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Dynamic Trunk Stabilization: A Conceptual Back Injury Prevention Program for

Volleyball Athletes

Article  in  Journal of Orthopaedic and Sports Physical Therapy · December 2008

DOI: 10.2519/jospt.2008.2814 · Source: PubMed

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 [ CLINICAL COMMENTARY ]
CHAD E. SMITH¹š@E>DDOB7D:"DPT, EdD, SCS, ATC, CSCS, FACSM²šF7KB97K:?BB¹
@EI;F>8HEIAO"PT, MS, SCS3š:7L?:D$C$978EHD"MD4

Dynamic Trunk Stabilization:

A Conceptual Back Injury Prevention
Program for Volleyball Athletes
igh spinal forces during the sport of volleyball make it essential the ankle and upper leg (J78B; ').1 Low

H to have well-developed trunk muscle function.120 Back and

shoulder injuries are common to volleyball and can primarily
be attributed to the stresses of frequent spiking and jump
serving, both activities characterized by simultaneous forceful spinal
hyperextension and rotation, in addition to extreme shoulder external
back injury risk increases with spinal
twisting, lateral bending, and asymmetri-
cal movements.3,48
The “trunk” refers to the body region
excluding the head, neck, and extremi-
ties. The most important trunk muscle
rotation (<?=KH;').15 Most acute volleyball injuries occur at the ankle function is to provide dynamic stabil-
ity.83 Instability is the inability to prop-
(23%) and knee (17%); however, the tion injury surveillance data for women’s erly maintain postural alignment, while
back (16%) is the third most injured volleyball injuries, Agel et al1 reported stability is the capacity to resist change
12
region. Most chronic volleyball that the low back ranked fourth and maintain or resume an original posi-
injuries occur at the knee (33%) among body regions injured dur- tion following displacement.125 Dynamic
and shoulder (20%), while the SUPPLEMENTAL ing games, following the ankle, trunk stability is the capacity to control
VIDEOS ONLINE
back (18%) is the next most in- knee, and shoulder. During prac- intervertebral and global trunk move-
jured region.132 In a 16-year review tice, however, the low back was the ments. The dynamic stability provided by
of National Collegiate Athletic Associa- third most injured region, following only the trunk also contributes to the control
of distal segment movements and load-
TIODEFI?I0 The sport of volleyball creates higher velocity dynamic multiplanar endurance, ing forces via coordinated trunk muscle
considerable dynamic trunk stability demands. coordination, and strength-power challenges recruitment. This muscle coordination
Back injury occurs all too frequently in volleyball, integrating upper and lower extremity movements, and recruitment occurs in response to
particularly among female athletes. The purpose while maintaining neutral spine alignment. Phase expected or unexpected perturbations
of this clinical commentary is to review functional 3 integrates volleyball-specific skill simulations such that proper posture (static stability)
anatomy, muscle coactivation strategies, assess- or intended movement path (dynamic
by breaking down composite movement patterns
ment of trunk muscle performance, and the char-
into their component parts, with differing dynamic stability) can be maintained.
acteristics of effective exercises for the trunk or
core. From this information, a conceptual progres-
trunk stability requirements, while maintaining Several researchers have investigated
sive 3-phase volleyball-specific training program is neutral spine alignment. Prospective research is the significance and interaction of vari-
presented to improve dynamic trunk stability and needed to validate the efficacy of this program. ables related to energy expenditure,
to potentially reduce the incidence of back injury TB;L;BE<;L?:;D9;0 Level 5. J Orthop Sports effects of posture on neutral spine align-
among volleyball athletes. Phase 1 addresses Phys Ther 2008;38(11):703-720. doi:10.2519/ ment, neuromuscular control, and per-
low-velocity motor control, kinesthetic awareness, formance factors related to back injury
jospt.2008.2814
and endurance, with the clinician providing cues
TA;OMEH:I0 abdominal muscles, electromyo-
prevention. These variables are familiar
to teach achievement of biomechanically neutral
spine alignment. Phase 2 focuses on progressively graphy, erector spinae, kinetics, lumbar spine to physical therapists and must be con-
sidered when designing injury prevention

1
Medical student, School of Medicine, University of Louisville, Louisville, KY. 2 Associate Professor, Division of Sports Medicine, Department of Orthopaedic Surgery, University of
Louisville, Louisville, KY; Member, Medical Resource Advisory Team, USA Volleyball. 3 Associate Professor, School of Physical Therapy, Lansing School of Nursing and Health Sciences,
Bellarmine University, Louisville, KY. 4 Professor, Division of Sports Medicine, Department of Orthopaedic Surgery, University of Louisville, Louisville, KY. Address correspondence to Dr
John Nyland, Division of Sports Medicine, Department of Orthopaedic Surgery, University of Louisville, 210 East Gray St, Suite 1003, Louisville, KY. E-mail: john.nyland@louisville.edu

journal of orthopaedic & sports physical therapy | volume 38 | number 11 | november 2008 | 703

<?=KH;'$The volleyball spike.
Collegiate Women’s Volleyball Injuries
J78B;'
Sustained at Practice and Games by Body Region1
FhWYj_Y[
Total Injuries
8eZoH[]_ed IkijW_d[Z
Ankle 29.4%
Knee ...
Shoulder ...
Back 7.9%
Leg 12.3%
conditioning and rehabilitation programs.
Less energy is needed to restore neutral
spine alignment following perturbation
than is needed to correct asymmetrical,
kyphotic, or lordotic postures.64,128 Barr et
al19 have reported that repetitious move-
ments that are altered by poor strength,
flexibility, fatigue, posture, or abnormal
neuromuscular control may promote
tissue damage. Others have shown the
importance of trunk muscle coactiva-
tion in providing stiffness and dynamic
trunk stability to protect the spine from
injury.59,62 This dynamic stability controls
[ CLINICAL COMMENTARY ]
the fishing rod is placed on the ground
(base of spine) and a small load is placed
on its tip (ie, top of spine), it easily bends
and buckles. However, if guide wires (ie,
trunk musculature) are placed along its
length and if wire tension is kept con-
stant, then the load the rod can success-
fully support is greatly increased.
Panjabi111 described spinal osseo-
ligamentous, muscle, and motor control
components as interdependent systems
designed to achieve trunk stability. Injury
or functional deficits within 1 system can
be partially compensated for by contribu-
tions from the other 2. The erector spinae
or epaxial muscles make up the bulk of
the dorsal lumbar musculature, consist-
ing of the iliocostalis, longissimus, and
spinalis (<?=KH;(). Also involved with dy-
Games
namic trunk stability are the multifidus,
Injuries per Total Injuries Injuries per
'&&&;nfeikh[i IkijW_d[Z '&&&;nfeikh[i
quadratus lumborum, psoas, and iliacus
0.83 44.1% 1.44
muscles (<?=KH; )). Abdominal muscles
... 14.1% 0.46
involved with dynamic trunk stability in-
... 5.2% 0.17
clude the rectus abdominis, internal and
0.22 4.8% 0.16
external oblique, and transversus abdo-
0.35 ... ...
minis (<?=KH;*). The architecture (length
and fiber arrangement) and the unique
morphology of each muscle determines
of this clinical commentary is to review its function.39,51
relevant functional anatomy, muscle co- Back neuromuscular fatigue, inflam-
activation strategies, assessment of trunk mation, deconditioning, and pain are
muscle performance, and the character- related to regional and lower extrem-
istics of effective trunk muscle exercises. ity neuromuscular dysfunction and atro-
From this information a conceptual train- phy.10,67,83,126,141,142 Maladaptive transversus
ing program is presented that is designed abdominis and multifidus motor control
to increase dynamic trunk stability and may also be related to altered posture,
decrease back injury incidence among muscle imbalance, and sedentary life-
volleyball athletes. styles. O’Sullivan et al110 reported that
low back pain induced trunk muscle dys-
<KD9J?ED7BJHKDA7D7JECO function has a greater negative effect on
coactivation and recruitment patterns
than on strength. Deconditioned trunk

excessive or poorly controlled trunk mo-
tion following perturbation14,29,31,32,142 and
attenuates the sudden forces that contrib-
ute to low back48,60 and lower extremity
pain and injury.28,70,141,142
Volleyball players are at risk for sus-
taining both acute and chronic back in-
jury.12,132 Having effective dynamic trunk
stability is vital to both back injury pre-
vention and to performance. The purpose
A
ntagonistic trunk muscle co-
activation is largely influenced by
dynamic trunk stability needs.61 Us-
ing models and calculations from Euler,
Crisco and Panjabi37,38 reported that com-
pressive loading of 90 N caused spinal
buckling when muscular contributions
were absent. McGill97,100 made the anal-
ogy that the spine and the trunk muscles
function together like a fishing rod and
supportive guide wires. When the butt of
muscles have a reduced capacity to with-
stand perturbation and repetitive loads,
causing strain on lumbar annular disc fi-
bers and potentially increasing back pain.
Individuals who experience low back pain
often have trunk muscle dysfunction,
particularly of the multifidii.71-73,76,77
The gluteal muscles and the trunk and
lower extremity fascial systems also con-
tribute to dynamic trunk stability. The

