[ technical note ]

HIROSHI ISHIDA, PT, PhD1 • SUSUSMU WATANABE, PT, PhD2

Influence of Inward Pressure of the

Transducer on Lateral Abdominal Muscle
Downloaded from www.jospt.org at National Cheng Kung University on April 7, 2021. For personal use only. No other uses without permission.

Thickness During Ultrasound Imaging

U
ltrasound imaging (USI) of the abdominal muscles is als with LBP. The relationship between
increasingly used in the management of conditions involving LBP and delayed activation of the TrA
muscle suggests that training of isolated
musculoskeletal dysfunctions associated with abdominal
TrA muscle contraction may be impor-
muscles, including certain types of low back pain (LBP).15 tant for normal motor control during
Copyright © 2012 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Training of the transversus abdominis (TrA) muscle is believed to be an active movement.12,14 In contrast, Ka-
important component in the rehabilitation of individuals with LBP.12,14 vcic et al8 have suggested that because
all muscles play a role during functional
Hodges5 showed that TrA muscle activa- ment in asymptomatic adults. However, tasks, training should involve activation
tion occurs prior to limb movement and activation of the TrA muscle prior to of all abdominal muscles in combina-
is independent of the direction of move- limb movement is delayed in individu- tion. Though direct force measurement
to compare the strength of individual
abdominal muscles is not possible, an
TTSTUDY DESIGN: Controlled laboratory study, sures analysis of variance was used to assess the
indirect measure of force-generating ca-
technical note. influence of inward pressure on the thickness of
Journal of Orthopaedic & Sports Physical Therapy®

pacity may be provided by muscle size,

TTOBJECTIVES: The purpose of this study was
to quantify changes in the thickness of the trans-
versus abdominis, internal oblique, and external
oblique muscles induced by different inward
pressures of the transducer during ultrasound
imaging (USI).
TTBACKGROUND: USI of the lateral abdomi-
nal muscles is increasingly used in managing
musculoskeletal dysfunction. However, to the
best of our knowledge, no study has evaluated
the influence of different inward pressures of
the transducer on the lateral abdominal muscle
thickness during USI.
TTMETHODS: Thirty healthy male volunteers
participated in this study. The thickness of the
transversus abdominis, internal oblique, and
external oblique muscles was measured with USI
by the same rater in 4 conditions of inward pres-
sures of 0.5, 1.0, 2.0, and 4.0 N. Intraclass cor-
relation coefficients (ICC1,1), with 95% confidence
intervals, were calculated, and a repeated-mea-
the lateral abdominal muscles.
TTRESULTS: The thickness of the transversus
abdominis, internal oblique, and external oblique
muscles was significantly different among the
4 conditions (P<.038). The mean difference
between the 0.5-N and 4.0-N conditions was
greater than the minimal detectable change of
the 0.5-N condition in the lateral abdominal
muscles.
TTCONCLUSION: The difference in magnitude
produced by the forces under different conditions
was meaningful. When using a technique that
involves a handheld transducer, the examiner
should attempt to maintain consistent inward
pressure of the transducer during USI to quantify
the thickness of lateral abdominal muscles.
J Orthop Sports Phys Ther 2012;42(9):815-818,
Epub 19 April 2012. doi:10.2519/jospt.2012.4064
TTKEY WORDS: muscle thickness, transversus
abdominis, ultrasound imaging
as demonstrated by various muscles.7,10
Therefore, the measurement of lateral
abdominal muscle thickness by USI
must be reliable and sensitive to provide
accurate and meaningful information
to assess muscle changes such as those
occurring during atrophy or hypertro-
phy.13,15 Diligent attention to steadying
the position, orientation, and inward
pressure of the transducer is required
during USI.15 However, to the best of our
knowledge, no study has evaluated the
influence of different inward pressures
of the transducer on lateral abdominal
muscle thickness during USI. Therefore,
the purpose of this study was to quantify
the changes in lateral abdominal muscle
thickness induced by different inward
pressures of the transducer during USI.

