Hernia (2011) 15:417–421
DOI 10.1007/s10029-011-0805-1
O R I G I N A L A R T I CL E
Assessment of abdominal muscle function using the Biodex
System-4. Validity and reliability in healthy volunteers
and patients with giant ventral hernia
U. Gunnarsson · M. Johansson · K. Strigård
Received: 6 September 2010 / Accepted: 22 February 2011 / Published online: 5 March 2011
© Springer-Verlag 2011
Abstract
Background The decrease in recurrence rates in ventral
hernia surgery have led to a redirection of focus towards
other important patient-related endpoints. One such end-
point is abdominal wall function. The aim of the present
study was to evaluate the reliability and external validity of
abdominal wall strength measurement using the Biodex
System-4 with a back abdomen unit.
Material and method Ten healthy volunteers and ten
patients with ventral hernias exceeding 10 cm were
recruited. Test–retest reliability, both with and without gir-
dle, was evaluated by comparison of measurements at two
test occasions 1 week apart. Reliability was calculated by
the interclass correlation coeYcients (ICC) method. Valid-
ity was evaluated by correlation with the well-established
International Physical Activity Questionnaire (IPAQ) and a
self-assessment of abdominal wall strength.
Results One person in the healthy group was excluded
after the Wrst test due to neck problems following minor
trauma. The reliability was excellent (>0.75), with ICC val-
ues between 0.92 and 0.97 for the diVerent modalities tested.
No diVerences were seen between testing with and without a
girdle. Validity was also excellent both when calculated as
correlation to self-assessment of abdominal wall strength,
and to IPAQ, giving Kendall tau values of 0.51 and 0.47,
respectively, and corresponding P values of 0.002 and 0.004.
U. Gunnarsson · K. Strigård (&)
Department of Surgery, CLINTEC, Karolinska Institutet,
Karolinska University Hospital, Gastrocentrum K53,
141 86 Huddinge, Stockholm, Sweden
e-mail: Karin.Strigard@ki.se
M. Johansson
Department of Physiotherapy, Karolinska Institutet,
Karolinska University Hospital, Huddinge, Stockholm, Sweden
Conclusion Measurement of abdominal muscle function
using the Biodex System-4 is a reliable and valid method to
assess this important patient-related endpoint. Further
investigations will be made to explore the potential of this
technique in the evaluation of the results of ventral hernia
surgery, and to compare muscle function after diVerent
abdominal wall reconstruction techniques.
Keywords Giant ventral hernia · Abdominal muscle
strength · Biodex System-4 · Girdle
Introduction
Ventral incisional hernias are common after abdominal
surgery, with an incidence of around 10%. Factors that
increases the risk up to 50% are smoking, high age, deteriora-
tion, prior abdominal surgery, immunosuppressive medication
and obesity [1]. Furthermore, the surgeon’s technique when
closing the abdominal wall is important for the develop-
ment of hernia [2]. Abdominal wall defects may cause back
pain due to impaired ability to use muscle groups important
for posture control [3]. Weakness of the abdominal wall
may also cause inability to perform some movements
where strength of the abdominal wall muscles is of impor-
tance. The strength of the abdominal wall muscles might be
reduced further due to the inability to conduct daily activi-
ties because of the volume of the hernia.
When evaluating techniques for reconstruction of
abdominal wall defects, as well as performance of surgical
settings, recurrence rate has been the most important end-
point. However, improvements in surgical technique and
prosthetic material has decreased the recurrence rate
by 50% [4], leading to a redirection of focus towards
other patient-related endpoints. Such endpoints include
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418
well-being or pain measured by questionnaires and/or
objective evaluation of abdominal wall strength. The latter
endpoint has been diYcult to assess due to diYculties in
measuring the strength of isolated abdominal muscles.
The Biodex Multi-Joint System-4 Pro provides the means
to measure strength in diVerent groups of muscles. The sys-
tem has been evaluated and tested for reliability in other mus-
cle groups in the Welds of rehabilitation and sports medicine
[5–8]. The system also includes a back-abdomen unit aimed
to measure performance of abdominal wall muscles. Should
it be possible to use this tool in the evaluation of patients with
large or giant ventral hernia, it would provide the possibility
to compare abdominal strength, before and after surgery, as
well as being useful for long term follow-up.