704 | november 2008 | volume 38 | number 11 | journal of orthopaedic & sports physical therapy

Semispinalis capitus
Spinalis capitus
Iliocostalis cervicis
Iliocostalis thoracis
Iliocostalis
lumborum
Lumbar fascia
<?=KH;($Deep and intermediate posterior spinal muscles (erector spinae).
fascial system is closely associated with
the regulation of trunk and extremity
posture, muscular biomechanics, motor
control, and proprioception.2,24,57,83,121,123,139
Thoracolumbar fascial tightening through
abdominal muscle activation effectively
introduces tension throughout this sys-
tem, increasing activation efficiency.18,53,135
Axioappendicular muscles, such as the
latissimus dorsi and gluteus maximus, fur-
ther contribute to dynamic trunk stability
journal of orthopaedic & sports physical therapy | volume 38 | number 11 | november 2008 | 705
Longissimus
capitus
Longissimus
cervicis
Longissimus
thoracis
Spinalis thoracis
and movement through their thoracolum-
bar fascial attachments.26,46 The pelvis is
maintained level in the frontal plane by
the gluteus medius and minimus mus-
cles, which act more as hip stabilizers and
pelvic rotators than pure hip abductors.57
During weight bearing, the femur is sub-
jected to bending strain by bodyweight,
causing medial compressive and lateral
tensile stresses, while the iliotibial tract
functions as a tension band counteracting
femoral shaft stresses with hip abductor
muscle activation.112 Aponeuroses from
the fascia lata separate the thigh and lower
leg muscles into compartments, securing
them to the femur and tibia, respectively,
and forming a rigid biomechanical bone-
fascia-tendon system.53 The function of
this system may be intensified by the in-
creased intracompartmental thigh muscle
volume and diameter of activation. This
phenomenon effectively tensions the fas-
cial compartments, shifting the iliotibial
tract farther away from the femur, increas-
ing its lever arm and possibly enhancing
lower extremity stability via a hydraulic
amplifier effect, as has been previously
described at the low back.58
Although muscle fiber type distribution
is similar between men and women, gen-
der differences in bony architecture and
muscle imbalances may influence trunk
biomechanics. The predominance of type
I (slow twitch) muscle fibers in the lum-
bar (mean  SD, 65%  10.3%, 63.6% 
11.9%) and thoracic (mean  SD, 62% 
9.3%, 67.8%  10.5%) erector spinae of
men and women, respectively, confirms its
significant function in maintaining static
trunk postural equilibrium by resisting
spinal flexion torque.96 The erector spinae
has a short lever arm, so the forces it cre-
ates to resist spinal flexion torque also
compresses the spine and intervertebral
discs, which may be detrimental to spine
health. Erector spinae lever arm length
may be influenced by vertebral body ge-
ometry and spinal posture. Women gen-
erally have a 17% smaller vertebral body
size than men and, therefore, have a 9%
smaller lever arm from the erector spinae
to the vertebral body center.56 In a flexed
spinal posture, lumbar erector spinae lever
arm length may decrease by 13.3%, and
muscle forces must increase to maintain
the same extensor torque levels.40 Under
normal conditions, the musculoskeletal
system can adjust; however, as vertebral
compression increases, the spine is placed
in greater flexion, further decreasing le-
ver arm lengths. This shifts the body’s line
of gravity more anterior to the vertebral
bodies, increasing spinal flexion torques,
 [ CLINICAL COMMENTARY ]
requiring larger erector spinae counter-
torques, and increasing spinal compres-
sion. Duan et al40 estimated that activities
associated with trunk flexion generated a
10-fold increase in vertebral compression
Quadratus
compared with upright standing. Lumbar lumborum
spinal flexion is associated with a change
in the line of action of the longissimus
and iliocostalis muscles, reducing their Psoas major
(dotted region)
capacity to resist shear forces and in-
creasing the compression force vector.101
Spinal posture may also be influenced
by trunk extensor strength imbalances,
possibly leading to greater kyphosis and
weakness. With decreased strength, the
erector spinae may be unable to maintain
the necessary extensor torque to support
an erect posture; consequently, kyphosis
and muscle length would increase, further
decreasing torque-generating capacity.101 Iliacus
Trunk extensor capacity for maintaining
needed strength levels, when confronted
with these postural changes, is unknown.
Largely based on comparative ana-
tomic and histologic studies, trunk mus-
cles have been theoretically classified into
local and global muscles (J78B;().21,54 Au-
thors have proposed theories suggesting
that local muscles are responsible for dy-
namic segmental spinal stability and pro- <?=KH;)$Quadratus lumborum, psoas, and iliacus muscles of the “core.”
prioception, and global muscles provide
composite stability, large movements, in addition to those located immediately torque production.21,54 Developing ap-
and torque production.21,54 Gibbons and adjacent to the spine. propriate global and local trunk muscle
Comerford54 proposed a trunk muscle In summary, low back pain and injury activation strategies in combination with
classification system consisting of local are more closely associated with trunk efficient use of gluteus maximus, latissi-
and global stability muscles, and global muscle coactivation and recruitment mus dorsi, and extremity fascial connec-
mobility muscles. Crisco and Panjabi38 pattern dysfunction than on reduced tions is vital to back injury prevention,
theorized that small, intersegmental strength.110 Integrated trunk and lower particularly among women.111
muscles that span 1 vertebral level, such extremity fascial systems contribute to
as rotatores, are inefficient in providing dynamic trunk and lower extremity sta- JHKDACKI9B;
stability and, instead, serve a greater role bility.18,53,121,139 Anthropometric character- 9E79J?L7J?ED
in controlling local intersegmental trans- istics such as spinal dimensions, posture,
lational forces and providing proprio- trunk weight, center of mass, muscle

ception, as previously conceptualized by
Peck et al113 and Nitz and Peck.106 Based
on these theories, more dynamic trunk
stability is believed to come from global
muscles that span several vertebral levels
and attach to the pelvis. Dynamic trunk
stability also increases when more later-
ally positioned muscles, such as the latis-
simus dorsi, are synergistically activated
torques, and cross-sectional area differ
between men and women, and these fac-
tors may influence dynamic trunk sta-
bility.23,33,41,56,81 Authors have proposed
theories suggesting that local trunk mus-
cles serve a greater dynamic segmental
spinal stability and proprioception func-
tion, while global muscles provide com-
posite stability, large movements, and
A
ppropriate trunk muscle coact-
ivation levels and timing are essen-
tial to healthy function. Hodges and
Richardson74,77 reported that increased
dynamic trunk stability provides a more
stable foundation for upper and lower
extremity movements. Trunk muscle
coactivation increases preemptively in
an unstable environment or when sud-
den loads are anticipated, particularly

