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Editorials
Editorials
control of multiple mechanical demands take the muscle away) and cannot be Although the early studies focussed on
on the trunk. tested in current biomechanical models this muscle,25 26 an abundant literature has
(as few include the contributions of IAP evolved that shows that the changes in
ASYMMETRICAL ACTIVITY OF and fascial tension). Animal studies are back pain are complex and involve many
TRANSVERSUS ABDOMINIS IS STILL underway to test the effect of reduced muscles and many control properties. One
MECHANICALLY USEFUL deep muscle activation on spine biome- of the factors that have perpetuated the
The second assumption is that if the chanics and it is hoped that this will shed confusion is that, although the changes in
contraction is not symmetrical it cannot light on this issue. transversus abdominis appear to be rela-
do anything for the spine. But, as men- tively consistent,25 26 the changes in the
tioned above, Allison et al’s1 data show other muscles are variable,27 28 and there-
IT’S NOT JUST ABOUT ARM
that, while the onset was not simulta- fore harder to find in a non-specific pain
MOVEMENTS; DATA FROM OTHER
neous, the muscle was active on both population. Recent work even suggests
METHODS SUPPORT THE ROLE OF
sides in a feedforward manner (i.e. active that many people with back pain may
TRANSVERSUS ABDOMINIS IN SPINAL
before any feedback could be available to have increased stability rather than
CONTROL
induce activation of the muscle (,50 ms decreased stability,29 potentially as a result
The third issue relates to Allison et al’s1
after the onset of deltoid EMG))13 and of increased activity of the more super-
and Cook’s2 failure to consider the wealth
both sides were active at the time of onset ficial trunk muscles, and this puts a whole
of data from numerous groups using other
of deltoid EMG (well before the move- new perspective on the meaning of
experimental designs. Arm movement
ment started and well before any reactive optimal spinal control; not simply to
tasks provide a window of opportunity
forces would affect the spine). Although increase stability, but to find a balance
to study the system, but there are many
Allison et al1 argue that the lack of activity between too much and too little.30 It is
other models which have provided insight
of transversus abdominis on the other side increasingly clear that rehabilitation
into the function of transversus abdomi-
or activity of the rectus abdominis (RA) should not target a single muscle, but
nis. In trunk movements,22 isometric
would limit the potential for transversus instead should involve careful evaluation
trunk tasks,22 trunk perturbations in sit-
abdominis to generate force, this is not of a whole system. While changes in
ting23 and lying,24 transversus abdominis is
what their data show, as transversus transversus abdominis (and other muscles
active in a manner that is unique amongst
abdominis on the other side is active by such as multifidus) can be a useful marker
the trunk muscles, that is, it is active with
the time the movement starts and may of dysfunction in the system (and recent
forces and movements in opposite direc-
well contribute to spinal control in spite data show that patients with delayed
tions in the sagittal plane. These tasks do
of a later onset. Furthermore, direct transversus abdominis do better with a
not include an axial rotation component
measurement of intra-abdominal pressure motor control training approach than
and that may make the interpretation
(IAP) clearly demonstrates that there is a people without a delay) (unpublished
easier (as it does not involve the func-
mechanical output of the muscle contrac- data), to limit treatment to this muscle
tional requirement to combine activity for
tion before the arm moves.8 14 In-vivo15 16 is unlikely to be beneficial. The days of
rotation with other aspects). These obser-
and modelling17 studies show that IAP contracting transversus abdominis as the
vations and the interpretation of unilat-
contributes to spinal control. Other stu- primary exercise and then sending the
eral flexion and extension movements
dies show that transversus abdominis is patient away are over. Instead, training of
raise the question: why does the nervous
the abdominal muscle most closely corre- transversus abdominis should be part of
system use a muscle in a similar manner
lated with IAP changes.18 Modelling stu- the intervention, when appropriate for
with two opposite directions of move-
dies that suggest that transversus the patient and the changes in their
ment? I concur with Allison et al1 that this
abdominis does very little for spinal control system.
does not necessarily mean that it con-
stability19 consider only the role of trans- Cook2 argues that training transversus
tributes to spinal control. That is simply a
versus abdominis as a flexor (for which it abdominis bilaterally may be redundant
hypothesis that we have gone on to test
has a trivial moment arm). This ignores as that may not be the way the muscle
in a number of biomechanical studies,
the biomechanical data that show that functions. Although this may not always
with results that show the activation can
transversus abdominis can contribute to be the case, it is likely to be so in some
control spinal motion.15 21 To conclude
spinal control via IAP or fascial ten- tasks. But evidence that the muscle is not
that a single observation from a single
sion.20 21 Both human and animal studies symmetrical (although bilateral) cannot
task refutes the conclusion of a whole
show that activation of transversus abdo- be used to say that bilateral training is not
range of different methodologies seems
minis has a mechanical effect on the spine effective or appropriate. There is a devel-
unfounded.
and the pattern of activation of the oping literature that shows that training
muscle in Allison’s data is not inconsis- muscles in this way changes the control of
tent with that assumption. What that IS THE DEBATE ABOUT TRANSVERSUS the muscle in other tasks. Not only does it
data shows is that, in addition to the ABDOMINIS MISSING A CRITICAL ISSUE? change the timing of activation of trans-
bilateral activation at the time the move- Having highlighted some of the assump- versus abdominis in arm movement and
ment starts, it also has activity that could tions made by Allison et al1 and Cook2 it is gait tasks31 32; it also changes the organisa-
be consistent with an additional role in also worth considering some issues in the tion of the motor cortex33 and this change is
control of axial rotation. clinical literature as a whole that have related to the change in timing during an
An issue that is accurately indicated by spawned some of this current debate. In arm movement task. Notably, this was
Allison et al1 is that there are no data to my view the whole debate around trans- only achieved by cognitive bilateral activa-
show that the spine is less optimally versus abdominis is missing a critical tion, and not by simple activation as part of
controlled when activation of transversus issue. Back pain is not an issue of a single a sit-up31 or other abdominal bracing
abdominis is changed. This is challenging muscle, it is associated with complex manoeuvre.34 Furthermore, focussed atten-
to test in humans (because it is difficult to changes across a whole system. tion on activation of the deeper muscles
Editorials
can also change the activation of many do not refute the original hypotheses of with mode and speed of locomotion. Gait Posture
2004;20:280–90.
