Journal of Back and Musculoskeletal Rehabilitation 29 (2016) 317–325 317

DOI 10.3233/BMR-150633
IOS Press

Abdominal hollowing and bracing strategies

increase joint stability in the trunk region
during sudden support surface translation but
not in the lower extremities
Minhee Kima , Yushin Kima , Sejun Oha , Dongwon Suhb , Seon-Deck Eunc and BumChul Yoona,∗
a
Department of Physical Therapy, College of Health Sciences, Korea University, Seoul, Korea
b
Barunsesang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Korea
c
Korea National Rehabilitation Research Institute, Seoul, Korea

Abstract.
BACKGROUND AND OBJECTIVE: Application of hollowing and bracing, abdominal activation strategies (AAS), has fo-
cused on improving trunk stability. This study aimed to clarify the AAS effect on body sway during support surface translation
while standing.
MATERIALS AND METHODS: Twenty healthy subjects (10 male, 10 female; aged 25.45 ± 3.22 years) performed hollowing,
bracing, and natural strategies while standing, and exerted to maintain their balance during forward and backward translation.
Ultrasonography evaluations confirmed the appropriate application of the 3 strategies by measuring abdominal muscle thickness.
Additionally, a motion analysis system was used to capture the whole body sway along the sagittal plane.
RESULTS: During backward translation, angular displacements of the trunk were significantly different among the 3 strategies
(upper thoracic: F = 13.758, p < 0.001; lower thoracic: F = 8.477, p = 0.001; and lumbopelvis: F = 8.651, p = 0.001).
AAS significantly decreased the sway by 25–36% in all inter-spinal segments compared with the natural strategy (p < 0.05).
During forward translation, only angular displacement of the lower thoracic was significantly different among the 3 strategies (F
= 7.640, p = 0.002), and bracing decreased the sway by 33.48% compared with the natural strategy (p = 0.003). No significant
differences were seen between hollowing and bracing during forward and backward translation.
CONCLUSIONS: AAS increased joint stability only in the trunk where joints are adjacent to abdominal muscles, but not in
the lower extremities. The low impact of AAS on the lower extremities might have important implications on the paradigm of
standing balance.

Keywords: Abdominal activation strategies, body sway, abdominal muscles, perturbation

1. Introduction terns of abdominal muscles by retraining motor con-

Abdominal activation strategies (AAS) have been
used as a training method to decrease lower back pain
and to improve trunk stability [1]. These techniques
can change conscious and automatic activation pat-
∗ Corresponding author: BumChul Yoon, Department of Physical
Therapy, College of Health Sciences, Korea University Jeongneung
3-Dong, Sungbuk-Gu, Seoul 136-703, Korea. Tel.: +82 29402833;
Fax: +82 29402830; E-mail: yoonbc@korea.ac.kr.
trol [2–4]. The AAS are the hollowing and bracing
strategy. The hollowing or drawing-in manoeuvre is
recommended for preferential activation of transversus
abdominis (TrA) and for minimizing superficial mus-
cle activation, involving the rectus abdominis and ex-
ternal oblique (EO) muscles [5,6]. Conversely, bracing
is the contraction of all the antero-lateral abdominal
muscles [7,8]. That is, the two AAS differ in targeted
muscle activation of the deep abdominal muscles or all
abdominal muscles.