706 | november 2008 | volume 38 | number 11 | journal of orthopaedic & sports physical therapy
when high-risk injury postures, such as quasi-static modeling, Gardner-Morse namic trunk stability through increased
extreme flexion-rotation, occur.62,64 Using and Stokes52 predicted improved dy- coactivation; however, it was proposed
the increased fatigue associated with
Rectus this strategy would likely result in com-
abdominis Abdominal promised stability.52 Excessive trunk
fascia
muscle coactivation also increases spinal
compression and decreases mobility, ad-
External versely affecting performance.26
oblique Motor control programs coordinate
global and local muscle recruitment and
influence intrinsic and reflexive mecha-
nisms to provide appropriate trunk
Transversus muscle stiffness and dynamic stability
abdominis
around a neutral spinal posture during
multiplanar movements.32 The intrinsic
Quadratus mechanism increases trunk stiffness by
lumborum feed-forward neuromuscular preactiva-
tion in anticipation of a perturbation.
Intrinsic stiffness alone, however, is gen-
erally insufficient to dynamically stabilize
the trunk during sudden high-velocity or
high-load perturbations.104 The reflexive
Lumbodorsal mechanism uses feedback from pertur-
fascia bation via the stretch reflex to modulate
Semispinalis
muscle spindle gain, further modifying
Iliocostalis intrinsic muscle stiffness and viscosity.
Longissimus Multifidus
Proportional and differential reflexive
responses enhance muscle stiffness with-
<?=KH;*$Cross-sectional abdominal and trunk muscles at approximately the level of the third lumbar vertebra.
out the metabolic costs of sole reliance on

Theoretical Classifications of Mammalian Paravertebral

J78B;(
Muscle Characteristics 21,54

IjkZo 9^WhWYj[h_ij_Y BeYWb Global

21
Bergmark Location, attachments Origin and insertion on spine Pelvic origin and thoracic spine insertion
Muscles Multifidus, transversus abdominis, and the Longissimus thoracis, rectus abdominis, and the
internal oblique muscles external oblique muscles
Function Spinal stability Prime movers
9^WhWYj[h_ij_Y BeYWbIjWX_b_p_d]CkiYb[i =beXWbIjWX_b_p_d]CkiYb[i =beXWbCeX_b_p_d]CkiYb[i
Gibbons and Location, depth Deeper musculature, origin and insertion Intermediate depth, mid location Superficial musculature, con-
Comerford54 located at the vertebra necting thorax and pelvis
Joint attachments Tend to be monoarticular or monosegmental Intermediate segmental connections Tend to be biarticular or multi-
segmental
Function Controls segmental motion with primary Controls composite range of motion with intermediate Produces range of motion and
eccentric work bias concentric-eccentric work bias torques with concentric work bias
Activation Activation is continuous, at slow velocities, Activation is noncontinuous, at intermediate velocities, Activation is noncontinuous,
generating low forces, independent on the generating intermediate forces, dependent on the dependent on the direction of
direction of activity direction of activity activity; high forces are gener-
ated and activation velocities
are high
Muscles Multifidus, rotators, interspinales, intertrans- Semispinales, spinalis, quadratus lumborum Sacrospinalis (longissimus,
versarii iliocostalis), psoas major

journal of orthopaedic & sports physical therapy | volume 38 | number 11 | november 2008 | 707
 [ CLINICAL COMMENTARY ]
J78B;) Intra-abdominal Pressure and Muscle Activation Studies

IjkZo IkX`[Yji C[j^eZi H[ikbji

36
Cresswell et al 6 healthy men Measured abdominal EMG and IAP during All abdominal muscles were activated, and IAP increased prior to ES activation during
sudden expected or unexpected trunk unexpected perturbations. During expected perturbations, the TA was always activated
perturbations with 5-kg load first, presumably to increase dynamic trunk stability by increasing IAP
Cresswell et al35 6 healthy men Measured abdominal EMG amplitudes and Increased IAP always occurred during isometric trunk extension without evidence of IO, EO,
IAP during active trunk movements in side or RA activation with near maximal TA EMG amplitudes
lying and standing
Hodges et al75 3 healthy men Measured spinal stiffness (L2, L4 level) Increased spinal stiffness was positively correlated with increased IAP
as IAP was increased via phrenic nerve
stimulation
Hodges and 30 (15 patients with Measured abdominal, multifidus, and deltoid TA was the first muscle activated and it was not influenced by upper extremity movement
Richardson78 LBP, 15 healthy EMG during rapid shoulder movements direction. All trunk muscles displayed group EMG activation timing differences, but TA
subjects) displayed the most significant difference
Zetterberg et al144 10 healthy men Measured EMG amplitudes during trunk During flexion the abdominal muscles were active, while the ES were inactive. During
movements with prescribed foot positions extension both the ES and abdominal muscles were active. Increased abdominal EMG
and pelvis immobilization amplitudes during attempted trunk extension were associated with increased IAP, while
increased RA EMG amplitude was associated with a more direct trunk stability function
Essendrop and 10 (5 men, 5 women) Measured IAP using a stomach catheter. Women used a higher IAP level and greater trunk extensor torque magnitude to handle heavy
Schibye46 judo athletes Measured abdominal EMG and calculated loads. The RA muscle did not contribute to IAP development
lumbar torques during simulated patient
fall prevention
Abbreviations: EMG, electromyographic; EO, external oblique; ES, erector spinae; IAP, intra-abdominal pressure; IO, internal oblique; L2, lumbar level 2; L4,
lumbar level 4; LBP, low back pain; RA, rectus abdominis; TA, transversus abdominis.

the intrinsic mechanism and prolonged
coactivation.143 With an appropriate mus-
cle spindle gain setting and trunk muscle
coactivation level prior to perturbation,
only minimal reflex responses are needed
to maintain dynamic trunk stability.143
Increased dynamic trunk stability de-
veloped solely through increased trunk
extensor muscle forces, however, would
violate system muscle function balance;
therefore, it is necessary to have balanced
antagonistic trunk flexor muscle coactiva-
tion.32,61 The dynamic trunk stability level
that exists prior to perturbation and the
reflex response that occurs following per-
turbation combine to influence composite
dynamic trunk stiffness and stability.143
Biomechanical adaptations associated
with neuromuscular fatigue and spinal
muscle stiffness may also influence back
injury risk. Augustsson et al12 proposed
that female volleyball athletes may have
more back injuries than men because of
less efficient preparatory trunk muscu-
lar coactivation ability and poor fatigue
resistance. Fatigue negatively influences
muscle spindle behavior and associated
reflex mechanics, including stretch sensi-
tivity, electromechanical delay, and elec-
tromyographic (EMG) signal response
amplitudes.13,143 It has been reported that
lumbar paraspinal muscle fatigue causes
biomechanical adaptations during lift-
ing tasks that contribute to back injury.27
Also, gender differences are known to ex-
ist for noncontractile joint stiffness30 and
for muscularly controlled active joint stiff-
ness.63,65,141 These factors may contribute
to increased back and lower extremity in-
jury risk among women.12 Women tend to
display reduced active muscular stiffness
and stiffness versus force gradients com-
pared to men; therefore, they may require
greater muscle coactivation to achieve
comparable dynamic stability.61 Studies
that clarify how these factors directly in-
fluence gender-specific injury patterns,
however, could not be identified. Because
of the physiologic costs associated with an
increased spinal load and the peripheral
neuromuscular fatigue created by exces-
sive or prolonged muscle coactivation, the
nonimpaired system relies less on preac-
tivation and more on reaction mechanics
(eg, a stabilizing spring) to maintain dy-
namic trunk stability.31,64,65
Dynamic trunk stability is more dif-
ficult to maintain when task intensity
increases. Dynamic trunk stability de-
creases and trunk muscle activation am-
plitudes increase with greater movement
velocity, acceleration, and momentum.
With increased trunk stability demands
during fast, forceful movements, larger
motor units are recruited and fine mo-
tor control modulation is reduced. Faster
movements also reduce the time available
for making neuromuscular corrections.
Feedback delay is a destabilizing factor
in neuromuscular control systems and
greater kinematic errors frequently occur
at faster movement velocities.60
Conventional classification terms, such
as agonist and antagonist, are difficult to
apply to trunk muscle function. Oddsson
and Thorstensson108 suggest that it is im-
portant to relate them to a specific task
and not simply to label them by anatomic
locations. Lavender et al,93 in examining
trunk EMG signal amplitudes during
asymmetric loads, suggested that it was
difficult to determine which muscles were
agonists or antagonists. Kavcic et al86 re-
ported that trunk muscles often perform

