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Manual Therapy 17 (2012) 531e537

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

Understanding the Active Straight Leg Raise (ASLR): An electromyographic


study in healthy subjects
Hai Hu a, b, Onno G. Meijer a, c, d, e, *, Paul W. Hodges f, Sjoerd M. Bruijn g, h, Rob L. Strijers i,
Prabath W.B. Nanayakkara i, j, Barend J. van Royen k, Wenhua Wu c, d, Chun Xia b, Jaap H. van Dieën a
a
Research Institute MOVE, Faculty of Human Movement Sciences, VU University Amsterdam, Amsterdam, The Netherlands
b
Department of Orthopaedic Surgery, Shanghai Sixth People’s Hospital, Shanghai Jiaotong University, Shanghai 200233, PR China
c
Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, PR China
d
Orthopedic Biomechanics Laboratory of Fujian Medical University, Quanzhou, Fujian, PR China
e
Department of Rehabilitation, Fujian Medical University, Fuzhou, Fujian, PR China
f
Center of Clinical Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
g
Research Center for Movement Control and Neuroplasticity, Department of Biomedical Kinesiology, K.U. Leuven, Belgium
h
Department of Orthopedics, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, PR China
i
Department of Clinical Neurophysiology, VU University Medical Center, Amsterdam, The Netherlands
j
Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
k
Department of Orthopedic Surgery, VU University Medical Center, Amsterdam, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: The Active Straight Leg Raise (ASLR) is an important test in diagnosing pelvic girdle pain (PGP). It is
Received 20 June 2011 difficult to understand what happens normally during the ASLR, let alone why it would be impaired in
Received in revised form PGP. In the present study, healthy subjects performed the ASLR under normal conditions, with weight
21 May 2012
added above the ankle, and while wearing a pelvic belt. Activity of the abdominal muscles, rectus femoris
Accepted 23 May 2012
(RF), and biceps femoris (BF) was recorded with surface electromyography (EMG), and transversus
abdominis (TA) with fine wire EMG. RF was ipsilaterally active, BF contralaterally, and the abdominal
Keywords:
muscles bilaterally. All muscle activity was higher with weight, and abdominal muscle activity was lower
Active Straight Leg Raise
Abdominal muscles
with the pelvic belt. In both these conditions, TA and obliquus abdominis internus (OI) were more
Symmetry asymmetrically active than obliquus externus. The abdominal muscles engage in multitasking,
Lumbopelvic stability combining symmetric and asymmetric task components. Hip flexion causes an unwanted forward pull on
the ipsilateral ilium, which is counteracted by contralateral BF activity. To transfer this contralateral force
toward ipsilateral, the lateral abdominal muscles press the ilia against the sacrum (“force closure”). Thus,
problems with the ASLR may derive from problems with force closure. Also abdominal wall activity
counteracts forward rotation of the ilium. Moreover, contralateral BF activity causes transverse plane
rotation of the pelvis, often visible as an upward movement of the contralateral anterior superior iliac
spine. Such transverse plane rotation is countered by ipsilateral TA and OI. The present study facilitates
the understanding of what normally happens during the ASLR.
Ó 2012 Elsevier Ltd. Open access under the Elsevier OA license.

1. Introduction after trauma (cf. Kanakaris et al., 2011). Several diagnostic exami-
nations are commonly used, especially the Active Straight Leg Raise
Pelvic Girdle Pain (PGP) affects over 20% of pregnant women (ASLR) (Mens et al., 1999, 2001, 2002), during which the subjects
(Wu et al., 2004; Mulholland, 2005; Vleeming et al., 2008; are supine and attempt to raise their leg by hip flexion, with the
Robinson et al., 2010; Gutke et al., 2010; Vermani et al., 2010), and knee in extension. In subjects with PGP, the test maybe painful or
may also occur in athletes with groin pain (Verrall et al., 2001), or limited (Mens et al., 2002). The ASLR was reported to have good
reliability, sensitivity, and specificity (Mens et al., 2001).
The ASLR assesses the ability to transfer load between the spine
and the legs via the pelvis (Mens et al., 1999, 2001; cf. Beales et al.,
* Corresponding author. Room D 656, Faculty of Human Movement Sciences, VU
2009a,b; Beales et al., 2010a,b; Hu at al., 2010a,b; Jansen et al.,
University, Van der Boechorststraat 9, 1081 BT Amsterdam, The Netherlands.
Tel.: þ31 20 598 8590; fax: þ31 20 598 8529. 2010), and can be used to differentiate PGP from hip or lumbar
E-mail addresses: ogmeijer@yahoo.com, o_g_meijer@fbw.vu.nl (O.G. Meijer). pain (Cowan et al., 2004; Mens et al., 2006; Roussel et al., 2007).

