ORIGINAL RESEARCH

ANATOMY & PHYSIOLOGY

Activity of Deep and Superficial Pelvic Floor Muscles in Women in

Response to Different Verbal Instructions: A Preliminary Investigation
Using a Novel Electromyography Electrode
Rafeef Aljuraifani, MSc,1,2 Ryan E. Stafford, PhD,1 Leanne M. Hall, PhD,1 and Paul W. Hodges, PhD1

ABSTRACT

Introduction: Verbal instructions are used clinically to encourage activation of the pelvic floor muscles (PFM).
Whether separate layers of PFM activate differently in response to instructions remains unknown.
Aim: To test the hypotheses that (i) instructions that aimed to bias activity of a specific muscle layer would
increase activation of the targeted layer to a greater extent than the other layer, (ii) activity of individual PFM
layers would differ between instructions, and (iii) PFM activity would be symmetrical for all instructions.
Method: PFM electromyography (EMG) was recorded using custom-designed surface electrodes in 12 women
without PFM dysfunction. The electrode included 4 pairs of recording surfaces orientated to measure EMG from
deep and superficial PFM on each side. 3 submaximal contractions were performed for 5 seconds in response to 7
verbal instructions. Root-mean-squared EMG amplitude was calculated for 1 second during the period when
participants most closely matched the target activation level. A repeated-measures ANOVA was used to test whether
PFM EMG differed between instructions and between regions. The EMG increase of individual muscles relative
to that of the reference muscle [deep/right PFM] was compared to no change with t-tests for single samples.
Main Outcome Measure: PFM EMG amplitude.
Results: Superficial PFM EMG was greater than deep PFM for all instructions (P ¼ .039). 2 instructions
induced the greatest amplitude of EMG for the superficial PFM: “squeeze the muscles around the vaginal
opening as if to purse lips of your mouth” and “draw the clitoris in a posterior direction” (P ¼ .036). Asymmetry
was found in the deeper PFM in 3 instructions designed to bias the superficial PFM.
Strength & Limitations: This preliminary study recorded activation of deep and superficial PFM layers in
females with a custom-designed novel electrode. Some cross-talk of recording between muscle layers is possible
but unlikely to impact the major findings.
Conclusion: Verbal instructions used to teach PFM contractions can influence their pattern of activity. This
study provides preliminary evidence that, in a selection of verbal instructions, the superficial PFM activates more
than the deep PFM, and that the deep PFM can have asymmetrical activation. Aljuraifani R, Stafford RE, Hall
LM, et al. Activity of Deep and Superficial Pelvic Floor Muscles in Women in Response to Different Verbal
Instructions: A Preliminary Investigation Using a Novel Electromyography Electrode J Sex Med
2019;16:673e679.
Copyright
2019, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Electromyography; Pelvic Floor Muscles; Verbal Instructions; Bulbocavernosus

INTRODUCTION
Female pelvic floor muscles (PFM) include the levator ani muscle
Received August 13, 2018. Accepted February 11, 2019. group located deep to the perineal membrane,1 and a layer superficial
1
The University of Queensland, Centre for Clinical Research Excellence in to the membrane (bulbocavernosus and ischiocavernosus muscles).2
Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences,
Each PFM is paired (left and right), has an independent nerve supply,
Brisbane, Australia;
2 and has distinct anatomic features.3 Deep PFM control continence,4
Princess Noura bint Abdulrahman, Riyadh, Saudi Arabia
provide pelvic organ support5,6 and contribute to a range of sexual
Copyright ª 2019, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved. functions.7e9 Although superficial PFM have primarily been
https://doi.org/10.1016/j.jsxm.2019.02.008 considered with respect to sexual function,10e12 they may also play a