1
Assistant Professor, Department of Rehabilitation, Kawasaki University of Medical Welfare, Kurashiki, Japan. 2Professor, Department of Rehabilitation, Kawasaki University of
Medical Welfare, Kurashiki, Japan. This study was approved by the Ethics Committee of the Kawasaki University of Medical Welfare. Address correspondence to Dr Hiroshi Ishida,
Department of Rehabilitation, Kawasaki University of Medical Welfare, 288 Matsushima, Kurashiki, 701-0193 Japan. E-mail: ishida@mw.kawasaki-m.ac.jp t Copyright ©2012
Journal of Orthopaedic & Sports Physical Therapy

journal of orthopaedic & sports physical therapy  |  volume 42  |  number 9  |  september 2012  |  815

42-09 Ishida.indd 815 8/21/2012 4:21:05 PM

 [ TECHNICAL NOTE ]

TABLE 1 Intraexaminer Reliability

ICC1,1 (95% CI) SEM* MDC*

TrA
0.5 N 0.99 (0.98, 0.99) 0.1 0.3
Downloaded from www.jospt.org at National Cheng Kung University on April 7, 2021. For personal use only. No other uses without permission.

1.0 N 0.98 (0.97, 0.99) 0.2 0.5

FIGURE. A custom-made holder was designed to 2.0 N 0.97 (0.95, 0.99) 0.2 0.6
enable hands-free application of the ultrasound
4.0 N 0.98 (0.97, 0.99) 0.2 0.5
transducer, which could maintain inward pressures
of approximately 0.5 N, 1.0 N, 2.0 N, and 4.0 N by IO
using 4 constant-force springs (CR-1, CR-2, CR-3, 0.5 N 0.99 (0.98, 0.99) 0.2 0.7
CR-4; Accurate Co Ltd, Tokyo, Japan). The location 1.0 N 0.99 (0.98, 0.99) 0.2 0.7
of the transducer holder was fixed, allowing repeated 2.0 N 0.99 (0.98, 0.99) 0.2 0.7
testing using the same position and orientation of the
4.0 N 0.99 (0.98, 0.99) 0.2 0.7
transducer.
EO
0.5 N 0.99 (0.98, 0.99) 0.2 0.6
METHODS 1.0 N 0.98 (0.96, 0.99) 0.3 0.9
2.0 N 0.92 (0.85, 0.96) 0.6 1.8
Copyright © 2012 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Subjects 4.0 N 0.99 (0.98, 0.99) 0.2 0.6

T
hirty healthy male volunteers Abbreviations: CI, confidence interval; EO, external oblique; ICC, intraclass correlation coefficient;
IO, internal oblique; MDC, minimal detectable change; SEM, standard error of measurement; TrA,
participated in this study. Their
transversus abdominis.
mean  SD age, height, and weight *Data are in mm.
were 21.1  1.1 years, 171.6  6.2 cm, and
63.7  7.9 kg, respectively. The exclusion
criteria were a history of LBP, known
Thicknesses and Percent Thickness
neuromuscular disease, and participation TABLE 2
Changes of the 3 Muscles
in competitive sports with a frequency of
Journal of Orthopaedic & Sports Physical Therapy®

more than 3 times a week. The protocol

Percent Change
for this study was approved by the Ethics
Thickness, mm* in Thickness, %* ANOVA P Value
Committee at the Kawasaki University
TrA <.001
of Medical Welfare. Subjects provided
0.5 N 4.4  1.2
their informed written consent prior to
1.0 N 4.2  1.1 –3.8  5.0
participation.
2.0 N 4.1  1.1 –6.4  5.5
4.0 N 4.0  1.1 –9.1  6.4
Equipment IO <.001
A therapist experienced in using the de- 0.5 N 10.4  2.7
vice was responsible for collecting the 1.0 N 10.2  2.5 –2.3  3.7
USI data. B-mode real-time ultrasound 2.0 N 9.9  2.4 –4.6  5.8
images of the lateral abdominal wall 4.0 N 9.3  2.3 –10.8  7.8
were captured, stored, and measured EO <.001
using an Aloka SSD-3500SX (Hitachi 0.5 N 10.7  2.4
Aloka Medical, Ltd, Tokyo, Japan), with 1.0 N 10.3  2.3 –3.8  3.1
a 10-MHz linear-array transducer. A 2.0 N 9.6  2.1 –10.6  3.7
custom-made holder, designed to enable 4.0 N 8.6  2.0 –19.6  5.3
hands-free application of the ultrasound Abbreviations: ANOVA, analysis of variance; EO, external oblique; IO, internal oblique; TrA, trans-
transducer, maintained inward pressures versus abdominis.
of approximately 0.5 N, 1.0 N, 2.0 N, and *Values are mean  SD.
4.0 N with 4 constant-force springs (CR-
1, CR-2, CR-3, CR-4; Accurate Co Ltd, transducer during abdominal USI of be- the thickness of the TrA, using a realis-
Tokyo, Japan) (FIGURE). Previous studies low 6.0 N.2,3 In this study, we quantified tic range of values for USI. We measured
have reported an inward pressure of the the influence of the range of forces on the force output of the transducer hold-