1356-689X Ó 2012 Elsevier Ltd. Open access under the Elsevier OA license.
http://dx.doi.org/10.1016/j.math.2012.05.010
532 H. Hu et al. / Manual Therapy 17 (2012) 531e537

During the test, subjects with PGP sometimes reported that they AgCl discs, with an inter-electrode distance of 20 mm (Kendall
felt “as if the leg is paralyzed” (Mens et al., 1999). Relatedly, ARBO, Neustadt am Dom, Germany). For OI, electrode placement
a “catching” sensation during walking was reported (Sturesson was 1 cm medial to the anterior superior iliac spine (ASIS), 0.5 cm
et al., 1997). These phenomena remain poorly understood. below the line joining both ASISs (Ng et al., 1998; Beales et al.,
The ASLR appears to consist of raising one leg, requiring ipsi- 2009a,b); for OE, 1 cm above the horizontal line through the
lateral hip flexor activity. Nevertheless, bilateral activity of muscles umbilicus, 1 cm lateral to the border of RA (McGill and Norman,
in the lumbopelvic region has been reported (Hu et al., 2010a). 1986), and for RA, 1 cm above and 2 cm lateral to the umbilicus.
Snijders and his colleagues proposed that the transversus abdom- For RF and BF, SENIAM recommendations were used (Hermens
inis (TA), obliquus abdominis internus (OI), and obliquus abdominis et al., 1999). Data was recorded at a sample rate of 2000 samples/
externus (OE) stabilize the pelvis by pressing the iliac bones against s with a multichannel Porti5 EMG system (TMS-international,
the sacrum, i.e., sacroiliac “force closure” (Vleeming et al., 1990a,b; Enschede, The Netherlands; Hu et al., 2010a).
Snijders et al., 1993a,b). A pelvic belt maybe used to substitute, or
partially substitute, the force required, which could be helpful 2.3. Kinematics
when the ASLR is painful or limited (Mens et al., 1999). Still, it is not
immediately obvious why raising one leg from a supine position Four clusters of three LED Markers each were fixed onto small
would require pelvic stability (cf. Mens et al., 1999; Hu et al., 2010a). lightweight custom-made triangular frames, and attached halfway
Moreover, Liebenson et al. (2009) reported on ipsilateral transverse along the upper and lower legs for registration with a 2  3 camera
plane rotation of the pelvis during the ASLR, which was interpreted system (OPTOTRAK 3020, Northern Digital, Waterloo, Ontario,
in terms of lumbar spine stability. However, it remains unclear why Canada), connected via a synchronization cable to the Porti5 EMG
the pelvis would rotate during the ASLR, or how this would relate to system. To determine leg movements, the heights of the centers of
stability. the clusters were calculated. The kinematic sampling frequency
Clearly, we need to improve our basic understanding of the was 50 samples/s.
ASLR. Several studies have attempted to disentangle symmetric,
stabilizing muscle activity from the asymmetric activity that is
needed to raise a leg. Some studies assumed that activity is 2.4. Conditions
symmetric if no asymmetry is observed (e.g., Beales et al., 2009b; cf.
Teyhen et al., 2009), but this may be a moot point (cf. Hodges, 2008 The ASLR was performed in supine position with the feet 20 cm
vs. Allison et al., 2008). Abdominal muscles engage in multitasking apart (Mens et al., 2001). Subjects were instructed to raise one leg
(Saunders et al., 2004; Hu et al., 2011), and muscle activity contains until the heel was 20 cm above the table, without bending the
both symmetric and asymmetric components. Hence, we need to knees, and keeping the leg elevated for about 10 s (“Normal”). To