J Sex Med 2019;16:673e679 673

674
role in organ support.2,13 The anatomic attachments of the super-
ficial PFM to the clitoris and the cavernous structures suggest a role in
clitoral erection11,12 associated with their activation with rapid
vaginal distention.12 Training programs for urinary incontinence,14
sexual pain disorders9,15 and other pelvic floor dysfunction16 include
exercise for the PFM. Verbal instructions are used to teach patients to
contract PFMs, but they are rarely reported in detail, despite their
potential impact on the pattern of PFM activation (which has been
shown in men17). Impact of specific cues on patterns of deep and
superficial PFM activation in women is unclear.
Various verbal cues are used to teach PFM contractions, but
rationales for instruction selection are generally not provided.
Although isolated activity of 1 muscle is unlikely,18 encourage-
ment of dominant activation of either the deep or superficial
PFMs may be beneficial for specific clinical conditions. For
example, in women with stress urinary incontinence, the
sequence of electromyography (EMG) onset of PFM layers is
modified,19 and exercise to target the superficial PFM might be
beneficial. Women with levator ani weakness may benefit from
an exercise program that targets the deep layer
Anatomy and function provide a basis to propose instructions to
bias activity to specific PFM. Activity of the PFM may be assessed
using a range of methods, including ultrasound imaging, digital
palpation, and EMG.20 Surface EMG has advantages because it
provides a non-invasive and objective measurement of muscle acti-
vation,21 and ultrasound imaging has not yet been validated as an
estimate of superficial PFM activation. Based on attachment of bul-
bocavernosus/ischiocavernosus to the clitoris, an instruction to “draw
the clitoris posteriorly” may target their activation. Both bulboca-
vernosus and ischiocavernosus attach to the clitoris and are capable of
pulling on it,22 and, therefore, such an instruction, although not
traditionally used, is likely to bias the activation of those muscles.
Alternatively, verbal instructions to “lift” the pelvic floor may bias
activity to deep PFMs, consistent with their role in elevation.6 Such
instructions are used traditionally to bias the activation of the deeper
levator ani in exercise programs to treat urinary incontinence.
PFM EMG might also be asymmetrical in response to instruction,
even in healthy nulliparous women.3 Although the impact of
asymmetrical activation on PFM function remains unclear, asym-
metrical levator ani injury from vaginal birth (eg, avulsion) con-
tributes to pelvic organ prolapse.5 Evaluation of potential asymmetry
in response to different instructions requires consideration. This
study aimed to test the hypotheses that (i) instructions that aimed to
bias activity of a specific muscle layer would increase activation of the
targeted layer to a greater extent than the other layer, (ii) activity of
individual PFM layers would differ between instructions, and (iii)
PFM activity would be symmetrical for all instructions.
MATERIALS AND METHODS
Participants
12 female participants with a mean (SD) age of 34 (10) years
were recruited. 2 participants were multiparous. Participants
Aljuraifani et al
were excluded if they were <18 years or had a history of any
major neurologic condition. Participants were also excluded if
they had any history of pelvic floor dysfunction, to limit possible
effects on PFM function or involvement in PFM training. The
Institutional Medical Research Ethics Committee approved the
study, and all participants provided informed written consent.
Electromyography
The single-use surface EMG electrode used to record EMG
from the deep and superficial PFM layers bilaterally was custom
made by addition of recording surfaces to a commercially avail-
able Educator device (Neen; Patterson Medical, Sutton-in-
Ashfield, United Kingdom). 4 recording surfaces were made
from pairs of silver wires (1 mm diameter) threaded through
holes drilled at specific sites on the Educator (Figure 1). For each
pair, 15 mm of wire was exposed on the surface of the Educator,
and 30 mm separated the deep from superficial electrode pairs.
The orientation of the wires was such that each pair of wires was
placed in the optimal direction perpendicular to the expected
fiber orientation. Recording wires were connected to multiwire
cable that exited the probe via a hole in the distal end. The probe
was sterilized before use and was inserted into the vagina. The
shape of the device assisted maintenance of a consistent location.
The cable was secured with tape to the inner thigh. EMG data
were bandpass filtered (20e1,000 Hz), amplified 2,000 times
(Neurolog; Digitimer, Hertfordshire, United Kingdom), and
sampled at 4 kHz using a Power1401 acquisition system coupled
with the Spike2 software (Cambridge Electronic Design Limited,
Cambridge, United Kingdom).
Procedure
Participants self-inserted the electrode after detailed instruction,
with emphasis on correct orientation and were then positioned in
long sitting with a back support reclined to w60 from horizontal.
They were instructed to keep the leg and back muscles relaxed to
limit potential for cross-talk. Participants performed 2 repetitions
of a PFM maximum voluntary contraction (MVC). Peak EMG of
the deep PFM on the side of hand dominance (all subjects were
right-hand dominant) was used to calculate a 25% MVC target
Figure 1. Custom-made surface (EMG) electrode designed to re-
cord from deep and superficial layers of pelvic floor muscles. Note
the location of pairs of silver wires (1 mm diameter, 15 mm long)
separated by 5 mm and oriented such that they were along the
approximate direction of muscle fibers. EMG ¼ electromyography.
J Sex Med 2019;16:673e679
Pelvic Floor Muscle Activation with Verbal Instruction