816 | september 2012 | volume 42 | number 9 | journal of orthopaedic & sports physical therapy

42-09 Ishida.indd 816 8/21/2012 4:21:06 PM


TABLE 3 Significant Differences of Mean Values Between Data by Bonferroni Test

TrA IO EO
Difference* P Value Difference* P Value Difference* P Value
Downloaded from www.jospt.org at National Cheng Kung University on April 7, 2021. For personal use only. No other uses without permission.

0.5 N versus 1.0 N –0.2 .006 –0.3 .021 –0.4 <.001

0.5 N versus 2.0 N –0.3 <.001 –0.6 .001 –1.2 <.001
0.5 N versus 4.0 N –0.4 <.001 –1.2 <.001 –2.1 <.001
1.0 N versus 0.5 N 0.2 .006 0.3 .021 0.4 <.001
1.0 N versus 2.0 N –0.1 .038 –0.3 .010 –0.7 <.001
1.0 N versus 4.0 N –0.2 <.001 –0.9 <.001 –1.7 <.001
2.0 N versus 0.5 N 0.3 <.001 0.6 .001 1.2 <.001
2.0 N versus 1.0 N 0.1 .038 0.3 .010 0.7 <.001
2.0 N versus 4.0 N –0.2 .010 –0.6 <.001 –1.0 <.001
4.0 N versus 0.5 N 0.4 <.001 1.2 <.001 2.1 <.001
4.0 N versus 1.0 N 0.2 <.001 0.9 <.001 1.7 <.001
4.0 N versus 2.0 N 0.1 .010 0.6 <.001 1.0 <.001
Abbreviations: EO, external oblique; IO, internal oblique; TrA, transversus abdominis.
Copyright © 2012 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

*Values are in mm.

er with a force plate (P08-1713; Kyowa oblique [IO], and external oblique [EO])
Electronic Instruments Co, Ltd, Tokyo, was measured at the center of the image RESULTS
Japan), and the validity of the device (mm). The percentage change of the

was 0.2 N. Gel was placed between the
transducer and skin. The transducer was
then placed transversely on the right side
of the body, with its center positioned 25
Journal of Orthopaedic & Sports Physical Therapy®
TrA, IO, and EO muscles from the 0.5-
N condition was calculated as the muscle
thickness at the 0.5-N condition minus
that at the 1.0-N, 2.0-N, or 4.0-N condi-
T
he intraexaminer reliability is
listed in TABLE 1. The ICCs of all in-
dices were greater than or equal to
0.92. Significant differences were ob-