disentangle the various mechanisms that are involved in per- increase statistical precision, this was done three times per leg per
forming the ASLR. The present study analyzed the ASLR in healthy condition. After every ASLR, subjects were asked to relax for
subjects. Our aim was to improve understanding the mechanisms approximately 10 s. The whole procedure was repeated with
involved, and thereby facilitate the clinical interpretation of the a weight added just above the ankle (“Weight”), so that the static
ASLR. moment of the leg with respect to the hip was increased by 50%. To
calculate the required amount of weight (Zatsiorsky, 2002; p. 605),
2. Methods manually measured lower extremity anthropometry was used.
Finally, the ASLR was repeated with a non-elastic pelvic belt (“Belt”;
2.1. Subjects 3221/3300, Rafys, Hengelo, The Netherlands), just below the ASIS
(Damen et al., 2002; Mens et al., 2006), with a tension of 50 N
Sixteen healthy nulliparous females were enrolled, mean  SD (Vleeming et al., 1992; Mens et al., 1999), fine-tuned with an inbuilt
age 27.5  2.7 years, weight 61.2  9.8 kg, height 167.9  7.6 cm, and gauge.
BMI 21.6  2.4 kg/m2. Exclusion criteria were: previous orthopedic
surgery, walking-related disorders such as low back pain (LBP) or 2.5. Data analysis
PGP, or a history of low blood pressure. Participants signed
a written informed consent. The protocol was approved by the local Data was analyzed with MATLAB 7.4 (The Mathworks, Natick,
Medical Ethical Committee. MA, USA). Kinematic data were filtered with a 4th order bi-
directional low pass Butterworth filter with a cutoff frequency of
2.2. Electromyography (EMG) 5 Hz. We determined the onset and the peak of leg raise, i.e., the
first point with zero velocity before/after a peak in velocity. Leg
To reduce the subjects’ burden, EMG was measured on one side raise velocity was calculated as the height of peak position divided
only. We arbitrarily selected the right side. TA was recorded with by the time to reach peak position.
CE-marked intramuscular fine-wire electrodes of 40 gauge insu- Due to technical problems with the amplifier, TA EMG was not
lated stainless steel (VIASYS Healthcare, Madison WI, USA). The usable in four subjects, which left twelve valid datasets for TA.
electrodes were threaded into sterile 50 mm hypodermic needles, EMG data were high-pass filtered at 250 Hz (1st order Butter-
and trimmed, with 2e3 mm long “hooks” extending from the tip. worth; Hu et al., 2010a), then full-wave rectified, and low-pass
After disinfection, the needle was inserted under semi-sterile filtered at 5 Hz (2nd order Butterworth). The median amplitude
conditions with ultrasound guidance. Insertion for the trans- during ASLR plateau (5 through 10 s after movement onset) was
versus abdominis was 2 cm medial to the midpoint of the vertical calculated.
from the spina iliaca anterior superior (SIAS) to the rib cage To quantify the asymmetry of activity of TA, OI, and OE, an
(Hodges and Richardson, 1997; cf. Hodges and Richardson, 1999). Asymmetry Index was calculated as: (ipsilateral  contralateral)
Some subjects felt anxious when the needle entered the muscle, activity/(ipsilateral þ contralateral) activity  100%, “ipsilateral”
but no lasting pain was reported. For OI, OE, rectus abdominis (RA), and “contralateral” referring to the leg being raised. Positive values
rectus femoris (RF), and biceps femoris (BF), EMG was recorded indicate more ipsilateral, negative values more contralateral muscle
with pairs of surface electrodes, consisting of 24 mm diameter Ag/ activity.
H. Hu et al. / Manual Therapy 17 (2012) 531e537 533