that was displayed to the participant with real-time PFM EMG on
a computer monitor. Participants performed 3 contractions
according to 7 different instructions, in random order, with the
intensity of contraction controlled by EMG feedback. Each
contraction was held for 5 seconds’ hold, followed by 10 seconds’
rest. The researcher performing the experiment was a physio-
therapist with experience in pelvic floor rehabilitation. The in-
structions included a combination of instructions described in
previous studies, instructions based on anatomy of the muscles,
and instructions based on discussion with experienced physio-
therapists. They were as follows:
1. “Squeeze around the pelvic openings”—aimed to encourage
activation of all PFM layers.
2. “Squeeze around the back passage without lifting”—aimed to
bias activation to the superficial PFM.
3. “Squeeze around the vaginal opening without lifting”—aimed
to bias activation to the superficial PFM.
4. “Squeeze and lift from the back as if to prevent passing
wind”—aimed to bias activation to the deep PFM.
5. “Tighten around the urethra as if to stop the flow of
urine”—aimed to bias activation to the deep PFM.
6. “Squeeze the muscles around the vaginal opening as if to
purse lips of your mouth”—aimed to bias to activation to the
superficial PFM.
7 .“Draw the clitoris in a posterior direction”—aimed to bias
activation to the superficial PFM.
Participants were asked informally whether the instruction was
clear and whether it made sense.
Data Analysis
Custom-written programs were used to analyze the data
(MATLAB r2015a; The MathWorks Inc, Natick, MA, USA).
Root-mean-squared EMG amplitude was calculated for 1 sec-
ond, during the period when participants most closely matched
the target activation level (25% MVC). This was identified using
a 1-second sliding window with 90% overlap. Root-mean-
squared EMG was also calculated for 1 second during the
MVC for EMG normalization, as well as during the rest interval
between contractions to identify baseline EMG noise.
Because the 25% MVC target was matched with variable accu-
racy between participants, the normalized EMG amplitude from
the remaining channels (deep/left, superficial/right, superficial/left)
were expressed as a proportion of that of the deep/right PFM. This
analysis accounts for differences in accuracy of matching the target
EMG and prevents loss of data. The analysis assumes the relation-
ship between is proportional, and addressed the objective of whether
the pattern of activation of the other muscles differed between tasks
when the deep/right PFM EMG amplitude was controlled.
Statistical Analysis
Because data were expressed relative to deep/right PFM EMG,
statistical analysis involved 2 steps. First, we investigated the
J Sex Med 2019;16:673e679
675
potential for differences between muscles within each instruction,
and between instructions for each muscle (superficial/left, su-
perficial/right, and deep/left) using repeated-measures ANOVA.
Second, potential differences between deep/right and each of the
other muscles within each task was investigated by comparison
the EMG of each muscle (as a ratio relative to deep/right PFM)
against no difference (ie, value of 1) using t-tests for single
samples. This analysis also enabled comparison between left and
right sides of deep PFM. It was not meaningful to compare deep/
right between tasks because this was controlled to be 25% MVC.
RESULTS
All participants indicated that the instructions were clear and
made sense to them. All instruction resulted in a measurable
change n PFM EMG.
Comparison Between Muscles Within Instructions
Repeated-measures ANOVA between muscles across all in-
structions showed a significant main effect for muscle (P ¼ .039;
Figure 2); superficial PFM EMG was greater than that of the
deep/left PFM (post hoc: superficial/left P ¼ .037, superficial/
right P ¼ .026). No significant Muscle  Instruction interaction
(P ¼ .19) indicates that the relationship was consistent across
instructions. Single-sample t-tests showed that the superficial
PFM EMG (both sides) was greater than that of the deep/right
PFM across instructions (all: P < .008; Figure 2),
Comparison Between Instructions for Each Muscle
Comparison of each PFM EMG as a proportion of deep/right
PFM EMG between instructions revealed that superficial PFM and
deep/left PFM (relative to that of deep/right) EMG was greater
during Instruction 7: “Draw the clitoris in a posterior direction”
(Main effect—instruction: P ¼ .036; post hoc: P ¼ .010; Figure 2)
and Instruction 6: “Squeeze the muscles around the vaginal opening
as if to purse lips of your mouth” (P ¼ .028) than Instruction 1:
“Squeeze around the pelvic openings.” There was no significant
interaction between Muscle  Instruction (P ¼ .19), which means
activity of deep/left PFM was also greater in these instructions (22%
greater than deep/right). Taken together with greater superficial
PFM EMG across tasks (see above), it is apparent that the superficial
PFM had the greatest EMG increase during these tasks (49e58%
greater than deep/right). 6 participants (50%) demonstrated the
greatest increase in superficial/right PFM EMG during Instruction
7, “Draw the clitoris posteriorly.” EMG for Instruction 7 was also
greater than the 2 instructions that aimed to encourage deep PFM
activation (Instruction 4: “Squeeze and lift from the back as if to
prevent passing wind” [post hoc: P ¼ .023] and Instruction 5:
“Tighten around the urethra as if to stop the flow of urine” [P ¼
.050]). There was no difference between Instructions 2 and 3 that
encouraged tightening without lift (ie, aimed to bias toward su-
perficial PFM)(P ¼ .66). Furthermore, there was no difference
between Instructions 6 and 7, which aimed to bias superficial PFM
activation (P ¼ .12).
676 Aljuraifani et al