The aim of the present study was to evaluate the reliabil-
ity of the Biodex back abdomen unit in terms of test–retest
stability, and its external validity in terms of correlation to
the well-established International Physical Activity Ques-
tionnaire (IPAQ) [9] and a self assessment of abdominal
wall strength. The study included healthy volunteers and
persons with giant ventral hernia, intending to evaluate per-
sons with a broad spectrum of abdominal wall function.
Materials and methods
Two groups of volunteers were recruited, one from the
healthy population and one group of patients with giant
ventral hernia (>10 cm). Ten test persons were included
in each group after written informed consent. The healthy
volunteers were health-care personnel without prior
Fig. 1 Biodex system-4 with
the back abdomen unit
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Hernia (2011) 15:417–421
abdominal surgery. Patients with giant ventral incisional
hernia were recruited from the waiting list for surgery.
Height, weight and BMI were recorded for all participants.
Since the attempt was to assess validity and reliability for a
broad spectrum of abdominal wall function, healthy volun-
teers were allowed to be younger than patients with a her-
nia. Before starting the test procedure the participants were
provided with general information about the procedure and
time was oVered for questions. Patients with ventral hernia
were obliged to wear a girdle preoperatively and the tests
were therefore performed both with and without girdle in
both groups. This assured reliability with the girdle and
also enabled us to detect any obvious diVerence in abdomi-
nal muscle function caused by the girdle.
Biodex
A Biodex Multi-Joint System-4 Pro machine with a unit for
testing back and abdominal muscle strength was used for
the tests. The device is developed to test and train speciWc
muscles or muscle groups. The results are given in Newton
metre (Nm). The muscle tests are isokinteic, which means
that a pre-designed movement speed cannot be exceeded.
DiVerent variables in the test situation are maximal strength
(peak torque) and maximal work. The test subject sits in a
chair-like position (Fig. 1), with the cristae iliaca, the centre
of movement, as anatomic landmarks. The angle of the
back, the height at which the test subject sits, and the angles
of their feet and legs were corrected. Markings on the sys-
tem made it possible to reproduce the exact position at the
retest situation. The thighs and chest were Wxed with straps.
Hernia (2011) 15:417–421
The legs were Wxed distally with the knees Xexed 90°, and
the arms were crossed over the chest so as to minimize the
inXuence of muscle forces from other parts of the body.
Reliability
Test–retest reliability was evaluated by comparison of mea-
surements at two test occasions 1 week apart. The same
investigator conducted all tests. Instructions were short and
precise with the same wording used on both test occasions
to avoid positive or negative inXuence from the investigator
[10]. On both test occasions the Wrst test was performed
with the girdle applied. To avoid exhaustion inXuencing the
results, the procedure was performed in exactly the same
order each time. Each session consisted of Wve training runs
before the Wnal test.
The test programme involved a maximal extent of move-
ment of 30°, 20° of extension and 10° of Xexion. The ana-
tomic reference was 90° in the hip related to the back. All
20 test persons performed two exercise series, separated by
a rest period of 5 min, one with and one without a specially
manufactured girdle. Each series consisted of Wve tests with
Wve repetitions: passive isokinetic test 30°/s £ 2; 60°/
s £ 2; and a static muscle strength test. The static maximal
force test starts with 10° of Xexion. There was 90 s rest
between each repetition.
External validity
External validity was calculated by comparison of
isometric strength measured by the Biodex System with the
result of the IPAQ [9] and the patient’s self-assessment of
their own muscle strength on a visual analogue scale
(VAS) ranging from 0 to 10 (0 = extremely weak and
10 = extremely strong). The VAS ruler appears to the test
person as a continuous line and only the investigator can
see the score. IPAQ is an instrument designed for measure-
ment of daily activity with a short form designed for popu-
lation surveillance of physical activity. These have been
developed and tested for use in adults (age range of 15–69
years) [9]. In the short Swedish version, there are 11 ques-
tions about daily activity over the previous 7 days [11].