2.6. Statistical analysis Table 1, Fig. 2), with in the first three muscles more ipsilateral, and
in BF more contralateral activity. The effect of Condition was
Outliers were identified from box plots (Figs. 2 and 3), and significant for all muscles (P-values  0.01), with more activity with
removed. For statistical analysis, generalized estimation equa- weight, and more RF and BF activity with the belt, but less activity
tions (GEEs) were used, i.e., repeated measures regression anal- with the belt in TA OI, OE, and RA. There were significant
yses that allow for missing values. First, the impact of Side Side  Condition interactions in TA, RF, and BF (P-values < 0.001;
(ipsilateral vs. contralateral) and Condition (Normal, Weight, Belt) Table 1, cf. Fig. 2). Ipsilateral TA and RF activity were higher with
on muscle activity was calculated (cf. Table 1), with contralateral weight, but BF lower, and ipsilateral TA activity was higher with the
as reference for Side, and Normal for Condition. Since non- belt, but RF and BF lower.
normalized EMG amplitudes of different muscles cannot be
compared, these analyses were performed for each muscle 3.2. Symmetry/asymmetry of the lateral abdominal muscles
separately. Then, to assess if Weight or Belt led, as predicted, to
more asymmetry, the impact of Condition and of Muscle (TA, OI, Box plots (Fig. 3) revealed that most, but not all, subjects had
OE) on the Asymmetry Index was calculated (cf. Table 2). Note more ipsilateral activity of the lateral abdominal muscles. The
that the Asymmetry Index is dimensionless, and allows for median Asymmetry Index ranged from 1.4% (OE with belt) to 35.8%
comparing different muscles. SPSS 16 was used throughout, with (TA with belt). TA activity appeared to be most, OE least asym-
P < 0.05 as threshold for significance. metrical, but inter-individual differences were considerable.
Asymmetry increased significantly with weight and with the belt
3. Results (P ¼ 0.04; Table 2), and there were significant Condition  Muscle
interactions (P ¼ 0.01), OI and TA being more asymmetrical with
The maximum velocity of leg raise was affected by Condition weight or with the belt than OE. No other significant effects were
(P < 0.001), being faster with the belt (0.25 m/s), and slower with found.
weight (0.22 m/s) than in the normal condition (0.23 m/s). Kine-
matically, there were no other significant effects. 4. Discussion

3.1. Muscle activity 4.1. Mechanisms underlying the ASLR

Fig. 1 provides a typical example of EMG activity. There was a Muscle activity during the ASLR had considerable inter-
significant main effect of Side in TA, OI, RF, and BF (P-values < 0.03; individual variability, as revealed in the Asymmetry Index of the

Fig. 1. Raw electromyograms, with signals (mV) over time (s), in one subject during three consecutive repetitions of contralateral and ipsilateral ASLR. Note the scale difference
between RF and the other muscles. The bottom panel gives the kinematical pattern, with the height (m) of the leg raise over time. Each ASLR lasted around 10 s, and subjects rested
about 10 s between repetitions. Baseline values of contralateral and ipsilateral ASLR are arbitrary. For the abbreviations of the muscle names, cf. Table 1.
534 H. Hu et al. / Manual Therapy 17 (2012) 531e537

TA OI
8

amplitude (µV)
amplitude (µV) 10 6

4
5
2

0
N W B N W B N W B N W B
contralateral ipsilateral contralateral ipsilateral

OE RA
amplitude (µV)

amplitude (µV)
6 3

4 2

2
1

N W B N W B N W B N W B
contralateral ipsilateral contralateral ipsilateral

RF BF

25
amplitude (µV)

amplitude (µV)

15
20
15 10
10
5
5
0 0
N W B N W B N W B N W B
contralateral ipsilateral contralateral ipsilateral

Fig. 2. Box plots of median muscle activity (mV) during ipsilateral and contralateral ALSR in three conditions (N ¼ Normal, W ¼ with Weight added, B ¼ with a pelvic Belt). Each box
runs from the 25 to the 75 percentile; the transverse line inside the box indicates the median, “þ” represents outliers, and the error bars represent the range, excluding the outliers.
Note the scale differences. For the abbreviations of the muscle names, cf. Table 1.