ISSN 1053-8127/16/$35.00 
c 2016 – IOS Press and the authors. All rights reserved
318 M. Kim et al. / Abdominal hollowing and bracing strategies increase joint stability
Previous studies have compared the effects of hol-
lowing and bracing on trunk stability [5,7–12]. Hol-
lowing is supported by the evidence indicating that TrA
is associated with anticipatory postural adjustments
and activated without directional preference during
arm movement [13]. Additionally, independent TrA
contraction can decrease the laxity of the sacroiliac
joint in prone individuals [11] and increase the stiff-
ness of spine joint [5,9]. Based on these findings, hol-
lowing has been used popularly in the clinical setting
to improve trunk stability.
However, some studies suggested that bracing is
more effective to increase trunk stability than hollow-
ing because incorporation of many muscles enhances
the motor patterns rather than targeting just a few mus-
cles [8,12,14]. One study reported that bracing de-
creased the trunk sway more during sudden trunk load-
ing when the individual is in a semi-seated position
with restricted motion of the lower extremities [12].
Further, co-activation of all abdominal muscles in-
creases the postero-anterior spinal stiffness [8]. Simu-
lation analysis using a spine stability index also sup-
ported the concept that bracing provides more trunk
stability than hollowing [10]. However, a multidimen-
sional study is required to compare the AAS of these
varying results. Furthermore, several studies demon-
strated the inter-relationship between the muscle ac-
tivity of the trunk and lower extremity movement, but
they were focused on functional tasks rather than dy-
namic balance tasks [15,16]. Therefore, it is neces-
sary to identify whether the AAS can stabilize body
sway effectively under unexpected perturbations while
in standing position, as a further study from previously
conducted ones on prone or sitting positions [8,11,12].
This study aimed to investigate the effect of the AAS
on body sway during support surface translation in the
standing position. We hypothesized that the amount of
body sway in the standing position is different among
the hollowing, bracing, and natural strategies. Addi-
tionally, we considered that AAS can alter the move-
ment of the lower extremities during sudden perturba-
tion. To test this hypothesis, we measured the whole
body sway as an index of the postural stability under
the AAS and the natural strategy.
2. Methods
2.1. Participants
Twenty healthy participants (10 male and 10 female,
aged 25.45 ± 3.22 years, 166.80 ± 6.79 cm in height,
and 62.45 ± 11.72 kg in weight) were recruited for this
study. The participants were excluded from the study
if they had any of the following: 1) back pain within
the last 3 months, 2) spinal deformity such as scoliosis
or kyphosis, 3) neurologic disorder affecting the sen-
sorimotor system, 4) pregnancy, or 5) spinal surgical
intervention. All participants received explanations of
the purpose and the experimental protocol of the study,
and they signed an informed consent form. The present
study was approved by the Institutional Review Board.
2.2. Apparatus
2.2.1. Ultrasound imaging
To instruct and verify the hollowing, bracing and
natural strategies, a B-mode ultrasonography machine
(Volusion I, GE Medical Systems, UK) equipped with
a 7.5-MHz linear volume transducer (RSP6-16-RS, GE
Medical Systems) was used in preparation and inter-
trial sessions. Measuring change in muscle thickness
using ultrasonography is a reliable noninvasive tech-
nique for identifying muscle activation and has been
demonstrated to consistently correlates with intramus-
cular electromyography and magnetic resonance imag-
ing [5,17,18]. The ultrasonography was set to measure
the muscle thickness of the lateral abdominal region
containing EO, internal oblique (IO), and TrA muscles.
To obtain clear images, the transducer was placed at the
intersection point between a transverse line across the
umbilicus and another line connecting the lower part
of the 12th rib and anterior superior iliac crest [19].
2.2.2. Platform
The support surface translation used in the current
study was a customized moving platform machine.
The moving platform (1.62 m long × 0.93 m wide ×
0.35 m high) was controlled by commercial software,
PANATERM version 5.0 (Panasonic Corp., Kadoma-
shi, Osaka, Japan). The moving platform was suddenly
moved in forward and backward directions to elicit the
anteroposterior body sway of the participant standing
on it. The moving platform travelled at 10 cm for 0.55 s
with a peak velocity of 35.2 cm/s, which is within the
medium speed range [20].
2.2.3. Motion analysis
A motion analysis system with six infrared cameras
(Motion Analysis Corporation, Santa Rosa, CA, USA)
was used to capture the whole body segment angular
displacement to measure body sway along the sagittal
plane. The body sway was recorded at a sampling rate
