Reliability of Ultrasound Imaging Measures of Transverse

PM R 8 (2016) 340-347
www.pmrjournal.org
Original Research
Reliability of Ultrasound Imaging Measures of Transverse

Abdominis and Lumbar Multifidus in Various Positions
L. Colby Mangum, MEd, ATC, Mark A. Sutherlin, PhD, ATC, CSCS,
Susan A. Saliba, PhD, PT, ATC, Joseph M. Hart, PhD, ATC
Abstract
Objective: To determine the reliability of measurement of muscle activation via ultrasound imaging measures of the transverse
abdominis (TrA) and lumbar multifidus (LM) in tabletop, seated, standing, and walking conditions.
Design: Descriptive laboratory study.
Setting: University research laboratory.
Participants: Sixteen healthy participants (age, 20.4 1.8 years; height, 167.7 9.0 cm; mass, 65.1 10.8 kg).
Interventions: None.
Main Outcome Measurements: The activation ratio (AR) of TrA and LM and preferential activation ratio of TrA in tabletop, seated,
standing, and walking positions were assessed by the same examiner during 2 ultrasound imaging sessions 24-72 hours apart.
Statistical analysis included determination of intraclass correlation coefficients (ICCs) using analysis of variance for each muscle
and position between sessions.
Results: Excellent reliability was found in TrA AR between sessions for healthy participants in the tabletop position (ICC3,k ¼ 0.903),
and acceptable to excellent reliability was found in seated (ICC3,k ¼ 0.613), standing (ICC3,k ¼ 0.553), and walking (ICC3,k ¼ 0.737)
positions. LM AR was fair in the tabletop position for these participants (ICC3,k ¼ 0.264). The preferential activation ratio for
healthy participants was substantially reliable in tabletop and seated positions (ICC3,k ¼ 0.668, 0.684) and showed fair reliability
for walking (ICC3,k ¼ 0.455).
Conclusions: Ultrasound imaging is a reliable method of measuring muscle thickness across multiple positions in healthy persons.
This measure may be used to compare abdominal muscle thickness across populations or after interventions. LM AR was only found
to be reliable in the tabletop position.
Introduction with LBP and other chronic conditions may have this
reduced activation of spinal stabilizing musculature,
The transverse abdominis (TrA) and lumbar multifidus which could lead to increased pain and decreased
(LM) muscles provide local spinal stabilization for the neuromuscular function and performance [7-9].
lumbopelvic region [1]. These muscles are commonly Ultrasound imaging (USI) has been used as a method
grouped with the global movers in this same area, of estimating activation by measuring muscle thickness
including the external and internal obliques, as key of the TrA and LM muscles between rested and con-
components for overall core stability [1,2]. Reduced tracted states [10]. Most of the current literature
activation of the TrA and LM muscles has been linked to focuses on collecting these images in a tabletop position
persons with low back pain (LBP), which can plague and in healthy persons [11,12]. However, it is important
many individuals, including those who lead an active to measure muscle activation in more functional posi-
lifestyle [3-5]. The failure of LBP to resolve presents a tions such as while seated and standing when the
problem that can manifest as episodic paindthat is, lumbopelvic region experiences loading conditions that
resolution of symptoms followed by their return, are associated with recurrent episodes of nonspecific
resulting in another active episode of pain [6]. Persons LBP and other related conditions [13,14].