lateral abdominal muscles (Fig. 3). When subjects perform the found, suggesting that most results were large, and related to
same task repeatedly, there are large variations in the force common mechanisms underlying the ASLR.
produced (Van Dieën et al., 2001), and it has to be expected that During the ASLR, hip flexors raise the leg, as revealed in the
different subjects use different strategies to perform the ASLR (cf. ipsilateral RF activity (Table 1, Fig. 2), which was even larger with
Latash et al., 2002). Nevertheless, many significant results were weight. In an earlier study, we found that the psoas is involved in
bilateral frontal plane stabilization of the lumbar spine during the
inter−subject distribution ASLR, and not in hip flexion (Hu et al., 2010b). For the ASLR, this
leaves those hip flexors that also exert a forward pull on the ilium,
i.e., iliacus, adductor longus, and RF (Mens et al., 1999; Hu et al.,
60 2010a; cf., e.g., Vleeming et al., 1992, 1996, 2008; Hungerford
et al., 2004). Contralateral BF activity, which was even larger with
40 weight, serves to prevent this forward rotation of the ipsilateral
ilium (Hu et al., 2010a). Note that the forward pull of ipsilateral hip
asymmetry index (%)

20
flexors, and the backward pull of contralateral BF may balance, so
that no actual movement of the ilium would occur.
Contralateral BF activity is only useful if the two sides of the
0
pelvis act as a single unit, such as when they are pressed together
by force closure. Then, the extension moment produced by the
−20 contralateral BF can be transferred toward the ipsilateral ilium
(Vleeming et al., 1990a,b; Snijders et al., 1993a,b; Hu et al., 2010a).
−40 With a pelvic belt, TA, OI, and OE were less active (Table 1, Fig. 2),
which revealed that the belt (partially) substituted force closure.
Note that abdominal wall activity may also rotate the pelvis pos-
−60
teriorly, and thus contribute to counteracting the forward rotation
N W B N W B N W B of the ipsilateral ilium. With a pelvic belt, the lateral abdominal
TA OI OE
muscles were less active, which could explain why contralateral BF
Fig. 3. Box plots of the Asymmetry Index (%) for TA and OI in all three conditions (cf. was more active in conditions with a belt. Note that it is the ipsi-
Fig. 2 & Table 1). lateral ilium that is being pulled forward, and, as long as force
H. Hu et al. / Manual Therapy 17 (2012) 531e537 535

Table 1
P-values, bold when significant, and corresponding regression coefficients (B) from GEEs on abdominal muscle activity during the ASLR, with side (ipsilateral vs. contralateral
ASLR) and condition (normal, with weight added, or with a pelvic belt) as factors, and including significant interactions. Note that GEEs calculate regression equations, and, for
instance, the first line reads as: TA activity (mV) ¼ 2.56 þ 1.26 (during ipsilateral ASLR) þ 0.47 (when weight is added), or  0.86 (in the condition with the belt), þ 1.24 (in the
condition with weight added during the ipsilateral ASLR), or þ 0.55 (with the pelvic belt during ipsilateral ASLR).

Muscle activity (mV) Intercept Sidea Conditionb Interactionc

P B P B P B P B
TA <0.001 2.56 0.004 1.26 0.010 W: 0.47 0.007 Ipsi  W: 1.24
B: 0.86 Ipsi  B: 0.55
OI <0.001 1.29 0.021 0.53 <0.001 W: 0.74 0.10
B: 0.38
OE <0.001 0.93 0.393 <0.001 W: 0.57 0.08
B: 0.23
RA <0.001 0.80 0.284 <0.001 W: 0.23 0.15
B: 0.15
RF <0.001 0.59 <0.001 5.82 <0.001 W: 0.50 <0.001 Ipsi  W: 2.35
B: 0.23 Ipsi  B: 0.35
BF <0.001 5.40 <0.001 4.38 <0.001 W: 3.59 <0.001 Ipsi  W: 3.32
B: 0.83 Ipsi  B: 0.81

Number of datasets used per muscle per condition (after removing data that could not be used, and after removing the outliers, cf. Fig. 2):

Contralateral Ipsilateral

N W B N W B
TA 12 12 11 12 12 12
OI 15 14 16 16 16 16
OE 15 16 13 15 15 15
RA 16 14 15 16 16 15
RF 14 16 15 14 14 14
BF 16 16 16 14 15 15

TA: m. transversus abdominis.