708 | november 2008 | volume 38 | number 11 | journal of orthopaedic & sports physical therapy
 Trunk Muscle Coactivation Studies During
J78B;*
Multidirection Isometrics, Perturbation, and Lifting

IjkZo IkX`[Yji C[j^eZi H[ikbji

107
Oddsson et al 8 healthy men Measured trunk EMG amplitudes as subjects Ventrally directed perturbations increased ES amplitudes. Dorsally directed perturba-
performed standing stoop lifts with a 20- tions decreased or completely stopped ES activation, signifying a greater trunk control
kg load, with and without sudden-slipping priority than when lifting alone. Interrupted ES activation during a slip was similar to fall
perturbation injury presentations
Radebold et al116 34 (17 subjects with Measured trunk EMG using a “quick-release” Subjects with LBP had delayed trunk EMG activation timing and had greater coactivation
LBP, and 17 matched harness, with subjects in a semiseated to provide compensatory dynamic stabilization
healthy subjects) position with pelvis fixation
Stokes et al126 13 (7 men, 6 women) Measured trunk EMG activation following Lower preload trunk EMG amplitudes were associated with larger responses after per-
healthy subjects sudden trunk perturbation, with subjects turbation. Adequate dynamic trunk stiffness was observed, without as great a need for
standing in a device that immobilized early or excessive preactivation
the pelvis
Chiang and Potvin29 13 healthy men Measured trunk EMG activation under differ- Larger trunk preactivation EMG amplitudes increased spinal stability. Agonistic and an-
ing preload conditions with pelvic support tagonistic muscles had increased amplitudes under higher loads, larger multisegmental
muscles were important for maintaining spinal stability, and larger preloads resulted in
decreased lateral trunk displacement after perturbation
Berkson et al22 44 (15 men with LBP Measured ES EMG amplitudes as subjects Subjects with LBP exerted forces comparable to healthy subjects. In positions that
and 29 healthy men) exerted forces while standing with their required trunk twisting or bending, subjects with LBP produced lower forces. No
feet in a stationary “work piece” relationship was found between abdominal muscle strength and LBP onset, suggesting
that endurance was the more important factor
Cholewicki et al32 10 (8 men, 2 women) Measured trunk EMG amplitudes following a Trunk extensor: flexor muscle coactivation around a neutral spine was evident with mean
healthy subjects 32-kg load, with subjects in a semiseated  SD coactivation amplitude ratios of 1.7%  0.8% MVIC without loads and 2.9% 
position with an immobilized pelvis 1.4% MVIC with loads
Abbreviations: EMG, electromyographic; ES, erector spinae; LBP, low back pain; MVIC, maximum voluntary isometric contraction.

several functions simultaneously, depend-
ing on instantaneous demands. Studying
the trunk muscle EMG signal amplitudes
of 10 healthy subjects, Andersson et al3
reported that amplitudes changed dras-
tically within the same task and could
even occur on opposite sides of the body,
depending on task posture, effort level,
and the presence of external resistance.3
Trunk muscles antagonistic to the domi-
nant movement are most effective in in-
creasing dynamic trunk stability and, if
inactivated, the greatest stability reduc-
tion occurs.86,89 Pope et al,115 Aspden,11 and
McGill99 have reported that erector spinae
activation occurs primarily to maintain
appropriate lumbar spine posture, while
other muscles generate torque.
Intra-abdominal pressure modulation
is directly related to dynamic trunk sta-
bility. Using a cadaveric model, Tesh et
al127 reported that increased fascial ten-
sion increased local spinal stability, while
increased intra-abdominal pressure had
a more diffuse effect, limiting interseg-
mental vertebral translational and ro-
tational forces. Several researchers have
specifically studied the influence of intra-
abdominal pressure on dynamic trunk
stability, particularly through transversus
abdominis activation (J78B;)).35,36,46,75,78,144
Increased intra-abdominal pressure oc-
curs as a feed-forward conscious pos-
tural strategy during lifting, during other
volitional forceful tasks, and as a reflex
response to sudden, high-loading situa-
tions.35,36 Based on transversus abdomi-
nis EMG activation timing differences
between individuals with low back pain
and healthy subjects, Hodges and Rich-
ardson78 surmised that pain reduced dy-
namic trunk stability.
Muscles best suited for certain move-
ments are activated together, at the trunk,
and throughout the body, as motor control
is task specific. Deconditioning, inhibi-
tion, or dysfunction of other muscles may
also negatively influence dynamic trunk
stability.78 Because the psoas and iliacus
muscles are not solely trunk muscles, the
term “core” refers to muscles that provide
dynamic stability to the composite lum-
bar spine-pelvis-hip region. Quadratus
lumborum is activated synergistically
with the erector spinae and psoas mus-
cles, contributing to 3-dimensional dy-
namic trunk stability.83,102 The multifidus
stabilizes spinal segments when aberrant
motion occurs during trunk rotation and
flexion.8,82 Using magnetic resonance im-
aging (MRI), Kader et al82 detected mul-
tifidus atrophy in 80% of patients with
lumbar disc degeneration and nerve com-
pression. Studying quadratus lumborum,
erector spinae, psoas, and iliacus EMG
signal amplitudes of 7 healthy subjects,
Andersson et al5 reported that the great-
est activation of the quadratus lumborum
and deep lateral erector spinae were ob-
served in side lying as subjects attempted
maximal effort ipsilateral side bending.
The greatest superficial medial erector
spinae muscle activation occurred during
bilateral prone lower extremity lifts. The
greatest quadratus lumborum and deep
lateral erector spinae EMG amplitudes
occurred when the flexion-relaxation
phenomenon was evident for the super-
ficial medial erector spinae. The flexion-
relaxation phenomenon represents the
lumbar extensor muscle relaxation that