mm anterior to the midaxillary line and
at the midpoint between the inferior rib
and iliac crest.9 The transducer was tilted
to position it in a plane in which the ul-
trasound wave was perpendicular to the
muscle fascia of the TrA muscle.6 Fur-
thermore, the location of the transducer
holder was fixed. After fixation, we could
therefore repeat testing under different
instrument conditions (different inward
pressures) using the same position and
orientation of the transducer holder.
Procedures
Subjects were positioned in the supine
position with their arms crossed over
their chest and their hands on their
shoulders. The 4 conditions (0.5 N, 1.0
tion, divided by the 0.5-N condition, and
multiplied by 100%. The average value of
the 3 collections for each condition was
used for analysis.
Statistical Analysis
SPSS Version 16.0J (SPSS Inc, Chicago,
IL) was used for statistical analyses. In-
trarater reliability of USI measurement
was examined by calculating the intra-
class correlation coefficient (ICC1,1) val-
ues with 95% confidence intervals. The
standard error of measurement [SEM =
SDpool ≈ 1 – ICC] and the minimal de-
tectable change (MDC) for a 95% con-
fidence interval [MDC = SEM ≈ 2.045
≈ 2] were calculated for each ultra-
sound measurement, where SDpool was
served in all parameters (TABLE 2). The
thickness of the 3 muscles is listed in
TABLE 2. Significant differences of mean
values between data, as assessed with the
Bonferroni test, are listed in TABLE 3. The
thickness of the TrA, IO, and EO muscles
was significantly different among the 4
conditions. The mean difference between
the 0.5-N and 4.0-N conditions was
greater than the MDC of the 0.5-N con-
dition for the TrA muscle, and the mean
difference between the 0.5-N and 4.0-N
conditions was greater than the MDC of
the 0.5-N and 4.0-N conditions for the
IO and EO, respectively.
DISCUSSION

N, 2.0 N, and 4.0 N) were performed in
random order. Ultrasound images were
captured when the subjects had com-
pletely exhaled. Data for each condition
were collected in triplicate. The thickness
of each of the 3 muscles (TrA, internal
the pooled standard deviation. One-way
repeated-measures analysis of variance
was utilized to assess differences. Post
hoc analysis was performed with the
Bonferroni test. Values were considered
statistically significant at P<.05.
W
e investigated the changes in
lateral abdominal muscle thick-
ness induced by different inward
pressures of the transducer during USI.
Previous studies have reported the rang-
es of ICC values for the measurement of

journal of orthopaedic & sports physical therapy  |  volume 42  |  number 9  |  september 2012  |  817