The degree of activity can be computed by weighting the
diVerent type of activities related to energy requirements
deWned in METs (Metabolic Equivalent Task) to yield a
score in MET-minutes. Results from the questionnaire are
classiWed as low, moderate or high activity.
The study was approved by the local Ethics Committee.
Statistical methods
Statistics were calculated using the STATISTICA software
(Statsoft, Tusla, OK). Age and other demographic data
419
were recorded as means and ranges. Comparisons between
dichotomous variables were made using the Fisher two-
tailed exact test, whereas ordinal data were compared using
the Mann-Whitney U-test. Correlations between the VAS,
IPAQ and isometric strength results were estimated by the
Kandall Tau method.
Reliability evaluation of the test–retest of muscle
strength was performed by the interclass correlation coeY-
cient (ICC) [12] calculated with SPSS software. An ICC
between 0.4 and 0.75 is considered fair-to-good, and a cor-
relation higher than 0.75 is excellent.
Results
Reliability
Basic demographic data for the two groups are shown in
Table 1. The patients in the ventral hernia group were older
and had a higher BMI than the healthy volunteers. One test
person in the latter group was excluded due to neck prob-
lems after minor trauma between tests, thus leaving nine
subjects for analysis.
Reliability between the test and retest was excellent in
both the healthy volunteer group and in the ventral hernia
group as calculated by ICC (Table 2). The healthy volun-
teers seemed more comfortable with the Xexion/extension
tests than with the isokinetic test. On the contrary, the isoki-
netic test was easier to perform among persons in the ven-
tral hernia group. No diVerences were seen between testing
with and without girdle in any of the groups. One person
with a girdle from each group showed no similarity
between the test and re-test.
External validity
When assessing external validity, all patients were calcu-
lated together for correlation of isometric strength against
self-assessment of abdominal wall strength and the results
of IPAQ. Both groups easily understood the instructions for
the isometric test, and the risk for false high or low values
are less than with the isokinetic tests. For this reason, the
Table 1 Demographic data (mean and range) of the two test groups
Healthy volunteers Ventral hernia
Age (years) 37.7 (25–61) 59.6 (34–76)
Men/women 3/7 4/6
Weight (kg) 67.4 (46.7–103.7) 84.2 (57.2–101.3)
Height (cm) 173.3 (162–195) 167 (155–176)
BMI 21.9 (17–29) 30.1 (23–37)
Abdominal operations 0
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420 Hernia (2011) 15:417–421

Table 2 Reliability evaluation with interclass correlation coeYcient abdominal hernia with a high validity in terms of correla-
(ICC) of the test–retest peak torque (Nm) for all test subjects. tion to well-established methods and with a high degree of
Isokinetic muscle test measured the abdominal muscles concentric test–retest reliability. This provides the possibility to objec-
and eccentric muscle strength, and the isometric muscle strength test,
only the static muscle strength tively assess an important patient-related endpoint—
abdominal wall function in terms of strength of the abdom-
ICC
inal wall muscles.
30°/s Patient-related endpoints have increased in importance
Concentric 0.957 since the classic endpoint, recurrence rate, has decreased
Excentric 0.958 considerably over recent years since the broad introduc-
30°/s (with girdle) tion of prosthetic mesh [4]. Important endpoints from the
Concentric 0.976 patient’s point of view include abdominal wall function,
Excentric 0.969 and adverse eVects of surgery such as long-lasting pain—
60°/s an endpoint that has grown in importance in the Weld of
Concentric 0.970
inguinal hernia surgery [13]. The endpoint “abdominal
Excentric 0.948
wall function” has been more diYcult to assess objec-
tively in patients with ventral hernia. The results of this
60°/s (with girdle)
study show the Biodex system to be a useful tool for such
Concentric 0.942
evaluations. One drawback with this method, however, is
Excentric 0.920
the considerable cost of the apparatus and the additional
Isometric
back/abdomen unit. Furthermore, the method of investi-
Concentric 0.966
gation necessitates a dedicated physiotherapist and a
Isometric (with girdle)
standardised programme to conduct the investigations.