OI: m. obliquus internus abdominis.
OE: m. obliquus externus abdominis.
RA: m. rectus abdominis.
RF: m. rectus femoris.
BF: m. biceps femoris.
a
The B-value is for ipsilateral compared to contralateral activity.
b
Comparing Weight (W) or Belt (B) with the normal condition.
c
Ipsilateral (Ipsi) compared to contralateral activity in the Weight (W) or Belt (B) condition, compared to normal.

closure is submaximal, abdominal backward rotation of the pelvis it is an “unwanted” side effect, and contralateral pelvis rotators
may involve more ipsilateral than contralateral activity (“þ  þ” in (¼ipsilateral trunk rotators) in the transverse plane, such as ipsi-
Table 3; cf. Beales et al., 2009a). It remained unclear why RA was lateral TA and OI (Urquhart and Hodges, 2005; Hu et al., 2010a),
less active in conditions with a pelvic belt. may counter this pelvis rotation toward ipsilateral. Beales et al.
Contralateral BF activity presses the contralateral heel against (2010b) did not measure TA, but reported increased ipsilateral OI
the bench (Beales et al., 2009a,b, 2010a), with more pressure when activity when weight was added. In the present study, more ipsi-
weight is added (Beales et al., 2010b). Pressing down the contra- lateral activity was found for both OI and TA with weight (Table 1,
lateral heel will cause the pelvis to move upwards on that side, that Fig. 2). Transverse plane counterrotation of the pelvis appears to be
is, ipsilateral transverse plane rotation of the pelvis, as reported by another role of TA and OI in the ASLR.
Liebenson et al. (2009). Note that there is no reason to suspect that We conclude that the ASLR consists of ipsilateral hip flexion,
such rotation would challenge lumbar spine stability. Nevertheless, a contralateral hip extension moment, force closure by the lateral

Table 2
P-values, bold when significant, and corresponding regression coefficients (B) from GEEs on the Asymmetry Index of TA, OI, and OE, with condition and muscle as factors, and
including their interaction (cf. Table 1).

Asymmetry Index (%) Intercept Conditiona Muscleb Interaction

P B P B P B P B
TA, OI, OE <0.001 8.91 0.043 W: 0.84 0.118 0.005 TA  W: 14.67
B: 7.68 TA  B: 23.67
OI  W: 3.93
OI  B: 12.71
Post hoc: TA, OI <0.001 9.62 0.005 W: 9.00 0.458 n.s.
B: 9.53

Number of datasets used per muscle per condition (after removing data that could not be used, and after removing the outliers, as identified in Fig. 3):

N W B
TA 12 12 11
OI 15 14 15
OE 15 14 12
a
Weight or belt compared to normal.
b
TA or OI compared to OE.
536 H. Hu et al. / Manual Therapy 17 (2012) 531e537

Table 3 Note that it is not clear how such problems emerge, maybe a reflex
Plausible roles of the abdominal muscles during the Active Straight Leg Raise. inhibition (Hurley and Newham, 1993) when pelvic compression is
Task component RA OE OI TA painful, but if so, a pelvic belt, which may substitute the force
I C I C I C I C
required, could, in principle, cause the same painful compression.
Diagnostic manual compression may help to complete the picture,
Force closure   þ ¼ þ þ ¼ þ þ ¼ þ
Posterior rotation þ  þ þ  þ þ  þ   and guide the choice of treatment.
of the pelvis Contralateral BF activity will be visible as the contralateral ASIS
Ipsilateral rotation     (þ)  þ  moving upwards. This can easily be observed, but the relevance of
of the trunk
that observation remains unclear.
I: Ipsilateral; C: Contralateral. In summary, problems with the ASLR may result from failing
 no role; (þ) probably a role; þ clearly a role. force closure. Palpation of the movements of both ilia, and of the
I ¼ C symmetrical task component.
long dorsal sacroiliac ligaments, as well as manual compression of
I  C ipsilateral activity similar to, or larger than contralateral activity.
the pelvis may help to complete the picture.