journal of orthopaedic & sports physical therapy | volume 38 | number 11 | november 2008 | 709
 [ CLINICAL COMMENTARY
occurs as the spine nears full flexion.
Trunk muscle studies during multidirec-
tion isometric activation, following per-
turbation, and while lifting support its
relationship to dynamic trunk stability
(J78B;*).22,29,32,107,116,125
In summary, activation of the trunk
musculature is highly task specific and
is not always predictable, based on our
current understanding of functional
anatomy and biomechanics.3,5 The great-
er the dynamic stiffness at each spinal
segment through intrinsic and reflex-
ive mechanisms, the greater the overall
trunk stability.104,143 Modestly increased
neuromuscular coactivation levels cre-
ate sufficient stability for most athletic
movements, so that the trunk functions
as a stabilizing spring.19,64,65,79 With appro-
priate preload muscle activation levels,
only minimal reflex responses are needed
to adequately maintain dynamic trunk
stability. Female volleyball athletes may
have more back injuries than men, due
to poorer preparatory trunk muscular co-
activation ability, poor fatigue resistance,
reduced active muscular stiffness, and less
stiffness versus force gradients.12,61 With
proper training, the system relies less on
preactivation and more on reaction me-
chanics, to maintain dynamic trunk sta-
bility along the natural physiologic spinal
coupling path.31,61,64,65 This training is es-
pecially important given the destabilizing
influence and kinematic errors associated
with faster athletic movement velocities.
Transversus abdominis activation and in-
creased intra-abdominal pressure contrib-
ute to increased spinal stiffness.35,36,46,78,144
Appropriate trunk muscle coactivation
levels, particularly between transversus
abdominis and multifidus,82 enable ef-
fective movement and dynamic trunk
stability, with assistance from fascial
connections through the trunk and ex-
tremities. Women rely on higher intra-
abdominal pressure and external torque
magnitudes than men to achieve the same
level of dynamic trunk stability.46 Trunk
muscle deconditioning, inhibition, or
dysfunction may negatively influence dy-
namic trunk stability.78 Individuals with
710 | november 2008 | volume 38 | number 11 | journal of orthopaedic & sports physical therapy
back pain have delayed trunk activation
timing and use greater coactivation lev-
els to increase dynamic trunk stability.116
Trunk endurance is generally more im-
portant than strength for preventing low
back pain onset,22 and trunk extensors’
EMG signal amplitude should be 2 to 3
times greater than trunk flexors’ EMG
signal amplitude to maintain neutral
spine alignment.32 Dynamic trunk stabil-
ity level is inverse to trunk displacement
magnitude following perturbation,29,125
and trunk extensor activation is disrupted
with sudden perturbation, compromising
dynamic trunk stability.107 Developing
trunk muscle motor control, kinesthetic
awareness, endurance, and coordination
is more important than developing abso-
lute strength-power, particularly for fe-
male volleyball players. However, having
an adequate trunk muscle strength-power
reserve is needed for unpredictable events
such as the quick, unanticipated move-
ments that routinely occur with athletic
activities such as volleyball.
7II;IIC;DJE<JHKDA
CKI9B;F;H<EHC7D9;
C
linicians and clinical inves-
tigators use a variety of perfor-
mance tests in evaluating trunk
muscle strength and endurance. These
tests should be reliable, easy to admin-
ister, and have acceptable measurement
properties to follow changes over time.
Surface EMG signal amplitude levels are
commonly used to determine whether a
specific exercise or clinical test provides
adequate stimulus to achieve the desired
response. Andersson et al,4 however, re-
ported that relative EMG signal ampli-
tudes were critically dependent upon the
normalization reference value used, high-
ly task dependent, and considerably in-
fluenced by hip and knee flexion angles.4
Additionally, O’Sullivan et al109 suggested
that trunk muscle activation patterns can
be more sensitively described by calcu-
lating ratios than by using independent
EMG amplitude levels.
Vezina and Hubley-Kozey133 measured
]
the EMG signal amplitude of the external
oblique, rectus abdominis, erector spinae,
and multifidus during pelvic tilting, su-
pine abdominal hollowing, and trunk
stability test (level I) performance in 24
healthy men. Trunk stability test (level I)
was performed with subjects in supine,
with flexed knees and feet flat on an exer-
cise table. While in this position, subjects
were instructed to bring their navel up and
in toward the spine and to progressively
lift each foot off of the table while main-
taining a posterior pelvic tilt until the hip
flexion angle was 90°. External oblique
recruitment was noted with each exercise.
Abdominal and erector spinae coactiva-
tion with less trunk extensor activity was
noted with pelvic tilting and abdominal
hollowing.133 None of the 3 movements
recruited any muscle at sufficient levels to
achieve a strength stimulus.
The abdominal muscle test evaluates
the ability of the abdominal muscles to
isometrically maintain a posterior pel-
vic tilt during lower extremity lowering
movements.55 Gilleard and Brown55 stud-
ied rectus abdominis, external oblique,
and internal oblique EMG signal am-
plitudes in 22 healthy subjects as they
performed the abdominal muscle test,
reporting 4 progressive difficulty levels:
level 1, hook lying with the knees flexed
to 90°; level 2, supine with the hips flexed
to 90° and with thigh support; level 3, the
same as level 2 but without thigh support;
and level 4, active unsupported hip flex-
ion to 90°. In levels 1, 2, and 3 one lower
extremity was lowered as the subject at-
tempted to maintain the posterior pelvic
tilt, while in level 4 both lower extremities
were lowered.55 Based upon EMG signal
amplitudes, levels 1, 2, and 3 were con-
sidered better for evaluating progressive
rectus abdominus strength, while level 4
was more appropriate for determining
internal and external oblique strength.55
A variety of tests may be needed to
evaluate volleyball players of differing
performance levels. Because it requires
greater abdominal muscle coactivation
to stabilize the pelvis and lumbar spine,
the double straight-leg lowering test
(DSLLT) is a challenging dynamic trunk
stability test.122 Shields and Heiss122 had
15 healthy subjects perform the DSLLT
and the bent knee abdominal curl-up
while rectus abdominus, external oblique,
and internal oblique EMG signal ampli-
tudes were measured. Greater external
oblique EMG amplitudes observed dur-
ing DSLLT performance, compared to
bent-knee abdominal curl-up perfor-
mance, were attributed to the narrower
trunk and upper extremity support base,
coupled with longer lower extremity
segment lever arms. This combination
created a greater intrinsic stabilization
requirement for controlling pelvic posi-
tion as hip flexor elongation attempted
to arch the lumbar spine.122,130 Shields
and Heiss122 concluded that the DSLLT
was more effective than the bent-knee
abdominal curl-up for evaluating ab-
dominal muscle coactivation. Youdas et
al,140 evaluating 90 healthy subjects for
standing lumbar lordosis and pelvic in-
clination, reported a gender difference
for the DSLLT, with men being able to
lower their lower extremities farther than
women (mean  SD, 39.4°  11.3° versus
49.6°  11.5°); however, no relationship
was found between lumbar lordosis and
pelvic inclination. They suggested that
isolated abdominal muscle strengthen-
ing or stretching was not sufficient to
correct faulty standing posture.140 Testing
both external oblique and rectus abdomi-
nis performance may be essential when
evaluating dynamic trunk stability.
In studying 38 healthy soldiers using
the isometric trunk stability test, Wohl-
fahrt et al138 reported that subjects who
could perform more than 51 curl-ups in
60 seconds also successfully completed
more isometric trunk stability test levels.
Dynamic trunk stability was also greater
among the subjects who performed curl-
ups more slowly (3 seconds per repeti-
tion) rather than quickly (1 second per
repetition). They suggested that when
curl-ups are performed to evaluate dy-
namic trunk stability they should be per-
formed at a slow, controlled rate to better
challenge endurance.138
journal of orthopaedic & sports physical therapy | volume 38 | number 11 | november 2008 | 711
Determining trunk extensor muscle
endurance is also an essential part of the
trunk performance evaluation. Biering-
Sorensen23 evaluated 82% (479 women,
449 men) of all 30- to 60-year-old in-
habitants of a Copenhagen suburb us-
ing a general health survey, and a low
back physical examination that included
anthropometric measurements, flex-
ibility measurements, and trunk muscle
strength and endurance tests. They re-
ported that men with good isometric
trunk extensor endurance had fewer low
back problems.23 Moffroid et al103 re-
ported an intrarater reliability of r = 0.87
when using the Sorensen test to evaluate
trunk extensor muscle endurance in 28
healthy female students. Arab et al6 eval-
uated the reliability of the Sorensen test,
prone isometric chest raise, supine iso-
metric chest raise, prone double straight-
leg raise, and supine double straight-leg
raise among 200 subjects (20-65 years of
age), with half of the subjects having low
back pain. While all 5 tests showed good
sensitivity, specificity, and predictive
value, the prone double straight-leg raise
test was superior for predicting low back
pain. Moreland et al105 evaluated the ex-
tensor dynamic endurance test among 39
healthy subjects, reporting an intraclass
correlation coefficient (ICC2,1) for inter-
rater reliability of 0.78 (95% CI: 0.68-
0.85). They also evaluated the partial
curl-up test. When 75 repetitions were
considered the maximum, the ICC2,1 for
interrater reliability was 0.89 (95% CI:
0.84-0.93).105 Lanning et al91 evaluated
105 NCAA Division III athletes to es-
tablish baseline trunk endurance values
using the 60-second back extension test.
They reported excellent intratester reli-
ability, with an ICC2,1 of 0.98 and a SEM
of 1 repetition. For the 60-second back
extension test, women’s volleyball ath-
letes (n = 10) could perform a mean 
SD of 45  11 repetitions.91 They also re-
ported fair intratester reliability, with an
ICC2,1 of 0.63 and an SEM of 6 repetitions
for the DSLLT, when using a goniometric
grid on an adjacent wall and a pressure
pad to provide visual posterior pelvic tilt
maintenance feedback.91 Women’s vol-
leyball athletes could perform a mean
 SD of 59  7 repetitions.91 Arendt7
described a core strength screening pro-
gram that included the ability to perform
and maintain (l30 seconds) a single-leg
bridge with each leg, forward plank, re-
verse plank, side bridge, and single-leg
partial squat with appropriate alignment.
An interesting finding reported by Evans
et al47 was that healthy female athletes
had poorer side bridge exercise endur-
ance than males.
In summary, surface EMG signal am-
plitude is highly dependent on the nor-
malization reference value that is used
and is influenced both by movement
task and lower extremity flexion angles.4
Trunk muscle activation characteristics
are more effectively reported as ratios be-
tween different muscles or muscle groups
than by interpretation of independent
EMG signal amplitude levels.109 Men gen-
erally display better performance during
the DSLLT than women.140 The rate of
test performance may influence results,
with a slower, controlled rate being more
indicative of the trunk or abdominal
muscle endurance that is needed to pro-
vide dynamic trunk stability.138 Several
tests have been developed that can reli-
ably determine trunk extensor23,91,103,105
and abdominal55,122,138,140 muscle strength
and endurance. Trunk muscle screening
using the DSLLT,90,122 extensor dynamic
endurance test,105 the 60-second back ex-
tension test,91 and baseline core strength
measurements7,47 enable valid and reliable
establishment of a normative database
among healthy athletes. Screening meth-
ods such as the isometric trunk stability
test,141 trunk stability test,136 abdominal
muscle test,57 and the Sorensen test23 may
be better suited for weaker individuals or
those who have a back injury history. The
prone double straight-leg raise test may
be useful to identify athletes who are at
greater risk for developing low back
pain.6 Dynamic trunk stability with up-
per and lower extremity integration can
be determined using bridge and partial
squat-type movements.7,49 Research is
 [ CLINICAL COMMENTARY ]
Trunk EMG: Spine Compression, Reaction Time,
J78B;+
Learning, and Back Health Studies

