[ RESEARCH REPORT ]

JULIE HIDES, PhD1šWARREN STANTON, PhD2šSHAUN MCMAHON, PhD3

KEVIN SIMS, PhD4š97HEBODH?9>7H:IED" PhD5

Effect of Stabilization Training

on Multifidus Muscle Cross-sectional
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Area Among Young Elite Cricketers

With Low Back Pain

A
thletes still suffer from low lighted the role of the multifidus capacity to stabilize the spine when
muscle in provision of segmental spinal stability is challenged.22,23
back pain (LBP), despite
stiffness,28,38 control of the spinal SUPPLEMENTAL Furthermore, the multifidus mus-
their high fitness levels segment’s neutral zone,29,30 and its
VIDEOS ONLINE
cle has been shown to contribute
and strength training
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

programs that are often intensive.
Even in noncontact sports LBP
and injuries are quite common. In
a recent injury report conducted
among Australian cricketers, it
was shown that the incidence
of LBP was 8%, and as high as
14% among fast bowlers.25,26 In
Journal of Orthopaedic & Sports Physical Therapy®
TIJK:O:;I?=D0 A single-blinded, pretreat-
ment-posttreatment assessment.
TE8@;9J?L;I0 To investigate, using ultrasound
imaging, the cross-sectional area (CSA) of the
lumbar multifidus muscle at 4 vertebral levels (L2,
L3, L4, L5) in elite cricketers with and without low
back pain (LBP), and to document the effect of a
staged stabilization training program on multifidus
muscle CSA.
tive ultrasound imaging (RUSI), progressed from
non–weight-bearing to weight-bearing positions and
movement training. Pain scores (using a visual ana-
logue scale) were also collected from those with LBP.
TH;IKBJI0 The CSAs of the multifidus muscles
at the L5 vertebral level increased for the 7 cricket-
ers with LBP who received the stabilization train-
ing, compared with the 14 cricketers without LBP
who did not receive rehabilitation (P = .004). In
addition, the amount of muscle asymmetry among

T879A=HEKD:0 Despite high fitness levels and

addition, the injury prevalence
(games missed due to injury) was
similar for fast bowlers and full-
contact football players.25 Bowling
workload9 and biomechanical analysis
of bowling action31 have been identi-
fied as 2 key issues in the prevention of
LBP in fast bowlers. However, the role
of physical preparation in terms of spe-
cific muscle re-education has not been
investigated.
There is considerable evidence for the
role of the lumbar multifidus muscle in
segmental stabilization of the lumbar
spine. Biomechanical studies have high-
often intensive strength training programs, athletes
still suffer LBP. The incidence of LBP among Aus-
tralian cricketers is 8% and as high as 14% among
fast bowlers. Previous researchers have found that
the multifidus muscle contributes to segmental
stability of the lumbopelvic region; however, the
CSA of this muscle has not been previously as-
sessed in elite cricketers.
TC;J>E:I7D:C;7IKH;I0 CSAs of the
multifidus muscles were assessed at rest on the
left and right sides for 4 vertebral levels at the start
and completion of a 13-week cricket training camp.
Participants who reported current or previous LBP
were placed in a rehabilitation group. The stabiliza-
tion program involved voluntary contraction of the
multifidus, transversus abdominis, and pelvic floor
muscles, with real-time feedback from rehabilita-
those with LBP significantly decreased (P = .029)
and became comparable to cricketers without LBP.
These effects were not evident for the L2, L3, and
L4 vertebral levels. There was also a 50% decrease
in the mean reported pain level among the cricket-
ers with LBP.
T9ED9BKI?ED0 Multifidus muscle atrophy
can exist in highly active, elite athletes with LBP.
Specific retraining resulted in an improvement in
multifidus muscle CSA and this was concomitant
with a decrease in pain.
TB;L;BE<;L?:;D9;0 Therapy, level 2b. J
Orthop Sports Phys Ther 2008;38(3):101-108.
doi:10.2519/jospt.2008.2658
TA;OMEH:I0 asymmetry, low back/lumbar
spine rehabilitation, rehabilitative ultrasound imag-
ing, therapeutic exercise, ultrasound imaging