Figure 2. Group data of the comparison of PFM EMG activity among 7 different instructions; Instruction 1: squeeze around the pelvic openings;
Instruction 2: squeeze around the back passage without lifting; Instruction 3: squeeze around the vaginal opening without lifting; Instruction 4:
squeeze and lift from the back as if to prevent passing wind; Instruction 5: tighten around the urethra as if to stop the flow of urine; Instruction 6:
squeeze the muscles around the vaginal opening as if to purse lips of your mouth; and Instruction 7: draw the clitoris in a posterior direction.
Differences between instructions is indicated by the top significance bar. Note that there was no muscle  instruction interaction. Conditions with
greater left/deep EMG than right/deep EMG are marked with (#). Superficial PFM EMG was greater than deep/left across all instructions (main
effect not shown). EMG ¼ electromyography; PFM ¼ pelvic floor muscle; Sup ¼ superficial; * ¼ P < .05.

Symmetry of PFM EMG
Post hoc analysis of the repeated-measures ANOVA showed no
difference between the left and right superficial PFM (P ¼ .78).
Potential differences between sides for the deep PFM using the
single sample t-test showed that deep/left PFM EMG was greater
than deep/right PFM EMG for 3 instructions aimed to bias
activation of superficial PFM (Instruction 6: “Squeeze the mus-
cles around the vaginal opening as if to purse lips of your
mouth,” P ¼ .018; Instruction 7: “Draw the clitoris in a pos-
terior direction,” P ¼ .040; Instruction 2: “Squeeze around the
back passage without lifting,” P ¼ .047; Figure 2). Inspection of
data for individual participants showed that this asymmetry was
present for 67e75% of the participants, depending on the
instruction.
DISCUSSION
These data support the hypothesis that the pattern of PFM
activation can be modified by verbal instruction. Superficial PFM
activated to a greater proportion of their MVC than deep PFM
during all instructions, and superficial and deep/left PFM EMG
varied between instructions. Although the absence of a signifi-
cant interaction between muscle and instruction indicates that
the superficial PFM and deep/left PFM changed in a similar
manner between instructions, consideration of the different an-
alyses together reveal key differences between instructions.
Notably, the largest superficial PFM EMG was evoked by 2
instructions that aimed to bias to these muscles (Instructions 6
and 7). Furthermore, although none of the instructions aimed to
evoke greater EMG on 1 side, our data showed systematic
asymmetry of deep PFM EMG in response to some instructions.
Deep and Superficial PFM Activation
Although deep and superficial PFMs activated with all in-
structions, there was a greater increase in superficial PFM EMG
relative to deep/right PFM (muscle used for feedback) for all
instructions. This implies women bias contraction to these
muscles when performing voluntary PFM contractions. Several
alternative methodologic explanations require consideration.
First, greater superficial PFM EMG might be explained by the
inferior mechanical efficiency of these muscles because of their
smaller size, which would require a systematically higher level of
activity relative to MVC. Second, cross-talk from hip muscles
might also contribute to the greater superficial PFM EMG. This
is unlikely to explain our finding because cross-talk would be
expected to be greatest during MVC. That would lead to rela-
tively lower activity during submaximal efforts when expressed as
a proportion of MVC, which is opposite to our finding. Third, it
is possible that sensory feedback from the electrode might be
greater at the superficial location, with potential impact on ca-
pacity to contract the muscles. Although this would not be
supported by the observation of uniform nerve density along the
length of the vaginal walls,23 the vaginal margin is known to be
more sensitive than other body parts, such as the anal margin and
the abdomen in healthy women.24