Concentric 0.975
Our results show the method to be valid and reliable at
our unit, but there may still be diVerences between
160 measurements performed at other units with diVerent
140 investigators.
120
Reliability in terms of test–retest stability was assessed
Isometric (Nm)

by the ICC method [12]. The ICC method has been used in
100
most previously published reliability studies of the Biodex
80
system with other muscle groups [5–8]. Compared to those
60 studies, the present reliability results are very good. There
40 are several methods available for evaluation of reliability,
20 the choice depending on the situation. In the present case
0 the requisites were in concordance with the description of
0 1 2 3 4 5 6 7 8 the ICC method [12], but reliability was also tested by other
Fig. 2 Isometric strength in Nm related to International Physical methods (i.e. Pearson and Spearman correlation, as well as
Activity Questionnaire (IPAQ) (blue diamonds) and visual analogue Wilcoxon signed rank test) with the same high degree of
scale (VAS) (pink squares). The three diVerent steps in IPAQ have correlation. It thus seems safe to conclude that the reliabil-
been transformed to 1 (=low activity), 2 (=moderate activity) and 3
ity between the two test occasions in this study may be clas-
(=high activity)
siWed as very high.
To assure validity, physical performance of a speciWc
isometric test was generally used for calculation of external muscle group should ideally be compared with another
validity. Correlation plots are shown in Fig. 2. There was a muscle group for internal validity, and with the results of
very strong correlation with both entities of external validity, other established instruments to assure external validity. In
giving Kendall tau values of 0.51 and 0.47, respectively, and the present case, where the goal was to measure perfor-
corresponding P values of 0.002 and 0.004. mance of a diseased organ (i.e. the abdominal wall) it is
not relevant to compare the performance of those muscles
with muscle from healthy parts of the body. To assure that
Discussion the method is valid also for measurements of a broad
spectrum of abdominal wall strength, including the non-
Abdominal muscle function can be evaluated using the diseased abdominal wall, a group of healthy controls was
Biodex System-4 in healthy persons and patients with included.

123
Hernia (2011) 15:417–421
IPAQ [9], and its short form translated into Swedish
[11], are well-established instruments for evaluation of
physical performance related to muscle function. A draw-
back may be that the instrument contains no speciWc evalu-
ation of diVerent parts of the body. It does, however, mirror
global performance where the abdominal muscles play an
important role. To our knowledge, no valid instrument for
assessment of abdominal wall function exists, and compari-
son with global performance is considered a reliable alter-
native [14]. To obtain a more speciWc measurement of
external validity, the test subjects were also asked to pro-
vide a self-assessment of their abdominal wall strength
measured using a VAS scale. This method has been vali-
dated for several endpoints in various disciplines [15, 16]
and provides a valid and reliable tool for assessment of the
patient’s experience, but is dependent on the construction
of the question given.
Together these measurements showed a very high degree
of external validity, which leads us to conclude that the
results of the Biodex measurements among the test persons,
regardless of whether they had a hernia or not, correlated
strongly with abdominal muscle strength.
An alternative method to assess abdominal wall function
may be by a speciWc questionnaire. The Biodex method
provides a broad spectrum of individual and objective test
results of muscle strength and function in diVerent load sit-
uations. Those values can be compared with results after
surgery and/or after training programmes. With greater
experience of this technique, it may be possible to identify
the most important points of measurement and to construct
speciWc questionnaires or other methods to speciWcally
evaluate the eVects of surgery on abdominal wall function.
These more simple methods would have the obvious advan-
tages of lower cost and the ability to perform the tests in the
surgical outpatient clinic at the same time as any clinical
investigation.
It is concluded that measurement of abdominal muscle
function using the Biodex System-4 is a reliable and valid
method to assess this important patient-related endpoint.
Further investigations will be made to explore the potential
of the Biodex system in the evaluation of the results of ven-
tral hernia surgery in terms of pre- and post-operative mus-
cle strength, and for comparison of abdominal wall function
after diVerent abdominal wall reconstruction techniques.
421
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