42-09 Ishida.indd 817 8/21/2012 4:21:07 PM


lateral abdominal muscle thickness at
rest by using USI (range, 0.98-0.99).11,13
The ICC values for the lateral abdominal
muscles in this study (range, 0.92-0.99)
were similar to those in previous studies.
The methods used in this study might
have contributed to the high intrarater
Downloaded from www.jospt.org at National Cheng Kung University on April 7, 2021. For personal use only. No other uses without permission.
reliability. Specifically, the experimental
setup might have positively influenced
the reliability values. The location of the
transducer holder was fixed, which al-
lowed repeated testing under different
instrument conditions (different inward
pressures) by using the same position and
orientation of the transducer holder.
In this study, inward pressures of the
transducer during USI decreased the
thickness of the lateral abdominal mus-
cles. These changes may be related to the
Copyright © 2012 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
muscles’ elasticity, although the pressures
on the muscles were low. The difference
in magnitude produced by the forces un-
der different conditions was meaningful
because the mean differences between
the 0.5-N and 4.0-N conditions were
greater than the MDC of the 0.5-N con-
dition in the lateral abdominal muscles.
We could say that maintaining consistent
Journal of Orthopaedic & Sports Physical Therapy®
inward pressure is necessary for manu-
ally holding the transducer during USI.
For example, Akbari et al1 found that 8
weeks of motor control exercise resulted
in an increase of approximately 0.5 mm
in TrA muscle thickness and that general
exercise resulted in an increase of 0.3 mm
at rest in individuals with LBP. Different
inward pressures of the transducer dur-
ing USI can induce these changes; thus,
the option for maintaining consistent
inward pressure of the transducer, such
as using a high-density foam cube4 and
the transducer holder described in this
study, may improve the ability to quan-
tify the minimal change of the lateral ab-
818  |  september 2012  |  volume 42  |  number 9  |  journal of orthopaedic & sports physical therapy
42-09 Ishida.indd 818
[ technical note
dominal muscle thickness induced by the
intervention. The transducer holder has
practical application in the clinical and
research setting because of its low cost.
In addition, it is simple and easy to use,
and may prevent measurement error in-
duced by different inward pressures of a
handheld transducer during USI.
CONCLUSION
T
he difference in magnitude pro-
duced by the forces under different
conditions was meaningful. When
using a technique that involves a hand-
held transducer, the examiner should
attempt to maintain consistent inward
pressure of the transducer during USI
to quantify the minimal change of lateral
abdominal muscle thickness. t
REFERENCES
1. A kbari A, Khorashadizadeh S, Abdi G. The effect
of motor control exercise versus general exercise
on lumbar local stabilizing muscles thickness:
randomized controlled trial of patients with
chronic low back pain. J Back Musculoskelet
Rehabil. 2008;21:105-112.
2. Ando K, Saito S, Aoki Y, Ozawa K, Masuda K.
Development of probe scan mechanism for
echography using pneumatic actuators and
its estimation control in contact force on body
surface. J Robot Soc Jpn. 2010;28:792-801.
3. Aoki Y, Masuda K. Development of medical
robot based on analysis of scanning procedure
for echography. J Inst Electr Install Eng Jpn.
2008;28:935-938.
4. Bunce SM, Moore AP, Hough AD. M-mode
ultrasound: a reliable measure of transversus
abdominis thickness? Clin Biomech (Bristol,
Avon). 2002;17:315-317.
5. Hodges PW. Is there a role for transversus
abdominis in lumbo-pelvic stability? Man
Ther. 1999;4:74-86. http://dx.doi.org/10.1054/
math.1999.0169
6. Jhu JL, Chai HM, Jan MH, Wang CL, Shau YW,
Wang SF. Reliability and relationship between
]
2 measurements of transversus abdominis
dimension taken during an abdominal drawing-
in maneuver using a novel approach of ultra-
sound imaging. J Orthop Sports Phys Ther.
2010;40:826-832. http://dx.doi.org/10.2519/
jospt.2010.3000
7. Kanehisa H, Ikegawa S, Fukunaga T. Comparison
of muscle cross-sectional area and strength
between untrained women and men. Eur J Appl
Physiol Occup Physiol. 1994;68:148-154.
8. Kavcic N, Grenier S, McGill SM. Quantify-
ing tissue loads and spine stability while
performing commonly prescribed low back
stabilization exercises. Spine (Phila Pa 1976).
2004;29:2319-2329.
9. Mannion AF, Pulkovski N, Gubler D, et al. Muscle
thickness changes during abdominal hollowing:
an assessment of between-day measurement
error in controls and patients with chronic low
back pain. Eur Spine J. 2008;17:494-501. http://
dx.doi.org/10.1007/s00586-008-0589-x
10. Maughan RJ, Watson JS, Weir J. Strength and
cross-sectional area of human skeletal muscle.
J Physiol. 1983;338:37-49.
11. Mew R. Comparison of changes in abdomi-
nal muscle thickness between standing and
crook lying during active abdominal hollow-
ing using ultrasound imaging. Man Ther.
2009;14:690-695. http://dx.doi.org/10.1016/j.
math.2009.05.003
12. O’Sullivan PB, Twomey L, Allison GT. Altered
abdominal muscle recruitment in patients with
chronic back pain following a specific exer-
cise intervention. J Orthop Sports Phys Ther.
1998;27:114-124.
13. Rankin G, Stokes M, Newham DJ. Abdominal
muscle size and symmetry in normal subjects.
Muscle Nerve. 2006;34:320-326. http://dx.doi.
org/10.1002/mus.20589
14. Richardson CA, Snijders CJ, Hides JA, Damen
L, Pas MS, Storm J. The relation between the
transversus abdominis muscles, sacroiliac joint
mechanics, and low back pain. Spine (Phila Pa
1976). 2002;27:399-405.
15. Teyhen DS, Gill NW, Whittaker JL, Henry SM,
Hides JA, Hodges P. Rehabilitative ultrasound
imaging of the abdominal muscles. J Orthop
Sports Phys Ther. 2007;37:450-466. http://
dx.doi.org/10.2519/jospt.2007.2558
@
MORE INFORMATION
WWW.JOSPT.ORG
8/21/2012 4:21:08 PM