1
Senior Lecturer, Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia; Clinical Supervisor, University
of Queensland Mater Back Stability Clinic, Mater Health Services, South Brisbane, Queensland, Australia. 2 Psychologist and Biostatistician, UQ/Mater Back Stability Clinic,
Mater Health Services, South Brisbane, Australia. 3 Performance Coordinator, Commonwealth Bank Centre of Excellence, Brisbane, Queensland, Australia. 4 Physiotherapist,
Commonwealth Bank Centre of Excellence, Brisbane, Queensland, Australia. 5 Reader, Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University
of Queensland, Brisbane, Australia. This study was approved by the Medical Research Ethics Committee at the University of Queensland, Australia, and funded in part by the
Cricket Australia Sports Science Medicine Research Program. Address correspondence to Dr Julie A. Hides, Division of Physiotherapy, School of Health and Rehabilitation
Sciences, The University of Queensland, Brisbane, Queensland 4072, Australia. E-mail: j.hides@shrs.uq.edu.au

journal of orthopaedic & sports physical therapy | volume 38 | number 3 | march 2008 | 101
 [ RESEARCH REPORT
to proprioception.5 Repositioning-accu-
racy tasks have been used to assess the
position sense of the spine, and young
healthy subjects were found to be ca-
pable of repositioning their spines accu-
rately. Repositioning accuracy was found
to be significantly lower in subjects with
LBP.5 In addition, when vibration was
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applied to the multifidus muscle with a
tuning fork (to distort the input from the
muscle spindles), healthy subjects were
no longer able to accurately reposition
their spines.5
Impairments of the multifidus mus-
cle have been documented in subjects
with LBP using imaging techniques.
There is evidence that the cross-sec-
tional area (CSA) of the multifidus is
selectively decreased compared with
other lumbopelvic muscles in patients
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
with chronic LBP.7 Multifidus muscle
atrophy has been successfully quanti-
fied using magnetic resonance imaging
(MRI) and computerized tomography
(CT) scanning in terms of both de-
creased muscle CSAs4 and presence of
alterations in muscle consistency (due to
fatty deposits or fibrous/connective tis-
sue infiltration), and atrophy is a com-
Journal of Orthopaedic & Sports Physical Therapy®
mon radiological finding.20 Researchers
have used real-time ultrasound imaging
(RUSI) to demonstrate segmental de-
crease in the CSA of the multifidus, ipsi-
lateral to painful symptoms, in patients
with acute unilateral LBP.16,18 A similar
localized (rather than generalized) pat-
tern of muscle atrophy of the multifidus
muscle has been demonstrated in sub-
jects with chronic LBP with unilateral
pain presentations.12
Rehabilitation programs that address
impairments in the multifidus muscle
may have long-term benefits in reducing
the risk of recurrent LBP. To determine
the effect of multifidus rehabilitation re-
currence rates, a randomized controlled
trial (RCT) was conducted on subjects
with first-episode acute LBP.16 All sub-
jects received medical management but,
in addition, subjects in the intervention
group were taught to perform voluntary
isometric contractions of the segmental
102 | march 2008 | volume 38 | number 3 | journal of orthopaedic & sports physical therapy
multifidus while receiving visual feed-
back using RUSI. Results showed that
while the pain and disability associated
with the initial acute episode resolved
within 4 weeks, CSA and symmetry of
the multifidus muscles did not recover
spontaneously in the control group.
Long-term follow-up at 1 and 3 years
showed that subjects in the exercise
group who restored multifidus CSA and
symmetry had lower LBP recurrence
rates.13 Other RCTs have also shown that
stabilization programs including multi-
fidus rehabilitation in association with
the transversus abdominis and pelvic
floor muscles are effective in reducing
lumbopelvic pain.10,27,35
In addition to the use of stabilization
training for rehabilitation and treatment
of subjects with LBP, it is also used as a
sport training method and commonly
incorporated into the programs of many
athletes.24 Adequate lumbopelvic stabil-
ity is thought to contribute to athletic
performance by aiding in the efficient
transmission of force generated by the
lower body through the trunk to the up-
per body.2 In support of this proposal, 2
RCTs have shown improvements in leg
power and agility24 and increased verti-
cal takeoff velocity6 in subjects who un-
derwent trunk stability training. Apart
from reversing impairments in muscles
affected by LBP, stabilization training
and enhancing lumbopelvic stability
may, as suggested by some authors, be
associated with improvement in athletic