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L.C. Mangum et al. / PM R 8 (2016) 340-347 341
Reliability of USI measures has been shown to be Table 1

strong in tabletop positions in both the TrA and LM Participant demographics
musculature [12,14]. The reliability of USI measures in Healthy (N ¼ 16) Median
loaded, stationary positions has been explored recently Mean (SD) [Minimum-Maximum]
but has only included TrA or LM muscles independent of Age, y 20.4 (1.8)
one another or measurement of both muscles in healthy Height, cm 167.7 (9.0)
Mass, kg 65.1 (10.8)
persons only [11,14,15]. Determining reliability of USI
BMI 23.0 (2.1)
measures in progressive postures, culminating in reli- VAS 0.3 (0.8)
ability during walking, would provide valuable infor- Godin 54.8 (30.7)
mation for future research. Reliability of methods to ODI-S1 0.4 (1.1)
calculate muscle activation of the TrA and LM, such as ODI-S2 0.3 (0.7)
Frequency of pain 0 [0-0]
the activation ratio (AR) and preferential activation
Tegner 6 [3-10]
ratio (PAR) [14,16], also should be considered in addi- RM-S1 0 [0-0]
tion to the thickness measure reliability. Those calcu- RM-S2 0 [0-0]
lations aim to isolate the TrA from other abdominal wall SD ¼ standard deviation; BMI ¼ body mass index; VAS ¼ Visual
measures and attempt to normalize for resting muscle Analogue Scale; Godin ¼ Godin Leisure-time Exercise Questionnaire;
thickness. If thickness measures are shown to be reli- ODI ¼ Oswestry Disability Index; S1 ¼ session 1; S2 ¼ session 2;
able, then the formulas that are based on thickness Tegner ¼ Tegner Activity Level Scale; RM ¼ Roland Morris Disability
measures should also be reliable. However, inclusion of Questionnaire.
the calculations and comparison of the formulae have
not often been incorporated into previous reliability Instruments
studies on the lumbopelvic stabilizing musculature [14].
Before research is able to support any group differences A portable LOGIQ Book XP (GE Healthcare, Waukesha,
in more functional positions between healthy persons WI) ultrasound unit with an 8-MHz linear transducer was
and patients with LBP, the method of measurement used to obtain and visualize USI of the TrA and LM
must be shown to be reliable. muscles during an unloaded tabletop position, as well as
The purpose of this study was to determine inter- during 3 other functional gravity-dependent positions.
session reliability of muscle thickness measures through The Biodex Gait Retrainer treadmill (Biodex Medical
USI of the TrA and LM muscles during different positions Systems, Shirley, NY) was used for the walking portion of
in healthy persons. data collection.
Testing Procedures
Methods
Participants reported for 2 testing sessions 24-72
A descriptive laboratory study was used to examine hours apart. A single examiner (LCM) recorded images
the between-session reliability for changes in muscle bilaterally from the lateral abdominal wall and lumbar
thickness of the TrA and LM muscles during tabletop, paraspinal region in several positions and in the
seated, standing, and walking conditions. Measures following orderdtabletop, seated, standing, and
were taken by one assessor (LCM) during 2 different walkingdto simulate a progression toward more loaded
sessions 24-72 hours apart. positions that coincide with a typical clinical rehabili-
tation progression. The order of measurements (right or
left, TrA or LM) was randomized.
Participants
Positions
Sixteen healthy persons with no history of LBP or After the starting muscle and side were determined
lower extremity injury participated in this study via randomization, the participant was positioned on
(Table 1). Participants who self-reported a history of the tabletop either supine for TrA or prone for LM,
more than 3 episodes of LBP within the past 3 years or a depending on the starting muscle. Each position is
minimum of 5 LBP episodes over their lifetime were depicted in Figure 1A-H. For tabletop measures, the
excluded from this study [17]. Participants reporting participant was supine in a hook-lying position with a
pain (ie, >8/10 on a visual analog scale), a history of foam roller under both knees for TrA and prone for
lumbar surgery, disk diseases, or any other LBP that was tabletop LM image collection. In the seated position,
previously diagnosed as a specific disease by a physician participants sat on a backless stool with feet flat on the
were also excluded. All participants provided informed floor and knees flexed at 90 and were instructed to sit
consent that was approved by our University’s Institu- up straight. Participants were instructed to stand up
tional Review Board for health sciences research. straight with their arms relaxed at their sides for the
342 USI Measures of TrA and LM
Figure 1. Ultrasound transducer placement in each position. (A) Tabletop transverse abdominis (TrA). (B) Tabletop lumbar multifidus (LM).