IjkZo IkX`[Yji :[iYh_fj_ed <_dZ_d]i

134
Videman et al, 937 male former Finnish Na-
McGill98 tional Team athletes and a
control group of 620 healthy
20-year-old Finnish men
Axler and McGill14 9 healthy men
Luoto et al95 160 (99 subjects with
chronic LBP and 61 healthy
controls)
Wilder et al137 22 (6 subjects with LBP and
16 healthy controls)
Karst and Willett84 25 (12 men, 13 women)
healthy subjects
Abbreviations: EMG, electromyographic; EO, external oblique; ES, erector spinae; IO, internal oblique; LBP, low back pain; RA, rectus abdominis; TA,
transversus abdominis.
Determined LBP odds ratios and compared
group findings
Rated 12 exercises by abdominal EMG
amplitude and estimated lumbar spine
intervertebral compression and shear
forces
Compared upper and lower extremity
reaction times before and after 6 mo of
rehabilitation. Subjects with LBP were
categorized into “good” and “poor” groups
based on Oswestry score
Measured ES and RA EMG reaction time
after fatigue, vibration, and walking in
response to a sudden 2-kg load before and
after a 2-wk rehabilitation program
Measured abdominal muscle EMG following
3 types of trunk curl exercise instructions
Former athletes had less LBP. Additional MRI evaluations identified more frequent
lumbar disc degeneration among soccer players and weight lifters. Sports and
exercise was associated with less LBP in adulthood
No single exercise produced an effective challenge to the RA, EO, and IO muscles,
while also producing low compression. Most exercises significantly increased
compression, even with a high trunk EMG amplitude: compression ratio
Subjects with LBP had delayed reaction times during the initial session. Reaction
times improved among control group men and for the “good” Oswestry score
group. Scores were worse for the “poor” Oswestry score group. Women in the
“good” group had the greatest improvements. Impaired reaction times were more
male specific, while postural impairments were more female specific
Reaction timing improved and magnitudes decreased in patients after the 2-wk
rehabilitation program
Subjects learned to effectively activate deeper abdominal muscles following a
single, brief therapy session, when appropriate verbal and tactile cues were
provided. Instructions were retained for at least 1 wk between sessions

needed to better delineate gender-specif- Andersson et al4 reported that strength
ic performance differences. increased when performing exercises
generating an EMG signal amplitude
9>7H79J;H?IJ?9I greater than 60% to 70% of the EMG
E<;<<;9J?L;JHKDA obtained during a maximal voluntary iso-
CKI9B;;N;H9?I;I metric contraction (MVIC). Granata and
Wilson64 reported that antagonist muscle
recruitment up to 45% MVIC greater
es, however, should be considered when
selecting exercises to improve dynamic
trunk stability.14 Trunk muscle fatigue
may decrease postural control in stand-
ing136 and low back pain is associated
with delayed upper extremity psychomo-
tor speed in response to visual cues.95 Ex-
ercise-based rehabilitation programs can

S
everal reports have evaluated
the relationship between trunk ex-
ercise, spine compression, trunk
muscle reaction time, and effects on long-
term back health (J78B;+).14,84,95,98,134,137 In
evaluating 15 healthy subjects, Vuillerme
et al136 reported that trunk extensor fa-
tigue reduced anterior-posterior and
medial-lateral axis postural control in
standing and increased center-of-pres-
sure variance. Rydeard et al117 reported
that subjects with low back pain who
performed a 4-week Pilates-type exer-
cise program had less pain and disability
at 1-year follow-up. Studying the effects
of standardized submaximal effort trunk
flexion, hip flexion, and lower extremity
lowering exercises on external oblique,
internal oblique, rectus abdominis, ili-
acus, sartorius, and rectus femoris EMG
signal amplitudes among 6 healthy men,
than equilibrium condition EMG signal
amplitudes were required to improve dy-
namic trunk stability during static lifting
exertions via agonist-antagonist coacti-
vation, particularly during asymmetric
postures.64 Several reports have suggest-
ed that trunk EMG signal amplitudes of
25% MVIC are sufficient to maximize
spinal stiffness during many activities of
daily living or exercises, while prolonged
activation at higher amplitudes may ad-
versely increase compression.8-10,36
In summary, previous sports and ex-
ercise program participation other than
weight lifting or soccer generally resulted
in less low back pain in adulthood. 98,134
Dynamic trunk stability training can
help maintain back health and decrease
disability.117 Both muscle EMG signal
amplitudes and spinal compression forc-
improve the reaction timing and muscle
activation efficiency of subjects with low
back pain.137 Back pain onset reportedly
may occur with prolonged trunk exten-
sor activation at only 5% MVIC levels.80
Exercises requiring low muscle activa-
tion of less than 5% to 30% MVIC are
generally adequate to improve trunk and
abdominal muscle endurance, stability,
and stiffness,8-10,36,64,79,80,89,133 while exer-
cises that require 35% to 45%8,36,64 and
more than 45% MVIC4,64,80,89 are needed
to achieve moderate and high strength-
power training effects, respectively. Even
a single exercise instruction session can
be sufficient to achieve and retain more
efficient abdominal muscle activation
characteristics.84 Because specific neu-
romuscular activation patterns differ
depending on posture, movement char-

712 | november 2008 | volume 38 | number 11 | journal of orthopaedic & sports physical therapy
 J78B;, Trunk Muscle Activation Studies During Exercise

