensor moment (e.g. Bearn, 1961; McGill and Nor-
man, 1987; Nachemson et al., 1986; Ortengren and
Andersson, 1977), the present study provides evidence
for a signicant effect of IAP on spinal stiffness. When
IAP was increased by 1.85.9 kPa, the spinal stiffness
was increased by 831% from control values recorded at
the end of a normal expiratory effort. Assuming that the
relationship between IAP and stiffness is linear
(although this may not be the case), extrapolation from
the linear regressions calculated for each subject
suggests that a large increase in stiffness may occur
with IAP changes of 5220 cm H2O that have been
recorded during functional activities (Cresswell et al.,
1993; Gandevia et al., 1990; Grillner et al., 1978;
Harman et al., 1988; Hemborg et al., 1985; Hodges et
al., 1997; Marras et al., 1985). The amplitude of stiffness
increase (831%) is similar to the 1241% increase in
stiffness observed during voluntary contraction of ES at
1030% of a maximal voluntary contraction (Shirley et
al., 1999). Our data cannot be explained by activity of
ES during the phrenic nerve stimulation because the ES
muscle was either inactive or minimally active. Further-
more, while a low-level ES activity was present during
some stimulation trials; when this was voluntarily
matched in additional trials without increased IAP, the
increase in spinal stiffness was less than that recorded
for the stimulation trials.
In the present study, stiffness of the spine was
increased by IAP without concurrent activity of the
abdominal muscles. This has been suggested previously
(McGill and Norman, 1993) and is consistent with the
elevation of IAP in tasks such as arm movements that
challenge the stability of the spine in multiple directions
 ARTICLE IN PRESS
P. W Hodges et al. / Journal of Biomechanics 38 (2005) 18731880
(Hodges et al., 1999), addition of loads to the front and
back of a harness over the shoulders (Cresswell et al.,
1994), with multiple directions of support surface
translation (Hodges et al., 2004). These data suggest
IAP modulation may contribute to the general stiffness
of the spine for control of perturbations in multiple
directions.
There has been debate whether IAP produces a trunk
extension moment and its signicance. Notably, it has
been argued that stability of the spine may be increased
by antagonist exion (abdominal muscle) and extension
(IAP) moments (Cholewicki et al., 1999a; Cholewicki
and McGill, 1996; Gardner-Morse et al., 1995). As the
abdominal muscles were not active in the present study,
increased spinal stability from antagonist moments is
unlikely to explain the increase in stiffness identied
here, although the stiffness of the relaxed exor muscles
cannot be excluded.
An important consideration is that IAP is not
elevated by selective activation of the diaphragm in
functional tasks (Cresswell et al., 1992; Hodges and
Richardson, 1997, Cholewicki et al., 2002) and abdom-
inal and back extensor muscles will be active. Thus, the
stability and stiffness of the spine will be dependent on
the net effect of all elements.
4.3. Effect of diaphragm contraction on spinal stability
Contraction of the diaphragm was used in
this experiment to produce an increase in IAP without
concurrent activity in the abdominal and back extensor
muscles. Recent data conrm that the activity of
the diaphragm occurs in association with tasks that
challenge the stability of the spine (Hodges
and Gandevia, 2000a, b; Hodges et al., 1997). The
diaphragm has a direct attachment to the spine via
its crurae that lie between the central tendon and the
anterolateral surface of L3 on the right and L2 on
the left (Williams et al., 1989). Thus, contraction of
the crural bres may mechanically inuence the
upper lumbar spine directly via its attachment. In the
present study, the stiffness was measured with the
force applied to the lumbar vertebrae at L2 which is
crossed by crural bres of the diaphragm, and at L4
which has no crural attachment. As stiffness was
increased at both the levels, it is unlikely that the
measured effect was due to the diaphragm muscle
attachment alone. However, there was a consistent
trend for a greater slope of the regression line tted to
the IAP-stiffness data when force was applied to L2
compared with L4. This suggests that the stiffness
increase at L2 was greater than that at L4 and is
consistent with a direct mechanical effect of the
diaphragm crurae.