(C) Seated TrA. (D) Seated LM. (E) Standing TrA. (F) Standing LM. (G) Walking LM. (H) Walking TrA.
standing measures. Before participants began the through the walking measurement. The patient then
walking portion, the ultrasound transducer was placed stepped onto the treadmill and self-selected a
through a hole in the center of a standard Velcro belt to comfortable walking speed, which was held constant for
ensure that the transducer remained properly in contact both sessions. The walking images were collected upon
heel strike of the ipsilateral side for resting and con- The participants were given up to 3 trials before
tracted measures. measures were recorded to contract the local muscu-
lature but were not given any type of verbal, tactile, or
Transverse Abdominis Measures visual feedback to improve upon the contraction. It was
The transducer placement for TrA measures was assumed that all participants were able to contract both
determined by placing the transducer head superior to their TrA and LM in order to avoid any potential group or
the iliac crest and along the midaxillary line [16,18] in individual bias via training. Once all images were
the transverse plane approximately 10 cm lateral to the collected in the session, all of the images were saved to
umbilicus, which was measured at the beginning of each an external drive.
session. The transducer was adjusted until the edge of The 3 measures from each side and each position
the thoracolumbar fascia was visible on the screen [19]. were averaged to give one representative measure of
The angle of the transducer on the skin was adjusted to thickness. The participant returned to repeat the same
portray the best image quality while keeping the measurement protocol (with the muscle and side ran-
transducer in the same position, perpendicular to the domized as in the first session) in a second session within
surface of the skin [16]. Three series of images were 24-72 hours of the first session.
collected while resting and while contracted at each
testing position and for each muscle. The participants
Data Processing
performed an abdominal draw-in maneuver for the
contraction and were instructed to contract by asking
After USI, a blinded investigator (MAS) randomly
them to pull their umbilicus toward their spine after
sorted images, and then muscle thickness in the 4 po-
expiration [18]. The measure of muscle thickness was
sitions was measured (by LCM) in millimeters using
assessed from the superior fascial border to the inferior
ImageJ software (National Institutes of Health,
fascial border of the muscle of interest in millimeters.
Bethesda, MD). The thickness of the TrA and LM for
For the TrA, the skin and adipose tissue, as well as the
every participant in each of the 4 postures was
external and internal oblique muscles, were identified
measured from the superior fascial border to the infe-
to ensure proper identification of the TrA beneath these
rior fascial border of each muscle (Figure 2A, B) in the
other structures.
same location in each participant’s set of resting and
contracted images. The AR for each muscle and PAR for
Lumbar Multifidus Measures TrA and LM for each side in each participant were
LM measures were obtained with the transducer calculated.
placed vertically on the lumbar region until the L4-L5
facet joint was visualized horizontally on the bottom of
the ultrasound screen. The same instructions for Outcome Measures
contraction of the TrA were given for the LM for each
position. The superior fascial border of the LM was the The primary outcome measures were TrA and LM AR
starting point for measurement, down to the visible L5 and TrA PAR as calculated from thickness measures via
spinous process. ultrasound images in 4 postures (tabletop, seated,
Figure 2. Ultrasound images with measurement technique. (A) Transverse abdominis (TrA) and lateral abdominal wall (external oblique [EO],
internal oblique [IO], and TrA). (B) Lumbar multifidus (LM; L4, L5 landmarks).
Table 2
Tabletop position intersession reliability of transverse abdominis activation ratio, lumbar multifidus activation ratio, and preferential activation
ratio
Session 1 Session 2 ICC(3,k) 95% CI ICC P Value SEM
AR TrA 1.48 0.40 1.55 0.49 0.90 0.72-0.97 <.001 0.14
PAR 0.04 0.03 0.05 0.04 0.67 0.05-0.88 .02 0.02
AR LM 1.00 0.04 1.02 0.034 0.26 0-0.74 .28 0.03
ICC ¼ intraclass correlation coefficient; CI ¼ confidence interval; SEM ¼ standard error of measurement; AR ¼ activation ratio; TrA ¼ transverse
abdominis; PAR ¼ preferential activation ratio; LM ¼ lumbar multifidus.