IjkZo IkX`[Yji :[iYh_fj_ed <_dZ_d]i

8
Arokoski et al 11 (5 men, 6 women) healthy
subjects
Arokoski et al9 24 (14 women, 10 men)
healthy subjects
Escamilla et al44 21 (11 women, 10 men)
healthy subjects
Escamilla et al45 14 (7 men, 7 women) healthy
subjects
Ekstrom et al43 30 (19 men, 11 women)
healthy subjects
Abbreviations: EMG, electromyographic; EO, external oblique; ES, erector spinae; IO, internal oblique; LBP, low back pain; MVIC, maximum voluntary
isometric contraction; RA, rectus abdominis; TA, transversus abdominis.
Measured lumbar paraspinal and gluteus
maximus EMG amplitudes during 18
exercises, with and without use of 1-kg
(women) and 2-kg (men) hand weights
Measured abdominal and lumbar paraspinal
EMG amplitudes during 16 exercises,
including standing balance activities
with and without hand weights (1 kg for
women, 2 kg for men)
Measured abdominal and paraspinal EMG
amplitudes during 12 abdominal muscle
exercises
Measured abdominal and paraspinal EMG
amplitudes during 7 abdominal exercises
and with commercial devices
Measured trunk, hip and thigh EMG ampli-
tudes during 9 exercises
Multifidus EMG amplitudes averaged 5% to 30% MVIC and paraspinal amplitudes
were greater for women at the fifth lumbar vertebra level. Hand weight use in-
creased paraspinal EMG amplitudes during walking and balance board activities
Prone lumbar extension created the greatest lumbar paraspinal EMG amplitudes.
Amplitudes were also high for standing, sitting, and bridging exercises. Women
could more effectively activate trunk stabilizing musculature than men; however,
they required greater abdominal and paraspinal normalized EMG amplitudes
relative to MVIC than men to achieve comparable dynamic trunk stability levels
The PowerWheel (Lifeline USA, Madison, WI) roll-out and hanging knee-ups with
upper extremity support were most effective. Upper and lower RA, IO, and EO
EMG amplitudes were greater during the hanging knee-up than during bent-knee
sit-ups. Roll-outs, pike movements, and knee-ups using the PowerWheel, hanging
knee-up with upper extremity support, and reverse crunches increased abdomi-
nal EMG amplitudes and recruited latissimus dorsi. The PowerWheel roll-out was
the most effective exercise for recruiting abdominal and latissimus dorsi muscles,
while minimizing rectus femoris and lumbar paraspinal activity
The Ab Slide and Torso Track were effective for activating abdominal and upper
extremity muscles, while minimizing paraspinal and rectus femoris activity
Exercises that provided the most consistent core strength stimulus (45%-55%
MVIC) were the bridge, unilateral bridge, side bridge, alternating arm-leg lift from
quadruped, and lateral step-ups. The forward lunge, active hip abduction, and lat-
eral shuttle training (Dynamic Edge, The Skier’s Edge, Park City, UT) provided lower
core EMG amplitudes, suggesting a greater endurance or motor control stimulus

acteristics (type, magnitude, velocity),
and spinal loads, these factors should
be considered during exercise selection
or creation to avoid violating the specific
adaptations to imposed demands (SAID)
principle of training and therapeutic
exercise.3,19,28,34,49,92
LEBB;O87BB#
IF;9?<?9JH7?D?D=
test before participating in more intense
activities.42 Individuals with a history of
low back pain often have poor hamstring
extensibility, poor spinal flexibility, a re-
duced lumbar lordosis, and hip muscle
weakness or imbalance.67 The athlete
should be encouraged to cognitively link
effective volleyball skill performance to
dynamic trunk stability and incorporate
structured visualization activities be-
tween sessions to reinforce the neuromo-
tor control aspects of the program.20
slide devices, dumbbells or cuff weights,
or support straps, can provide an effective
and fun adjunct to skill development.68
Unilateral bridging exercises performed
on a stability ball while maintaining neu-
tral spine alignment promote greater
internal and external oblique muscle
coactivation levels than similar exercises
performed on a stable surface.7,124,131
Rather than focusing solely on vol-
leyball, young athletes between 6 and 12
years of age should participate in a variety

A
n effective dynamic trunk sta-
bilization program for volleyball
athletes should focus on developing
appropriately timed and modulated trunk
muscle coactivation, while maintaining
neutral spine alignment in positions of
relevance during skill performance. In
addition to possessing adequate trunk
muscle endurance, motor control-kines-
thetic awareness, and strength-power, the
volleyball athlete should not experience
discomfort with active trunk mobility,
should have good hamstring extensibil-
ity, and should display a negative Stork
In addition to basic running, jumping,
and throwing, early volleyball training
should include foundational agility, bal-
ance, and coordination activities. Within
this scenario, technique takes precedent
over training strictly to improve strength
or endurance. Functional trunk and core
neuromuscular control-kinesthetic aware-
ness, muscle endurance, and strength-
power development using bodyweight
resistance, with or without use of devices
such as resistance and stability balls, elas-
tic resistance bands, abdominal roller or
of activities to maximize sensori-motor
development.16,85 Foundational trunk and
core development can be extrapolated to
activities of daily living and sports other
than volleyball. It has been estimated
that up to 95% of neural system develop-
ment occurs by 7 years of age; therefore,
appropriate coordination development
during these formative years is essential,
particularly for female athletes.70,118,141,142
Between 13 and 16 years of age, however,
the focus shifts to developing foundation-
al volleyball skills such as setting, serving,

journal of orthopaedic & sports physical therapy | volume 38 | number 11 | november 2008 | 713
 [ CLINICAL COMMENTARY ]
Phase 1
Foundational abdominal
trunk extensor coactivation
to maintain neutral spinal
column alignment

Hook lying
Side lying
Supine
Prone
Seated
Kneeling, half-kneeling
Standing

Phase 2 Phase 3
Dynamic trunk stability with Volleyball-specific movement
progressive frontal- skill simulations with
<?=KH;+$Dynamic stability training on the Center
of Rotational Exercise (Ground Force 360; Webb’s
transverse plane and upper- appropriate trunk posture
Machine Design, Clearwater, FL). lower extremity integration maintenance

digging, blocking, and spiking. Between

17 and 20 years of age, instruction focus-
es more on tactical components and team
dynamics. During this phase, only sports
with complementary movement patterns,
skill sets, and physiological energy system
requirements to volleyball such as basket-
ball, tennis, or soccer are encouraged.17
During this phase, volleyball practices
include focused individualized instruc-
tion, with fine-tuning of both ancillary
and sport-specific capabilities.16,17 These
phases are intended to seamlessly flow
between each other to develop the appro-
priate combination of stamina, strength,
speed, skill, and suppleness.16,17 Scannell
and McGill,119 in studying the effects of
a trunk exercise program on the passive
lumbar spine stiffness in 150 healthy sub-
jects who presented with either excessive
or reduced lordotic postures, reported
that a 12-week program was effective in
achieving more neutral spine alignment.
The prescriptive use of more than 1
exercise is generally needed to improve
dynamic trunk stability in a functionally
relevant manner.100 Thomson129 reported
that when selecting exercises to improve
dynamic trunk stability, those requiring
greater internal and external oblique ac-
tivation should be a priority because they
Quadruped, "bird dog"
Multidirectional bridging,
rolling
Double single-leg squats
AP, ML, diagonal lunges
AP, ML, diagonal double
single-leg hops
AP, ML, diagonal double
single-leg jumps
<?=KH;,$Three phases approach to improving dynamic trunk stability in volleyball athletes. Abbreviations: AP,
anterior-posterior; ML, medial-lateral.
have the greatest capacity to enhance sta-
bility through increased intra-abdominal
pressure. Several researchers have evalu-
ated trunk EMG amplitudes during exer-
cise performance (J78B;,).8,9,43-45
Innovative exercise devices that pro-
vide controlled range of motion, spinal
loading, and concentric-eccentric resis-
tance, with 3-dimensional trunk-lower
extremity integration during simulated
athletic movements, may decrease the
total number of exercises needed to
achieve the same training effect (<?=KH;
+). Holistic screening methods like the
star excursion test may also enable more
precise determination of an athlete’s ca-
pacity to maintain dynamic trunk-core
Pass
Set
Spike
Serve
Block
Dig
Dive
Roll
stability, coordination, and balance dur-
ing integrated trunk-lower extremity
movements.66,69,114
To be effective, the program should
blend clinical experience and scientific
evidence, while not violating the SAID
principle.34 An exercise selection, se-
quence, and volume progression that
best suits a particular athlete depends
on a variety of factors, including previ-
ous injury history and mechanism(s) of
any existing injury, general fitness level,
training goals, and future loading ex-
pectations. In designing a program for
the average healthy individual, McGill100
recommended beginning with trunk flex-
ion-extension (sagittal plane) and gradu-