muscles of the trunk.35 These data suggest the role of transversus abdominis in 10. Hodges P, Gandevia S. Activation of the human
that training of bilateral activation is an trunk control; in fact, they are very diaphragm during a repetitive postural task. J Physiol
effective training stimulus to change the congruent with the evolution of our 2000;522:165–75.
way the muscle is activated in function, understanding of the function of the 11. Hodges PW, Pengel HM, Sapsford R. Postural and
respiratory functions of the pelvic floor muscles.
despite the fact that this may not be the deep muscles. The basic observations Neurourol Urodyn 2007. In press.
only way it is active in function. This from the early studies that were con- 12. Hodges P. Differential activity of the right and left
principle of a training stimulus that does ducted 15 years ago provided a starting costal diaphragm during non-respiratory tasks in
humans. In: Proceedings Australian Neuroscience
not reflect every function is true for many point.25 The subsequent data have Society; Sydney.
exercise approaches. For instance, eccentric shaped and evolved the interpretation. 13. Aruin AS, Latash ML. Directional specificity of
loading is effective in management of We all agree that clinical practice often postural muscles in feed-forward postural reactions
tendinopathy, but this is not the only adopts research findings in a simplified during fast voluntary arm movements. Exp Brain Res
1995;103:323–32.
way those muscles function. and hardline approach. Allison et al’s1 14. Hodges PW, Butler JE, McKenzie D, et al.
data do not refute the viability and Contraction of the human diaphragm during postural
potential efficacy of the approach. adjustments. J Physiol 1997;505:239–48.
WHY ARE MOTOR CONTROL 15. Hodges P, Kaigle Holm A, Holm S, et al.
Current literature suggests that the
INTERVENTIONS SUCCESSFUL IN Intervertebral stiffness of the spine is increased by
clinical application of the findings is evoked contraction of transversus abdominis and the
TREATING BACK PAIN?
beneficial. In an ideal world the experi- diaphragm: in vivo porcine studies. Spine
Finally, I agree with Cook2 and Allison et 2003;28:2594–601.
mental testing of an idea would be
al1 when they argue that we do not know 16. Hodges P, Shirley D, Eriksson AEM, et al. Intra-
completed and all issues resolved and abdominal pressure can directly increase stiffness of
why motor control interventions are
understood before implementation into the lumbar spine. J Biomech 2005;38:1873–80.
effective. We don’t know that the effect
practice, but this is not practical as 17. Cholewicki J, Juluru K, McGill SM. Intra-abdominal
is explained by increased stability of the pressure mechanism for stabilizing the lumbar spine.
nothing would ever be implemented.
spine due to activation of transversus J Biomech 1999;32:13–17.
And, after all, research that has a clinical 18. Cresswell AG, Thorstensson A. Changes in intra-
abdominis and other deep muscles. Core
application must be done in an iterative abdominal pressure, trunk muscle activation and force
work by our group has focussed on this during isokinetic lifting and lowering. Eur J Appl
manner with communication back and
very issue over recent years. In a series of Physiol Occup Physiol 1994;68:315–21.
forth between clinicians and researchers. 19. Kavcic N, Grenier S, McGill SM. Determining the
studies we aimed to evaluate the potential
In that way clinical practice can inform stabilizing role of individual torso muscles during
mechanisms for efficacy of a motor
research and research can be accurately rehabilitation exercises. Spine 2004;29:1254–65.
control approach to the management of 20. Tesh KM, ShawDunn J, Evans JH. The abdominal
implemented into practice. The challenge
neck pain. These studies showed that the muscles and vertebral stability. Spine 1987;12:501–8.
for us all is to keep our blinkers off and 21. Barker P, Guggenheimer K, Grkovic I, et al. Effects
motor intervention not only changed the
keep an open mind when looking at our of tensioning the lumbar fasciae on segmental
control of the deep neck flexor muscles stiffness during flexion and extension. Spine
data and looking at patients so that we
(Jull et al, unpublished data), but was also 2005;31:397–405.
have a chance to move forward.
associated with improvements in pos- 22. Cresswell AG, Grundstrom H, Thorstensson A.
ture36 and neck proprioception.37 In terms Competing interests: None declared. Observations on intra-abdominal pressure and
patterns of abdominal intra-muscular activity in man.
of the back, recent data in a small clinical Accepted 11 November 2008 Acta Physiol Scand 1992;144:409–18.
trial suggest that the intervention can 23. McCook D, Vicenzino B, Hodges P. Activity of deep
Br J Sports Med 2008;42:941–944. abdominal muscles increases during submaximal
reduce the muscular stabilisation of the doi:10.1136/bjsm.2008.051037 flexion and extension efforts but antagonist co-
trunk by reducing activity of more super- contraction remains unchanged. J Electromyogr
ficial muscles.35 This could suggest that Kinesiol. Published Online First 19 December 2007.
the approach leads to more optimal REFERENCES doi: 10.1016/j.jelekin.2007.11.002.
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Editorials
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These include:
References This article cites 26 articles, 2 of which can be accessed free at:
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Notes