performance.3
The present study was conducted
on elite cricketers attending a national
training camp. This presented a unique
opportunity to study elite athletes over a
defined assessment period, where partici-
pant management and activities are stan-
dardized and monitored. The aims of this
study were (1) to document multifidus
CSA in elite cricketers with and without
LBP and (2) to determine the effect of a
specific stabilization exercise program on
the size and symmetry of the multifidus
muscle and on self-reported pain levels of
cricketers with LBP.
]
METHODS
Subjects
T
he participants in the study
were 26 young male elite cricketers
selected to attend a 13-week nation-
al training camp. Subjects who reported a
history of LBP and indicated it was severe
enough to interfere with current sporting
or training performance were allocated to
the LBP group. There were 10 subjects
eligible for the LBP group and 16 eligible
for the no-pain group. In all cases, the
pain location was unilateral in distribu-
tion and all subjects reported previous
episodes of LBP. All participants gave in-
formed consent and the rights of subjects
were protected. The study was approved
by the Ethics Committees of the institu-
tions that hosted the study (University of
Queensland and Wesley Hospital, Bris-
bane, Australia).
Procedures
Participants in the study were undertak-
ing a 13-week cricket training program
that consisted of two 6-week training
blocks separated by a 1-week break. The
focus of the first 6 weeks and the first 2
weeks of the second block of the training
camp was participation in drills, prac-
tice of individual skills, and gym sessions
using cycle and other ergometers and
weight training. Participants performed
approximately 4 hours of cardiovascular
training, 6 hours of individual skill train-
ing, 5.5 hours of fielding training, 4 hours
of group skill training, 3 hours of weight
training, and 2 hours of theory lectures
per week for the 8 weeks. In the final 4
weeks of the training camp, the partici-
pants played cricket matches for 4 days
per week, with a rest day on the fifth day.
Ultrasound imaging and question-
naire assessments were completed in a
hospital setting at the start and comple-
tion of the 13-week program. Self-report-
ed questionnaires were used to determine
general information, cricket history, and
medical history. Subjects were asked if
they were currently receiving any medical
or physiotherapy treatment. For muscu-
 loskeletal conditions, a research assis-
tant helped subjects to complete pain
drawings (location of pain) on a body
chart. Pain intensity of LBP at the time
of testing was established using a visual
analogue scale (VAS). This consisted of a
10-cm line where 0 represented “no pain”
and 10 represented “intense, excruciating
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pain.” An activity level score was obtained
for each participant using the Habitual
Activity Questionnaire (HAQ).1
Ultrasound Imaging CSAs of the mul-
tifidus muscle were measured from L2
to L5 vertebral segments. Reliability of
performing these measures has been pre-
viously reported,11,15,30,32 and previous clin-
ical trials have shown the highly trained
assessor in the present study (J.H.) to be
repeatable and reliable with ultrasound
measurements of the multifidus mus-
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
cle.11,18 The validity of measurements ob-
tained using ultrasound imaging has also
been demonstrated by comparison with
MRI15 measurements.
The ultrasound imaging apparatus
(Aplio SSA770; Toshiba, Inc, Nasu, Ja-
pan) was equipped with a 5-MHz convex-
array transducer with a footprint of 6 cm.
Subjects were placed in a prone position
Journal of Orthopaedic & Sports Physical Therapy®
with a pillow placed under the abdomen
to minimize lumbar lordosis. Measure-
ments were conducted at rest. The spinous
processes of the L2 through L5 vertebrae
were palpated and the skin was marked
with a pen prior to imaging. Subjects were
instructed to relax the paraspinal muscu-
lature, electroconductive gel was applied,
and the transducer placed transversely
over the spinous process of the vertebral
level being measured (ONLINE VIDEO). This
produced images in which the spinous
process and laminae could be seen, with
multifidus muscles visible on both sides of
the spine (<?=KH;'7).
Anatomical landmarks were used to
ensure consistency of measurements at
each vertebral level. The echogenic ver-
tebral lamina was used consistently as a
landmark to identify the muscle’s deep
border. This was important, as there is a
large difference in CSA over the span of
1 vertebral level if a consistent landmark
journal of orthopaedic & sports physical therapy | volume 38 | number 3 | march 2008 | 103
<?=KH;'$(A) Bilateral transverse ultrasound image