J Sex Med 2019;16:673e679

Pelvic Floor Muscle Activation with Verbal Instruction
ACTIVATION OF THE PFM DIFFERED BETWEEN
INSTRUCTIONS
Based on anatomy and previous data for men,17 we hy-
pothesized that superficial and deep PFM EMG during
voluntary contractions might be influenced by instructions.
Our data show that, across instructions, deep/left PFM
followed the same pattern as superficial PFM, but the deep/left
PFM EMG amplitude was smaller. The instructions that ach-
ieved the greatest EMG (and largest superficial PFM EMG)
were those proposed to bias toward the superficial PFM. In-
structions that focused attention to superficial structures (pos-
terior clitoris motion and pursing lips) encouraged greater
activation of superficial PFM than more generalized “squeeze”
instructions. These cues were based on the anatomy of the
superficial muscle layer; “posterior clitoral motion” refers to the
orientation of the ischiocavernosus in a posterolateral direction
from attachment to the clitoris25; and “pursing the lips” refers
to the bulbocavernosus, which encircles the urethral/vaginal
openings ventrally and laterally.25 The “clitoris” cue also evokes
greater superficial PFM EMG than cues to “lift,” which is an
action attributed to the deeper levator ani muscles, and tight-
ening around the urethra, which might target the sphincter
muscles. The previous study in men17 found greater striated
urethral sphincter EMG than levator ani and bulbocavernosus
muscles, with a specific instruction to “shorten the penis,” but
it found no difference between that latter PFM during 4 in-
structions. This differs from our observation of greater activa-
tion of superficial PFM across all tasks. We did not record from
the sphincter muscles, but, as highlighted above, the “urethra”
cue might bias to this muscle and should be investigated in
further studies. This could be studied non-invasively with shear
wave elastography.26
This study did not find an instruction that evoked greater
activation of deep than superficial PFM. 1 consideration is that
the neural mechanisms involved in voluntary activation of the
PFMs may not have the flexibility to activate the deep muscles
selectively. Such subtle control may not be possible, because
voluntary activation of these muscles is rarely required in normal
function, and the representation of these muscles on the motor
cortex is small compared with other body regions.27 During
involuntary tasks, such as coughing, differential activation of
deep and superficial PFM has been identified (Aljuraifani et al,
unpublished data)28 This suggests that the muscles can be
controlled independently. Additional verbal cues might achieve
selective activation of deep PFM and should be considered in
further research. It is important to consider that it might not be
necessary to bias more to deep PFM to achieve clinical change,
and concurrent activation of muscle layers is likely to be bene-
ficial. It is plausible to speculate that, in some circumstances, for
example, in the presence of excessive activity of specific muscles
(as has been proposed in chronic pelvic pain29 and dyspar-
eunia30), activation of 1 muscle, with less of another, might be
clinically important.
J Sex Med 2019;16:673e679
677
Asymmetrical PFM EMG
Although this study did not use instructions that aimed to bias
activity to a specific side, EMG recorded from the deep/left PFM
was significantly greater than that of the deep/right PFM for 3
instructions that aimed to bias the superficial PFM (Instruction
7, “Squeeze the muscles to draw the clitoris posteriorly”; In-
struction 6, “Squeeze the muscles as if to purse the lips of the
mouth”; and Instruction 2, “Squeeze the muscles around the
back passage without lift”). Although feedback was provided
using deep/right EMG recording, participants were not informed
regarding which side or layer the feedback represented. As re-
ported by Auchincloss and McLean,3 evidence for symmetrical
PFM EMG in nulliparous healthy women and specific tasks is
inconclusive. Early investigations reported symmetry of pubo-
coccygeus in healthy women,31 and asymmetry in clinical pop-
ulations,32 but symmetry was not observed in healthy women in
a more recent investigation.3 When deep and superficial muscle
layers were recorded separately in the present study, asymmetry
was only found for the deep PFM. Because participants were
healthy, this implies that symmetrical activation of deep PFM
may not be required for normal function. Enck and Vodusek18
suggested that asymmetrical PFM activation in women without
pelvic floor dysfunction might be explained by “functional
asymmetry,” which refers to a naturally occurring unilateral
differences in the central and peripheral neural control of PFM.
This description was based on a group of studies that showed
asymmetry in the cortical representation33 and pudendal nerve
termination supply34 to the ano-rectal musculature.35 Our data
show that this may also be true for muscles recorded vaginally.
Clinical Implications
Physiotherapists use verbal instructions to train PFM in a
range of conditions. Our data provide evidence that, regardless of