standing, and treadmill walking) with each in a resting substantial reproducibility (ICC3,k ¼ 0.61) and TrA AR
and contracting state [16]. was moderately reliable for standing (ICC3,k ¼ 0.55;
Activation Ratio ¼ (Musclecont/Musclerest) [16] Table 4). The walking position (Table 5) had an even
higher TrA AR reliability compared with the seated and
" # standing positions (ICC3,k ¼ 0.74). The PAR for the TrA
ðTrAcontracted =LatAbdWallcontracted Þ TrAresting LatAbdWallresting
PAR ¼ had substantial reliability for the participants in
TrAresting LatAbdWallresting
tabletop (ICC3,k ¼ 0.67) and seated (ICC3,k ¼ 0.68)
positions and was fair for the walking condition
(ICC3,k ¼ 0.46).
Statistical Analysis Measurement of the LM was only found to have poor
reliability (ICC3,k ¼ 0.26) in the tabletop position,
Intraclass correlation coefficients (ICC3,k) and which is presented in Table 2. The standard error of
95% confidence intervals were used to calculate reli- measurement representing precision of the measures is
ability in changes in muscle thickness for the TrA also presented in each table for each position,
AR, LM AR, and PAR in each of the 4 positions. The respectively.
heterogeneity of the images was tested with analysis
of variance to confirm that the images collected Discussion
through the randomization process were diverse
enough to validate the ICC values generated. Standard The USI methods used in this study to assess TrA
error of measurement was calculated to determine thickness and AR had acceptable to excellent reli-
the precision of the measures. All statistical analyses ability in all 4 positions assessed for healthy partici-
were conducted using SPSS version 20.0 (IBM Corp, pants. The tabletop reliability for the AR mirrored
Armonk, NY). results from previous studies [10,13,14] with strong
reliability, as well as in the seated and standing posi-
Results tions for the TrA. The addition of the walking task and
the reliability consistency within that position bolsters
Full participant characteristics are presented in the current literature and sets up future studies that
Table 1, including age, body mass index, and patient- could examine TrA activation in a more functional
reported outcome measures based on pain, disability, position. The assessment of LM only produced reliable
and level of activity that further confirm the inclusion of results in the tabletop position; the other positions
only healthy participants. were not reliable in the assessment of LM thickness
In the tabletop position, the AR for the TrA had and activation.
almost perfect reliability (ICC3,k ¼ 0.90), which repre- The AR formula, which divides muscle thickness in a
sented the highest reliability across all positions and contracted state by muscle thickness at rest [16], has
muscles. Tables 2-5 present all tabletop, seated, shown to be a more reliable method of using the
standing, and walking reliability measures, respectively. thickness measures as a function of activation for TrA.
In the seated position (Table 3), the AR for TrA had By normalizing the size during a contracted state to the
Table 3
Seated position intersession reliability of transverse abdominis activation ratio, lumbar multifidus activation ratio, and preferential activation
ratio
AR TrA 1.23 0.20 1.22 0.20 0.61 0-0.87 .04 0.12
PAR 0.15 0.31 0.002 0.02 0.68 0.10-0.89 .02 0.12
AR LM 1.00 0.03 1.01 0.33 e e e 0.23
Table 4
Standing position intersession reliability of transverse abdominis activation ratio, lumbar multifidus activation ratio, and preferential activation
ratio
AR TrA 1.26 0.18 1.25 0.21 0.55 0-0.84 .08 0.13
PAR 0.11 0.02 0.02 0.04 0.01 0-0.65 .50 0.03
AR LM 1.01 0.02 1.01 0.03 e e e 0.03
resting size, clinicians can determine the ability to co-contraction utilizing the abdominal draw-in maneu-
activate the TrA. However, that formula does not take ver, may not result in a consistent LM contraction and
into account the ability to isolate the TrA without therefore may affect the reliability of the measure [21].