at the L5 vertebral level showing atrophy of the left
multifidus muscle in a cricketer with left-sided low
back pain (R, right side). (B) The cross-sectional area
(CSA) of the left and right multifidus muscles has
been traced to demonstrate atrophy of the multifidus
muscle on the left side and the resultant asymmetry
between sides. The CSA of the right multifidus muscle
is 8.7 cm2 and the CSA of the left multifidus muscle
is 7.35 cm2, representing a 15.5% smaller CSA on the
side ipsilateral to painful symptoms.
is not used. The multifidus muscle is bor-
dered superiorly by the thoracolumbar
fascia, and the medial border was pro-
vided by the acoustic shadow from the
tip of the spinous process of the vertebral
level being assessed. The lateral border
was formed by the fascia surrounding
the multifidus and separating it from the
longissimus component of the lumbar
erector spinae muscle. This border was
often the most difficult to image, as it lies
parallel to the sound waves emitted from
the transducer. In cases where this fascia
was difficult to identify, the orientation of
the transducer was altered slightly to im-
age the muscle from a more lateral per-
spective, thus allowing a better depiction
of the lateral border of the muscle.
Bilateral images of the multifidus
muscles were obtained where possible
(<?=KH; '7), except in the case of larger
muscles where left and right sides were
imaged separately. Ultrasound images
were stored for off-line analysis. ImageJ
Version 1.36b (National Institutes of
Health, http://rsb.info.nih.gov/ij/) was
used for image visualization and mea-
surement (<?=KH;'8). The CSA of the mul-
tifidus muscles was measured by tracing
around the muscle border. For consisten-
cy, the inner edge of the border was used.
The investigator who performed the ul-
trasound imaging and measurements was
blinded to group allocation.
Physiotherapy Intervention Subjects
in the LBP group were provided with a
6-week stabilization training program.
Instead of lifting weights in the gym,
they undertook a program of stabilization
training using RUSI to provide feedback
of contraction of the deep muscles, in-
cluding the multifidus and the transver-
sus abdominis (TrA) muscles. They were
taught to contract the TrA muscle (draw-
in the abdominal wall), isometrically con-
tract the multifidus muscle with a focus
on each vertebral level, and draw-up the
anterior aspect of the pelvic floor.15,17
For the multifidus, the anatomical
location of the muscle was shown using
a model of the lumbar spine, and pic-
tures of the muscle were provided and
explained. A demonstration of a volun-
tary isometric contraction of the biceps
muscle was performed as a simple exam-
ple of the type of contraction required.
Subjects were further instructed to take
a relaxed breath in and out, hold the
breath out and then try to “swell” or con-
tract the muscle. Subjects were also in-
structed not to move their spine or pelvis
when they contracted the muscle (ie, the
type of muscle contraction required was
a slow, gentle, sustained contraction).
Subjects were first provided with tactile
facilitation (the physiotherapist placed
their fingers adjacent to the spinous pro-
cess of the vertebral level being facilitated
to direct the contraction). Once subjects
were able to achieve a voluntary isomet-
ric contraction of the multifidus muscle,
they were provided with biofeedback
in the form of visual observation of the
muscle contraction as it occurred us-
ing RUSI. This was conducted using
Diasonics Synergy ultrasound imaging
 [ RESEARCH REPORT ]
apparatus (NEC Corporation, Tokyo, Ja-
Descriptive Data for Cricketers With
pan) equipped with a 5-MHz curvilinear TABLE 1
and Without Low Back Pain (LBP)
transducer. The subject was initially posi-
tioned in a non–weight-bearing position,
No LBP LBP
and the multifidus muscle was imaged
in parasagittal (longitudinal) section, al- Variable Mean SD Mean SD P Value*
lowing visualisation of the zygapophyseal Height (cm) 182.7 5.7 183.0 4.4 .92
joints, muscle bulk, and thoracolumbar Body mass (kg) 84.0 7.7 86.3 3.9 .48
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fascia (<?=KH; (). A mobile monitor dis- Age (y) 21.4 2.0 21.9 2.5 .67
playing the output from the ultrasound HAQ 9.9 0.7 10.4 1.3 .30
equipment was positioned in the subject’s Abbreviation: HAQ, Habitual Activity Questionnaire.1
* Difference between groups.
line of view. Subjects were asked if they
could “feel” the multifidus contracting,
as perception of voluntary contraction
of the segmental multifidus muscle may
be indicative of the proprioceptive role of
the multifidus muscle.15
For the TrA muscles, subjects were
initially positioned in a supine hook-lying
position. Then the following standard in-
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

