ORIGINAL ARTICLE

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.
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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.
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