abdominal muscles, sagittal plane pelvis stabilization by the


4.4. Limitations
abdominal wall, and activity of contralateral transverse plane
rotators of the pelvis.
The present study was limited to healthy subjects. Muscles
were only studied on the right side, although right and left ASLR
4.2. The notion of “symmetry” were performed. Four sets of TA data could not be used, and
outliers were removed before statistical testing. Still, a consistent
The lateral abdominal muscles were more asymmetrically active pattern of significant effects was found, suggesting that power
with weight and with a belt (Table 2, Fig. 3), apparently because was no major problem. The use of surface EMG for OI and OE in
weight increases the ipsilateral task component, and the belt the present study may have affected results. Crosstalk between
decreases the symmetrical task component. For TA and OI this was the OI and OE, and between TA and OI, cannot be excluded. On the
more so than for OE (Table 2, Fig. 3), possibly because OE was not other hand, fine-wire EMG of TA would only reflect the activity of
used to counter transverse plane rotation of the pelvis. Between TA the mid region of that muscle, whereas different functional roles
and OI, no difference was found in degree of asymmetry (Table 2). of different parts of TA have been described (Urquhart and
Authors tend to report “symmetry” when statistical analysis Hodges, 2005). Finally, only women were measured and gener-
does not reveal a significant effect of side (e.g., Danneels et al., alization of our results to the male population may not be
2001; Beales et al., 2010b). Strictly speaking, this is inaccurate, straightforward.
because one cannot prove exact symmetry on statistical grounds.
More importantly, this tendency distracts from the fact that
4.5. Conclusions
muscles engage in multitasking (Saunders et al., 2004; Hu et al.,
2011), with some task components being symmetrical, and others
The ASLR consists of ipsilateral hip flexion, a contralateral hip
asymmetrical (Hodges, 2008).
extension moment, force closure by the lateral abdominal muscles,
“Symmetry” is a mathematical concept (De Sautoy, 2008). It
sagittal plane pelvis stabilization by the abdominal wall, and
maybe a property of tasks, as understood biomechanically, not an
activity of contralateral transverse plane rotators of the pelvis.
empirical property of muscle activity or shape. Theoretically, force
Problems with the ASLR may result from failing force closure. Other
closure implies symmetric TA, OI, and OE activity. On the other
tests are available to confirm, or falsify, the clinical hypothesis that
hand, the lack of a statistical effect of side on OE (Table 1) does not
the patient is having problems with force closure.
prove that OE was engaged in force closure only, as it may also have
played a role in sagittal plane control of the pelvis. All four
abdominal muscles have different symmetric and asymmetric task Acknowledgments
components (Table 3). TA and OI, for instance, were expected to
have a clear symmetric task component, but were found to have Financial support was obtained from Stryker Howmedica
significant asymmetry. Nederland, Biomet Nederland, and the Dutch Society of Exercise
Therapists Cesar and Mensendieck (VvOCM). PWH was supported
4.3. Clinically understanding the ASLR by a Senior Principal Research Fellowship from the National Health
and Medical Research Council (NHMRC) of Australia. The Authors
Hip flexors exert a forward pull on the ipsilateral ilium, which gratefully acknowledge Erwin van Wegen, Mark Scheper, Ilse van
in the ASLR is prevented, at least in part, by contralateral BF, and Dorst, Annemarie ten Cate, Hans van den Berg, Roland van Esch,
force closure is needed to transfer the contralateral extension and Tijmen van Dam for their help and suggestions. Jan Mens gave
moment toward ipsilateral. Thus, failing force closure is a likely very useful suggestions for the interpretation of data, and Darren
cause of problems during the ASLR. The sacroiliac joint is more Beales was friendly enough to share his experiences with similar
stable with the ilium in posterior rotation (Mens et al., 1999; experiments. We express our thanks to Steve Barker for his skillfull
Vleeming et al., 2008), but in subjects with PGP, actual forward linguistic editing of an earlier version of the text. This project could
rotation has been observed (Hungerford et al., 2004). Forward not have been performed without the stimulating initiative of the
rotation of the ipsilateral ilium, and backward rotation con- late Paul I.J.M. Wuisman, Professor of Orthopedic Surgery at the VU
tralaterally, can both be established by palpation, which may University medical centre.
confirm that failing force closure is the problem. Moreover,
forward rotation of the ilium stretches the ipsilateral long dorsal References
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H. Hu et al. / Manual Therapy 17 (2012) 531e537 537

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