structions were given regarding how to

perform the drawing-in maneuver: “Take
a relaxed breath in and out, hold the
breath out and then draw-in your lower
abdomen without moving your spine.”
A transverse image of the anterolateral
abdominal wall was obtained and the ul-
trasound transducer was aligned perpen- <?=KH;($Ultrasound image of the multifidus muscle in parasagittal section at rest (left side of picture) and
dicular to the anterolateral abdominal on contraction (right side), showing the view used to provide feedback of voluntary isometric multifidus muscle
Journal of Orthopaedic & Sports Physical Therapy®

muscles. Subjects were able to see the ul-
trasound monitor and received feedback
of performance of the voluntary contrac-
tion. Subjects were taught to cocontract
the TrA, anterior pelvic floor, and multifi-
dus muscles. Subjects were encouraged to
hold their contractions, while breathing
normally, for at least 10 seconds and to
repeat at least 10 times.
Time was allocated for practice on a
daily basis (15 to 30 minutes per day).
All exercises were performed in a pain-
free position and manner. Subjects were
taught to first activate the muscles in
lying positions and, as performance im-
proved, they were progressed to upright
(sitting and standing) positions. Subjects
were encouraged to maintain a lumbar
lordosis and thoracic kyphosis when in
upright positions and taught to perform
voluntary contractions of the multifidus,
TrA, and pelvic floor muscles in sitting
and standing positions. RUSI was used
contraction to subjects. In this case, the thickness of the muscle has been measured to show the resultant increase
in thickness due to muscle contraction (relaxed multifidus muscle thickness, 2.68 cm; contracted value, 3.20 cm).
to provide feedback in all of these posi-
tions. Subjects were also taught to disso-
ciate hip movements from lumbopelvic
movements in sitting and standing posi-
tions. This involved checking the ability
to hold a lumbar lordosis and thoracic
kyphosis while leaning forward in sitting
and standing positions (ie, the ability
to hold a lumbopelvic position with the
addition of gravitational load). Subjects
were asked to lean forwards from the
hips and possible substitution strategies
were observed. The most common sub-
stitution strategy observed was flexion
of the lumbar spine, but some subjects
extended at the thoracolumbar junc-
tion. There was also an emphasis placed
on gaining endurance of the multifidus
muscle. This was trained by being able
to lean forward from the hips and hold
this position while maintaining a lumbar
lordosis, thoracic kyphosis, and normal
respiration. RUSI was also used to pro-
vide feedback of multifidus contraction
during this phase of training. Techniques
of squatting and lunging were examined,
and subjects were instructed to maintain
their lumbar lordosis and thoracic kypho-
sis throughout the movement. After the
6-week stabilization training program,
subjects in the LBP group were allowed
to resume graduated weight training with
the rest of the squad.
Statistical Analysis Among the 26 crick-
eters who participated in the training
camp, 1 participant was excluded due to
a musculoskeletal condition (osteitis pu-
bis) that confounded allocation to either
group and 1 participant (no LBP) was
unavailable for the postintervention ul-

104 | march 2008 | volume 38 | number 3 | journal of orthopaedic & sports physical therapy
 Cross-sectional Area (CSA) of the Multifidus Muscle (mean  SD) at 4
TABLE 2 Vertebral Levels for Cricketers With and Without Low Back Pain (LBP)
Before and After Attending a Cricket Training Camp

Cricketers Without LBP Cricketers With LBP

Pretraining Camp Posttraining Camp Pretraining Camp Posttraining Camp
Vertebral Level Large Side Small Side Large Side Small Side Large Side Small Side Large Side Small Side
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L2 (cm2) 2.79 1.11 2.63 1.0 2.91 1.05 2.88 1.04 3.39 1.37 3.27 1.23 3.55 1.30 3.48 1.28
L3 (cm2) 4.34 1.51 4.29 1.44 4.58 1.35 4.53 1.33 5.09 1.86 4.96 1.77 5.34 1.67 5.28 1.64
L4 (cm2) 6.53 2.15 6.45 2.21 6.83 1.69 6.79 1.71 7.06 2.65 6.93 2.73 7.78 2.08 7.73 2.11
L5 (cm2) 8.04 1.70 7.98 1.79 8.43 1.72 8.39 1.67 7.43 2.09 6.81 2.20 9.37 2.12 9.24 2.07

activity level (HAQ) for those who were

Between-Side Percentage Difference in
in the treatment group (cricketers with
the Cross-sectional Area (CSA) of the
LPB) versus the cricketers without LBP
TABLE 3 Multifidus Muscle (Pretraining and
(TABLE 1).
Posttraining Camp) for Cricketers With
Pain VAS scores (range, 0-10) of par-
and Without Low Back Pain (LBP)*
ticipants in the LBP group changed from
a mean  SD value of 4.3  3.0 (range,
Cricketers Without LBP Cricketers With LBP
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