1879
5. Conclusion
IAPin the absence of abdominal and back extensor
activityaugments stiffness of the spine. Thus, modula-
tion of IAP provides an additional mechanism for the
central nervous system to control spinal stability during
functional activities and may simplify this control by
providing a non-direction-specic increase in stiffness.
Acknowledgements
Financial support was provided by the National
Health and Medical Research Council and Physiother-
apy Research Foundation of Australia.
References
Bartelink, D.L., 1957. The role of intra-abdominal pressure in relieving
the pressure on the lumbar vertebral discs. Journal of Bone and
Joint Surgery 39B, 718725.
Bearn, J.G., 1961. The signicance of the activity of the abdominal
muscles in weight lifting. Acta Anatomica 45, 8389.
Cholewicki, J., McGill, S.M., 1996. Mechanical stability of the in vivo
lumbar spine: implications for injury and chronic low back pain.
Clinical Biomechanics 11, 115.
Cholewicki, J., Juluru, K., McGill, S.M., 1999a. Intra-abdominal
pressure mechanism for stabilizing the lumbar spine. Journal of
Biomechanics 32, 1317.
Cholewicki, J., Juluru, K., Radebold, A., Panjabi, M.M., McGill,
S.M., 1999b. Lumbar spine stability can be augmented with an
abdominal belt and/or increased intra-abdominal pressure. Eur-
opean Spine Journal 8, 388395.
Cholewicki, J., Ivancic, P.C., Radebold, A., 2002. Can increased intra-
abdominal pressure in humans be decoupled from trunk muscle co-
contraction during steady state isometric exertions? European
Journal of Applied Physiology 87, 127133.
Cresswell, A.G., Grundstrom, H., Thorstensson, A., 1992. Observa-
tions on intra-abdominal pressure and patterns of abdominal intra-
muscular activity in man. Acta Physiologica Scandinavica 144,
409418.
Cresswell, A.G., Blake, P.L., Thorstensson, A., 1993. The effect of an
abdominal muscle training program on the intra-abdominal
pressure. Scandinavian Journal of Rehabilitation Medicine 26,
7986.
Cresswell, A.G., Oddsson, L., Thorstensson, A., 1994. The inuence of
sudden perturbations on trunk muscle activity and intra-abdominal
pressure while standing. Experimental Brain Research 98, 336341.
Cresswell, A.G., Thorstensson, A., 1994. Changes in intra-abdominal
pressure, trunk muscle activation and force during isokinetic lifting
and lowering. European Journal of Applied Physiology and
Occupational Physiology 68, 315321.
Gandevia, S.C., McKenzie, D.K., 1986. Human diaphragmatic EMG:
changes with lung volume and posture during supramaximal
phrenic stimulation. Journal of Applied Physiology 60, 14201428.
Gandevia, S.C., McKenzie, D.K., Plassman, B.L., 1990. Activation of
human respiratory muscles during different voluntary manouvres.
Journal of Physiology (London) 428, 387403.
Gardner-Morse, M., Stokes, I.A.F., Laible, J.P., 1995. Role of muscles
in lumbar spine stability in maximum extension efforts. Journal of
Orthopaedic Research 13, 802808.
 ARTICLE IN PRESS
1880 P. W Hodges et al. / Journal of Biomechanics 38 (2005) 18731880
Grillner, S., Nilsson, J., Thorstensson, A., 1978. Intra abdominal
pressure changes during natural movements in man. Acta
Physiologica Scandinavica 103, 275283.
Harman, E.A., Frykman, P.N., Clagett, E.R., Kraemer, W.J., 1988.
Intra-abdominal and intra-thoracic pressures during lifting and
jumping. Medicine and Science in Sports and Exercise 20, 195201.