evoking a contraction of the entire abdominal wall. The In our study, the AR was shown to be reliable for LM in
goal of most rehabilitation programs is to teach the the tabletop position alone and therefore should only be
patient to contract the local spinal stabilizers (TrA and assessed in a prone position, unless another method of
LM muscles) while keeping the global mover muscles activating the LM is discovered. Isolating and identifying
(the obliques) quiet. the contraction of the LM and the visualization of that
The PAR formula takes into account the thickness segment is challenging in the seated, standing, and
measure of the TrA and the entire lateral abdominal walking positions. Collecting the LM image at the L4-L5
wall, thus providing an assessment of the individual’s level may not be optimal for functional positions, and
ability to isolate the spinal stabilizers [16,20]. How- the L5-S1 level could be investigated further [23].
ever, there may be an increased source of error with Consistent with previous electromyographic studies that
the PAR measure with the addition of the lateral have collected posterior low back musculature activa-
abdominal wall muscles into the formula, particularly tion in walking at heel strike [24], we attempted to
during more challenging positions. Because the TrA is measure the LM AR at the same time point. Future
considered to be a protective stabilizer [21], assess- research should utilize a timing mechanism to capture
ment of the PAR could be included along with the more the ultrasound image at exactly the appropriate
reliable AR and as the muscle function during more moment to improve consistency with this measure.
challenging positions is studied. Including more infor- Finally, if isolating the LM is truly a novel task for the
mation individually by adding the lateral abdominal patient, then a practice session may be beneficial in
wall thickness measures at rest and while contracted ensuring a LM contraction, because it is a highly variable
may be more beneficial, but the chance for error in- measure in these functional positions. For this study,
crease also must be weighed when making the choice the participants were simply instructed to bring their
of using an AR or a PAR. umbilicus toward their spine after exhalation, as pre-
Previous research has also reported poor reliability in viously recommended [18].
the assessment of the LM using USI beyond a tabletop Various calculations may be used to determine
position [3,10,22]. The LM can be challenging to mea- muscle activation, but it is important to develop a
sure even in static positions, compared with the TrA, method to measure and determine activation in more
because there are fewer landmarks to identify with functional positions that is consistently reliable in
ultrasound, making the transducer placement and healthy persons. The TrA AR and PAR both show
identification of each segment of the muscle’s borders moderate to excellent reliability using the ultrasound
more difficult. Targeting a specific portion of the LM measurement technique from this study. These mea-
most appropriate for ultrasound assessment also sures have acceptable reliability in these healthy
has been problematic because of its various segments. participants; therefore, it can be used to make group
The contraction instructions for the LM, which is a comparisons in future research. Exploring group
Table 5
Walking position intersession reliability of transverse abdominis activation ratio, lumbar multifidus activation ratio, and preferential activation
ratio
AR TrA 1.24 0.17 1.36 0.25 0.74 0.25-0.91 .01 0.09
PAR 0.01 0.02 0.02 0.03 0.46 0-0.81 .13 0.02
AR LM 1.00 0.04 1.01 0.05 e e e 0.04
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Disclosure
L.C.M. University of Virginia Exercise and Sport Injury Laboratory, 210 Emmet St J.M.H. University of Virginia Exercise and Sport Injury Laboratory, 210 Emmet St
South, Charlottesville, VA 22904. Address correspondence to: L.C.M.; e-mail: South, Charlottesville, VA 22904
lcm5xj@virginia.edu Disclosures outside this publication: grants, Sanofi (clinical trial) and NSF (STTR
Disclosure: nothing to disclose grant with UVA); other, Founding owner of Springbok, Inc
Submitted for publication December 4, 2014; accepted September 21, 2015.
M.A.S. University of Virginia Exercise and Sport Injury Laboratory, 210 Emmet St
South, Charlottesville, VA 22904
Disclosure: nothing to disclose
S.A.S. University of Virginia Exercise and Sport Injury Laboratory, 210 Emmet St
South, Charlottesville, VA 22904
Disclosure: nothing to disclose

Reliability of Ultrasound Imaging Measures of Transverse

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PM R 8 (2016) 340-347

Reliability of Ultrasound Imaging Measures of Transverse

Reliability of USI measures has been shown to be Table 1

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