0.5-10.0) at the start of the training camp

Vertebral Level Pretraining Camp Posttraining Camp Pretraining Camp Posttraining Camp
to 2.3  2.2 (range, 0.0-6.0) by the end
L2 5.7 1.0 3.5 2.0
L3 1.2
L4 1.2
L5 0.8
* Percentage difference in CSA = ([large-side CSA – small-side CSA]/large-side CSA)  100.
trasound imaging measurement session.
Journal of Orthopaedic & Sports Physical Therapy®
A further 3 participants did not complete
the training camp (2 had LBP, 1 had no
LBP) and were lost to the ultrasound fol-
low-up assessment, leaving 21 subjects
for analysis (7 in the LBP group and 14
in the non-LBP group).
Analysis of variance (ANOVA) was
used to initially test for group similar-
ity in age, height, body mass, and HAQ
score at baseline assessment (pretrain-
ing). For the subjects in the LBP group,
repeated-measures ANOVA was used to
test for change in pain VAS scores by the
end of the program. A repeated-measures
analysis of covariance (ANCOVA) with a
type I sums-of-squares model was then
conducted to examine the effect of the
treatment on the multifidus CSA of crick-
eters with LBP, compared with the group
of cricketers who did not have LBP and
did not receive the stabilization exercise
intervention. The dependent variable in
the analyses was the CSA of the multifi-
1.1 2.6
0.6 1.8
0.5 8.3
dus muscle measured at L2, L3, L4, and
L5, analyzed separately for each vertebral
level due to the systematic increase in CSA
across level. The covariates in the analy-
ses were age, height, and body mass. The
repeated measures were time (pretrain-
ing versus posttraining) and asymmetry
(large versus small side). In all subjects
with LBP, the relatively smaller side for
multifidus CSA always equated to the
painful side reported on the body chart.
The independent measure was treatment
group (LBP or no LBP). In this explor-
atory study the P value for each analysis
was retained at .05.
RESULTS
he sample mean  SD age,
T height, and body mass was 21.2
 2.0 years, 183.2  5.4 cm, and
84.8  6.4 kg, respectively. There was
no statistically significant difference
(P.05) for age, height, body mass, and
journal of orthopaedic & sports physical therapy | volume 38 | number 3 | march 2008 | 105
of the training camp (P.05). This repre-
1.1
sented a 50.1% decrease over the course
0.6
of the training camp. A reduction in pain
1.4
was reported by all participants with
LBP.
Results of the ANCOVA for multifidus
CSA for each vertebral level showed that
statistically significant main effects and
interaction effects for time and asym-
metry were evident at L2, L3, L4, and L5
vertebral levels (all, P<.05). This pattern
of results indicates that across vertebral
levels for both groups (a) muscle size in-
creased during the course of the training
camp, (b) there was significant amount
of muscle size asymmetry among these
cricketers, and (c) there was a significant
decrease in asymmetry during the course
of the training camp (2-way interaction).
These patterns are represented by the
means in TABLE 2 and percentage changes
shown in TABLE 3. Additional effects of the
analysis were found specifically for the L5
data.
At the lowest vertebral level (L5) there
was an additional effect related to change
in size of the muscle. The results showed
a statistically significant 2-way interac-
tion between treatment group and time
(F = 11.83, P = .004), indicating that the
 [ RESEARCH REPORT
increase in muscle size during the course
of the training camp (reported above) was
not the same for both groups. The means
in TABLE 2 indicate a smaller L5 multifi-
dus muscle size for the subjects with LBP
compared to those without LBP at the
start of the training camp, which was not
evident at the end of the training camp.
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The effect of training with stabilization
exercises was not evident for multifidus
CSA at the L2, L3, and L4 vertebral levels
(all, P.05).
At the L5 vertebral level there was also
an effect related to change in asymmetry
of the multifidus muscle. A statistically
significant 3-way interaction between
the factors of treatment group, time,
and asymmetry (F = 5.95, P = .029) was
found. The means in TABLE 2 and percent-
age changes shown in TABLE 3 indicate
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
that the decrease in asymmetry during
the course of the training camp (report-
ed above) was greater for the LBP group
receiving the stabilization training at the
L5 level. This 3-way interaction effect is
depicted in <?=KH;). This effect related to
stabilization training was not evident for
multifidus CSA at the L2, L3, and L4 ver-
tebral levels (all, P.05).
Journal of Orthopaedic & Sports Physical Therapy®
DISCUSSION
T
he results of this study showed