Hemborg, B., Moritz, U., Lowing, H., 1985. Intra-abdominal pressure
and trunk muscle activity during lifting. IV. The causal factors of
the intra-abdominal pressure rise. Scandinavian Journal of
Rehabilitation Medicine 17, 2538.
Hodges, P.W., Richardson, C.A., 1997. Feedforward contraction of
transversus abdominis in not inuenced by the direction of arm
movement. Experimental Brain Research 114, 362370.
Hodges, P.W., Butler, J.E., McKenzie, D., Gandevia, S.C., 1997.
Contraction of the human diaphragm during postural adjustments.
Journal of Physiology 505, 239248.
Hodges, P.W., Cresswell, A.G., Thorstensson, A., 1999. Preparatory
trunk motion accompanies rapid upper limb movement. Experi-
mental Brain Research 124, 6979.
Hodges, P., Gandevia, S., 2000a. Activation of the human diaphragm
during a repetitive postural task. Journal of Physiology 522,
165175.
Hodges, P., Gandevia, S., 2000b. Changes in intra-abdominal pressure
during postural and respiratory activation of the human dia-
phragm. Journal of Applied Physiology 89, 967976.
Hodges, P.W., Cresswell, A.G., Daggfeldt, K., Thorstensson, A., 2001.
In vivo measurement of the effect of intra-abdominal pressure on
the human spine. Journal of Biomechanics 34, 347353.
Hodges, P.W., Cresswell, A.G., Thorstensson, A., 2004. Intra-
abdominal pressure response to multidirectional support-surface
translation. Gait Posture 20, 163170.
Keith, A., 1923. Mans posture: its evolution and disorders. British
Medical Journal 1, 587590.
Lee, M., Svensson, N.L., 1990. Measurement of stiffness during
simulated spinal physiotherapy. Clinical Physics and Physiological
Measurement 11, 201207.
Lee, M., Kelly, D.W., Steven, G.P., 1995. A model of spine,
ribcage and pelvic responses to a specic lumbar mani-
pulative force in relaxed subjects. Journal of Biomechanics 28,
14031408.
Marras, W., Joynt, R.L., King, A.I., 1985. The force velocity relation
and intra-abdominal pressure during lifting activities. Ergonomics
28, 603613.
McGill, S.M., Norman, R.W., 1987. Reassessment of the role of intra-
abdominal pressure in spinal compression. Ergonomics 30,
15651588.
McGill, S.M., Norman, R.W., 1993. Low back biomechanics in
industry: the prevention of injury through safer lifting. In:
Grabiner, M.D. (Ed.), Current Issues in Biomechanics. Human
Kinetics Publishers, Champaign, IL, pp. 69120.
Morris, J.M., Lucas, D.M., Bresler, B., 1961. Role of the trunk in
stability of the spine. Journal of Bone and Joint Surgery 43A,
327351.
Nachemson, A.L., Andersson, G.B.J., Schultz, A.B., 1986. Valsalva
maneuver biomechanics: effects on lumbar trunk loads of elevated
intra-abdominal pressures. Spine 11, 456462.
Ortengren, R., Andersson, G.B.J., 1977. Electromyographic studies of
trunk muscles with special reference to the functional anatomy of
the lumbar spine. Spine 2, 4452.
Sarnoff, S.J., Sarnoff, L.C., Whittenberger, J.L., 1951. Electrophrenic
respiration. VII. The motor point of the phrenic nerve in relation to
external stimulation. Surgery Gynecology and Obstetrics 93,
190196.
Shirley, D., Lee, M., Ellis, E., 1999. The relationship between
submaxiaml activity of the lumbar extensor muscles
and lumbar posteroanterior stiffness. Physical Therapy 79,
278285.
Shirley, D., Ellis, E., Lee, M., 2002. The response of poster-
oanterior lumbar stiffness to repeated loading. Manual Therapy
7, 1925.
Williams, P.L., Warwick, R., Dyson, M., Bannister, L.H. (Eds.), 1989,
Grays Anatomy. Churchill Livingstone, London.