714 | november 2008 | volume 38 | number 11 | journal of orthopaedic & sports physical therapy
 J78B;- Suggested Exercises by Dynamic Trunk Stability Program Phase
F^Wi['
14,100
Pelvic tilting
Abdominal hollowing and bracing97,124
Alternating pressure from a quadruped position8
Single-leg extension from quadruped100
Side-lying hip abduction43
43,124
Bridging
Cat stretch100
Active leg swing in standing8
Lateral step-ups (10-cm step)43
43
Progressive lunges
Abdominal curl-ups14,89
ally integrating hip and knee movements
(longer lever arms to increase resistance),
while facilitating and maintaining neutral
spine alignment. Lastly, specific muscle
groups should be trained as needed, us-
ing isolated multiplanar movements.100
Arokoski et al8,9 recommended gradually
progressing from exercises requiring 5%
to 30% MVIC trunk EMG signal am-
plitude levels to those requiring 30% to
50%, and from slow to fast exercise veloc-
ities to reduce reaction time and improve
dynamic trunk stability.
With consideration for these reports
we have designed a 3-phase dynamic
trunk stability program for the volley-
ball athlete that also integrates upper
and lower extremity influences on dy-
namic trunk stability and lower extrem-
ity injury prevention.28,53,67,94,126,141,142 The
program should also contribute to a
performance advantage, which should
improve adherence. Phase 1 focuses on
developing foundational motor control,
kinesthetic awareness, and endurance
during slower velocity movements, with
clinician-provided cues to establish bio-
mechanically neutral spine alignment in
journal of orthopaedic & sports physical therapy | volume 38 | number 11 | november 2008 | 715
F^Wi[(
89
Horizontal trunk extension (Roman chair)
Lateral trunk flexion with fixed legs89
Hanging knee-ups with upper extremity support straps44
Power Wheel roll-out44
Torso Track or Ab Slide45
Prone bridges43
Lateral step-ups (20-cm step)43
Quadruped alternating upper and lower extremity lifts8,43,100
Lateral bridges14,43,100
Reverse crunch on 30° incline44
Dynamic cross-knee curl-up14,100
Prone bent-knee unilateral hip extension8
Quarter sit-ups14
various general activities of daily living
positions. Phase 2 progresses to higher
velocity, more dynamic multiplanar en-
durance, strength-power, and coordi-
nation challenges incorporating upper
and lower extremity movements.7,87,88,92,97
Phase 3 integrates volleyball-specific skill
simulations, taking composite movement
patterns and “deconstructing” them into
component parts that focus on maintain-
ing neutral spine alignment at specific
phases to challenge dynamic trunk sta-
bility (<?=KH;,).68
Volleyball requires repeated maximal
or near maximal effort vertical jumps, fre-
quent change of direction sprints, diving
or digging to make a save, and repeated
overhead upper extremity movements
when spiking or blocking.68 The average
volleyball play lasts about 6 seconds, fol-
lowed by a rest of 14 seconds, not includ-
ing player substitutions and time-outs.50
Based on this work-rest ratio, the vol-
leyball athlete relies primarily on the ad-
enosine triphosphate-creatine phosphate
energy system. However, there are also
about 50 rallies per game. Therefore, con-
ditioning programs should ultimately con-
F^Wi[)
Upper extremity-trunk supine serve simulation using a stability
ball and a volleyball or resistance ball (<?=KH;-7)
Upper extremity-trunk-lower extremity dive simulation using a
stability ball and a volleyball or resistance ball (<?=KH;-8)
Upper extremity-trunk seated serve simulation using a stability
ball and a volleyball or resistance ball (<?=KH;-9)
Upper extremity-trunk-lower extremity standing passing simula-
tion using a stability ball and a volleyball or resistance ball
(<?=KH;-:)
sist of 50 or more 5- to 10-second repeats,
each followed by 10 to 15 seconds of rest.25
Because 10% of rallies exceed 15 seconds,
some training activities should last 20 to
45 seconds.68 These parameters should be
considered when performing the exercises
recommended for phases 2 and 3 of our
program (J78B;-"<?=KH;-"EDB?D;L?:;EI).
Phase 1, however, should not compromise
its focus on slow-velocity, subtle aspects
of maintaining neutral spine alignment,
motor control, kinesthetic awareness, and
endurance. During phase 2, progressively
higher velocity, more advanced endurance,
strength-power, and coordination exer-
cises are performed. These exercises are
integrated with multidirectional hopping
and jumping agility and reaction time ma-
neuvers. Phase 3 represents a transition
zone with phase 2, where the clinician
interacts with the athlete to achieve en-
durance and strength-power goals while
revisiting appropriate dynamic trunk sta-
bility and neutral spine alignment during
the performance of specific volleyball task
subcomponents. This integrated activity
would serve either for preseason or in-
season back injury prevention training
 [ CLINICAL COMMENTARY ]
or for progressive rehabilitation, with the
injured athlete gradually returning to full
practice activities.
In summary, it is essential to develop
effective motor control and kinesthetic
awareness while also establishing cognitive
links between exercise tasks and volleyball
performance.20,68 For young individuals
between 6 to 12 years of age sensorimo-
tor developmental experiences should be
emphasized.16,17,85 Body weight resistance
during bridging movements7,43,47,124,131 on
unstable surfaces,8,124,131 with and without
use of devices such as the PowerWheel,
Ab Slide, and upper extremity support
straps,44,45 can effectively stimulate greater
muscle activity of the trunk musculature.
Women tend to have greater EMG signal
amplitude of the trunk extensors than
men to achieve similar dynamic trunk sta-
bility levels.8,9 Appropriate exercises and
cues enable effective teaching and main-
tenance of neutral spinal alignment.119
The exercise program should be individu-
alized, based on a variety of factors (in-
cluding injury history and fitness level),
generally beginning with slower velocity
trunk flexion-extension movements, and
gradually integrating progressively higher
velocity upper and lower extremity move-
ments while maintaining neutral spinal
alignment.100 Exercise volume should
modify work and rest intervals to closely
match physiological requirements,25,50,68
and movement patterns should closely
simulate the biomechanical demands of
volleyball.49,68

IKCC7HO

T
o decrease the incidence of
back injury among volleyball ath-
letes a focused exercise plan is
suggested. Screening methods such as
the DSLLT, extensor dynamic endur-
ance test, the 60-second back extension
test, and baseline core endurance and
<?=KH;-$Phase 3 exercise examples. Upper extremity-trunk supine serve simulation using a stability ball and a strength measurements can help estab-
volleyball or resistance ball (A), upper extremity-trunk-lower extremity dive simulation using a stability ball and a lish a normative database among healthy
volleyball or resistance ball (B), upper extremity-trunk seated serve simulation using a stability ball and a volleyball athletes. Screening methods such as the
or resistance ball (C), and upper extremity-trunk-lower extremity standing passing simulation using a stability ball isometric trunk stability test, trunk sta-
and a volleyball or resistance ball (D).
bility test, abdominal muscle test, and

716 | november 2008 | volume 38 | number 11 | journal of orthopaedic & sports physical therapy
the Sorensen test may be better suited for
weaker individuals or those who already
have a back injury. Learning or relearning
how to maintain neutral spine alignment
and effective trunk muscle coactivation
is essential, particularly among female
athletes. Motor control, kinesthetic
awareness, strength-power, and reaction
timing are important; however, having
adequate trunk muscle endurance may
be the single most important factor. No
single conventional exercise is likely to
address all dynamic trunk stability needs
and exercise selections should consider
trunk muscle activation levels and spinal
compression. Local and global muscle
activation levels are best determined by
calculating EMG signal activation ampli-
tude ratios than by relying on individual
muscle EMG signal amplitudes.
This conceptual program consists of
3 phases: phase 1 primarily addresses
motor control, kinesthetic awareness,
and endurance, using slow-velocity
movements, with the clinician provid-
ing cues to establish a biomechanically
neutral spine alignment; phase 2 uses
progressively higher velocity and more
dynamic multiplanar endurance, coor-
dination, and strength-power challenges
integrating upper and lower extremity
movements; and phase 3 integrates vol-
leyball-specific skill simulations breaking
down composite movements into compo-
nent parts with differing dynamic trunk
stability requirements, while continuing
to emphasize the maintenance of neutral
spine alignment. This program is concep-
tual, and prospective research is needed
to validate its efficacy. T
H;<;H;D9;I
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720 | november 2008 | volume 38 | number 11 | journal of orthopaedic & sports physical therapy

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