that elite athletes with LBP exhib-
ited specific deficits in a muscle that
is known to play a key role in segmental
stabilization of the lumbar spine. Inves-
tigators have previously found a deficit
in the multifidus in elite athletes. Roy et
al33 used power spectral analysis of EMG
activity to examine fatigue rates of the
multifidus muscle in male varsity row-
ers. Using the fatigue rates of the mul-
tifidus to discriminate between subjects
with chronic LBP and control subjects,
the investigators correctly identified all
control subjects and 93% of the subjects
with LBP. The results of the current study
would also suggest that despite vigorous
training and activity, elite athletes can
still present with specific muscle impair-
ments, and these should be tested for
106 | march 2008 | volume 38 | number 3 | journal of orthopaedic & sports physical therapy
]
12
10
8
CSAs (cm2)
6
4
2
0
Pretraining Postraining
No-LBP
Asymptomatic side
<?=KH;)$Multifidus muscle cross-sectional areas (CSAs) at the L5 vertebral level for cricketers (mean 
standard error), showing a 3-way interaction effect (P = .029) between the factors of treatment group (LBP or no
LBP), time (pretraining camp versus posttraining camp), and asymmetry (large versus small side).
to direct appropriate physical therapy
management.
While the phenomena of both rapid16,18
and localized4,7,12,20 multifidus muscle at-
rophy in subjects with LBP have been
previously documented by researchers,
the mechanism has been until recently
poorly understood. Hodges et al19 inves-
tigated this by producing experimental
disc and nerve root injuries in animal
studies. The CSA of the multifidus mus-
cles was measured in 21 pigs from L1 to
S1 with ultrasound imaging before and
3 or 6 days after lesions, including inci-
sion into the L3-4 disc, medial branch
transection of the L3 dorsal ramus, and
a sham procedure. The CSA of the mul-
tifidus was reduced at the L4 vertebral
level ipsilateral to the disc lesion, but was
reduced at a greater number of levels and
extended further distally (L4-L6 levels)
after nerve lesion. There was no change
after the sham intervention or on the op-
posite side. These data help to resolve the
controversy that multifidus CSA reduces
rapidly and specifically after lumbar in-
jury. The changes after the disc lesion
affected 1 vertebral level with a different
distribution to denervation. These find-
ings would suggest that if athletes have
*
Pretraining Postraining
LBP
Symptomatic side
a localized injury to a lumbar structure,
rapid, segmental atrophy is likely to fol-
low. Human studies documenting this
phenomenon in first-episode LBP have
shown that the multifidus muscle does
not spontaneously recover, despite full
resumption of premorbid work, sport,
and leisure activities.16 These findings
would suggest that, following injury or
the onset of LBP, athletes’ programs
should include exercises specifically tar-
geting the multifidus muscle, to prevent
possible perpetuation of the injury rein-
jury cycle.
The stabilization training exercises
used in this study were low load in nature
and did not induce pain. The cricketers
in the LBP group stopped high-resistance
exercise while they learned to “switch
on” the multifidus, TrA, and pelvic floor
muscles prior to resuming higher-load
exercises. RUSI was used to provide
feedback of isometric voluntary isomet-
ric contraction of the multifidus muscle
to the subjects. The use of RUSI to pro-
vide feedback has been shown previously
to enhance the ability to isometrically
contract the multifidus muscle in normal
subjects.37 Using a rehabilitation proto-
col that involved progression from sta-
 bilization training to high-load exercise
has been shown in a prior study8 to lead
to hypertrophy of the multifidus muscle
with a concomitant decrease in pain in
subjects with chronic LBP. Results of
the current investigation also showed
a significant decrease in reported pain
levels for the subjects in the LBP group
Downloaded from www.jospt.org at National Cheng Kung University on January 2, 2019. For personal use only. No other uses without permission.
who underwent stabilization training.
This difference in VAS pain scores was
statistically significant and exceeded the
minimum clinically significant difference
in VAS pain scores reported in clinical
studies.22,36
Results of studies performed on
asymptomatic subjects without a his-
tory of LBP have previously shown that
the multifidus muscle is symmetrical
between sides.11,12,15,18,34 Hides et al18
documented multifidus asymmetry
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
in subjects with acute unilateral first
episode LBP, and similar results were
found in subjects with chronic LBP
with unilateral pain presentations of