instruction type, the superficial PFM have a greater activation
than deep PFM. If bias toward the deep muscles is desirable,
other methods (eg, electrical stimulation) or other instructions
may be required. It remains to be tested whether greater
enhancement of superficial PFM during tasks that activate the
deep muscles has any negative impact on the efficacy of clinical
interventions that use these instructions. In fact, if the superficial
PFM contribute to continence and pelvic organ support, this
may be beneficial. An important consideration is that it is
plausible that different patterns of muscle activation would be
required to treat different conditions (eg, incontinence, sexual
dysfunction, prolapse), and the present data suggest that no
single instruction will be suitable for all presentations.
The clinical relevance of PFM asymmetry remains unclear. It
has been hypothesized that asymmetry of the anal sphincter
innervation in healthy individuals is a likely explanation of
preservation of fecal continence in unilateral external anal
sphincter injury.34 Whether asymmetry of drive to deep PFM
has similar benefit with unilateral injury to innervation of these
muscles after childbirth has not been tested.
678
Strengths and Limitations
The current study has several strengths. First, the study de-
scribes a novel EMG electrode to study the deep and superficial
layers of the PFM in a non-invasive manner. Although some
other designs have been presented,19 the orientation of electrodes
approximately aligned to the muscle fibers and bipolar configu-
ration of the new electrode was optimized to ensure EMG
amplitude and reduce noise. Second, the results provide insight
regarding the bias of activation of the superficial PFM in
response verbal instructions. This requires consideration if the
objective of training is to bias to the deep PFM without acti-
vation of superficial PFM.
There are several limitations that require consideration. First,
this is the first study to report use of the novel electrode, and,
although our data provide observations that confirm signals arose
from separate muscles, and thus face validity, future work should
be considered be undertaken to further validate the recording
method. Second, although cross-talk between recordings of deep
and superficial muscles is possible with this custom-designed
EMG electrode, this would only underestimate the differences
that we successfully identified. Third, we cannot discount the
potential for the internal probe to alter typical PFM activation.
No difference between PFM EMG recorded with internal and
intramuscular electrodes in other studies36 suggests that the in-
ternal probe is unlikely to affect PFM activation. Fourth,
although it is possible that the position of the recording elec-
trodes relative to the target muscles changed during the experi-
ment because of probe movement, the probe shape will have
limited the potential for rotation. Fifth, we did not measure
features such as genital hiatus dimensions or experience with
PFM training, which might affect response to instructions.
Finally, although the modest sample size is a potential limitation
of the study, the observation of significant differences in activa-
tion between muscle layers indicated that sample size was suffi-
cient to meet the objectives of the study.
CONCLUSIONS
These data provide new insight into deep and superficial PFM
activation during voluntary contractions performed in response
to different instructions. Using a novel electromyography elec-
trode, we provide preliminary evidence that superficial PFM are
activated to a higher proportion of their maximum than deep
PFM in healthy women across all instructions. Specific in-
structions that achieved greatest activation of superficial PFM
were those that focused attention to superficial structures. Deep
PFM responded asymmetrically to some instructions. Whether
clinical outcomes differ when different instructions are used re-
quires consideration.
Corresponding Author: Dr Paul W. Hodges, PhD, School of
Health and Rehabilitation Sciences, The University of Queens-
land, Brisbane, Queensland, Australia 4072. Tel: þ7 3365 4506;
E-mail: p.hodges@uq.edu.au
Aljuraifani et al
Conflict of Interest: The authors report no conflicts of interest.
Funding: supported by the National Health and Medical
Research Council (NHMRC) of Australia (Fellowship [PWH]
(app1002190) and Program Grant [ID631717]).
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Rafeef Aljuraifani; Ryan E. Stafford; Paul W. Hodges
(b) Acquisition of Data
Rafeef Aljuraifani; Ryan E. Stafford; Leanne M. Hall; Paul W.
Hodges
(c) Analysis and Interpretation of Data
Rafeef Aljuraifani; Ryan E. Stafford; Leanne M. Hall; Paul W.
Hodges
Category 2
(a) Drafting the Article
Rafeef Aljuraifani; Ryan E. Stafford; Leanne M. Hall; Paul W.
Hodges
(b) Revising It for Intellectual Content
Rafeef Aljuraifani; Ryan E. Stafford; Leanne M. Hall; Paul W.
Hodges
Category 3
(a) Final Approval of the Completed Article
Rafeef Aljuraifani; Ryan E. Stafford; Leanne M. Hall; Paul W.
Hodges
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