a duration greater than 12 weeks.4 In
subjects with chronic LBP, between-
side asymmetry has been documented
in patients presenting with a unilateral
pain distribution.12 In all these cases, the
Journal of Orthopaedic & Sports Physical Therapy®
smaller muscle was found ipsilateral to
symptoms. Based on the means shown
in TABLE 2, the CSA of the multifidus
muscle on the side ipsilateral to symp-
toms was 8.3% smaller than the other
side, and this between-side difference
was only significant at the L5 vertebral
level. Similar to the reported findings of
subjects with acute unilateral LBP,16 the
asymmetry resolved (the smaller side in-
creased in CSA) in subjects who under-
went specific rehabilitation. However,
CSAs of the multifidus muscle increased
on both sides of the spine at the L5 level
in the cricketers with LBP by 26.2% on
the side ipsilateral to symptoms and by
20.7% contralateral to symptoms. This
was greater than the increase in muscle
CSAs seen in the cricketers without LBP
in response to the training camp, who
showed increases of 4.6% and 4.8%.
The effect of stabilization training on
an athlete’s performance was not inves-
journal of orthopaedic & sports physical therapy | volume 38 | number 3 | march 2008 | 107
tigated in this study, although it is also
used as a sport training method24 and
2 RCTs have shown improvements in
lower extremity power and agility24 and
increased vertical takeoff velocity6 in
subjects who underwent trunk stability
training. Proposed explanations for this
include optimization of the ability of the
lower extremity muscles to provide force
by providing a stable base from which the
muscles could contract, enhancing the
neural drive to the lower extremity mus-
cles, and increasing the overall awareness
and control of trunk and pelvic position.
Anecdotal reports from the current study
may lend support to the latter explanation,
as subjects with LBP who received the in-
tervention commented that their ability
to squat with weights was improved after
intervention, as they could “feel” where
their backs were in space as they added
load. This would be an advantage, as bio-
mechanical models have suggested that
the lumbar spine is best able to cope with
compressive forces when it is positioned
in a lordosis,22 and the multifidus muscle
is known to perform this role.23
One of the limitations of this study
was the lack of a LBP control group. This
was not possible in the present study.
A future RCT that would allow testing
for spontaneous recovery related to the
other training activities undertaken on
the training camp could be conducted.
The sample size in the current study was
small but comparable with other studies
conducted on elite athletes. While this
investigation was focused on the associa-
tion between stabilization training and
LBP, future studies could formally test
position-reposition sense and also in-
clude performance indicators as outcome
measures.
CONCLUSIONS
T
his study provides evidence
that despite rigorous training
programs, elite athletes with LBP
may demonstrate specific impairments
in the multifidus muscle. A staged sta-
bilization program, including volun-
tary contraction of the multifidus (with
feedback from RUSI), TrA, and pelvic
floor muscles and movement training,
was commensurate with an increase in
multifidus muscle CSA and restoration
of between-side symmetry in elite-level
cricketers. While this was concomitant
with a reduction in reported pain levels,
a cause-and-effect explanation is not
possible due to the wide-ranging nature
of activities undertaken simultaneously
at the training camp. Future studies
could include and monitor a control
group with LBP that does not under-
take the staged stabilization training
program and also assess the long-term
effects of the program.T
A;OFE?DJI
<?D:?D=I0 Stabilization training using
ultrasound imaging to provide feedback
about muscle contraction increased the
cross-sectional area and improved sym-
metry of the multifidus muscle at the L5
vertebral level among young elite crick-
eters with LBP.
?CFB?97J?ED0 Muscle atrophy and pain
related to LBP may be reversed using
specific core stability training for elite
athletes.
97KJ?ED0 The comparison group in this
study consisted of asymptomatic play-
ers. The results from this study need to
be reproduced in a larger sample with a
comparison group of players with LBP.
ACKNOWLEDGEMENTS: The authors thank the
subjects studied, Toshiba Australia (Jason Cot-
ter) and GE Australia (Jane Wilson) for provi-
sion of ultrasound imaging equipment, Tom
Johnsen (Scientific Officer), and the Cricket
Australia Sports Science Medicine Research
Program for financial support.
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