 M. Kim et al. / Abdominal hollowing and bracing strategies increase joint stability
Fig. 1. Modelling of the inter-spinal segment and lower extremities.
UT; upper trunk, LT; lower trunk, LP; lumbopelvis.
of 200 Hz and low-pass filtered subsequently with a
cutoff frequency of 2 Hz.
A partially modified Helen-Hayes marker set was
used to detect the body segment of the participants
from the data obtained by the motion capturing cam-
eras. The marker set in the study was focused to the
trunk and the lower extremities as follows: spinous
processes of C7, T7, T12, and S1 vertebrae, the bilat-
eral anterior superior iliac spines and posterior superior
iliac spines, midway between the greater trochanter
and the femoral condyle, lateral and medial aspects of
the knee, midway between the femoral condyle and lat-
eral malleolus, lateral and medial malleolus, and the
heel and 2nd metatarsal head. The Cortex v1.0 software
(Motion Analysis Corporation, Santa Rosa, CA, USA)
was used to produce a multi-segment model based on
the marker set (Fig. 1). Additionally, four markers were
placed on the moving platform to capture the move-
ment of the support surface.
2.3. Procedure
2.3.1. Training of ASS
Before the testing, subjects received five times of in-
struction on how to perform the hollowing and bracing
strategy in the standing position [21]. The ultrasonog-
raphy was performed for the participants to receive vi-
sual feedback information on the thickness of the lat-
eral abdominal muscles. For the hollowing strategy,
319
the participants were instructed to draw the abdominal
wall into the inside of the abdomen slowly and gen-
tly, maintaining the lumbar spine in a neutral position
while standing [22,23]. For the bracing strategy, the
participants were instructed to contract the entire ab-
dominal wall and to expand the lateral abdominal wall
without drawing in the lower abdomen, and maintain-
ing the lumbar spine in a neutral position while stand-
ing [24–26]. During hollowing and bracing, the partic-
ipants were asked to breathe normally and shallowly.
2.3.2. Sudden perturbation
While wearing a safety harness, the subjects stood
on top of the computer-controlled platform with their
bare feet shoulder width apart, arm crossed over their
chest, and eyes closed and covered with blindfold.
They were instructed to maintain balance without step-
ping during all the trials. Occasional heel – lift did oc-
cur during trials and subsequent analyses except the
stepping trials by visual inspection. The foot position
of each subject was marked on the platform to main-
tain a consistent starting position. The subjects were
asked to perform the hollowing, bracing, and natural
strategies and were then subjected to a sudden random
perturbation within 10 s. For the natural strategy, the
participants gave no specific instructions to elicit their
own strategies for standing balance.
To confirm the successful hollowing and bracing, we
scanned the static view using the ‘freeze’ setting of the
ultrasound machine prior to applying the sudden per-
turbation. All images were recorded at the end of ex-
halation to minimize the effect of breathing [27].
Each subject performed total of 18 trials that in-
cluded the following: two directions of translations
(forward and backward), and 3 strategies (hollowing,
bracing, and natural) repeated 3 times. The sequence of
18 trials was blinded to the subjects and performed ran-
domly. Each subject was given a rest break of 3 min-
utes after every trial.
2.4. Data analysis
2.4.1. Thickness of abdominal muscles
The absolute muscle thickness was defined as the
maximum distance between the lower and upper fas-
cias of each muscle (Fig. 2). In cases of hollowing and
bracing, change ratio of abdominal muscle thickness
from those of the natural strategy were calculated. For
example, the TrA and EO + IO change ratio was cal-
culated as (TrA contract – TrA rest)/(TrA rest × 100)
and (EO + IO contract – EO + IO rest)/(EO + IO rest)
× 100, respectively [28].
320 M. Kim et al. / Abdominal hollowing and bracing strategies increase joint stability

Table 1
Absolute thickness of abdominal muscles at rest, hollowing, and bracing
Natural Hollowing Bracing F p-value
(ICC3,1 , 95% CI) (ICC3,1 , 95% CI) (ICC3,1 , 95% CI)
EO 0.37 ± 0.12 †0.44 ± 0.12 ††0.46 ± 0.15 9.782 < 0.001∗
(0.86, 0.71–0.94) (0.84, 0.66–0.93) (0.86, 0.70–0.94)
IO 0.59 ± 0.09 †0.72 ± 0.13 ††0.77 ± 0.12 45.520 < 0.001∗
(0.73, 0.43–0.89) (0.81, 0.61–0.92) (0.78, 0.54–0.91)
TrA 0.41 ± 0.10 †0.58 ± 0.16 ††0.50 ± 0.16 29.114 < 0.001∗
(0.76, 0.50–0.90) (0.81, 0.60–0.92) (0.72, 0.41–0.88)
Values represent mean ± SD. The asterisk indicates a statistically significant difference. †denotes that hollowing resulted in thickness value more
significant than resting. ††denotes that bracing resulted in a value significantly greater than resting. ICC, intra-class correlation coefficient; CI,
confidence interval; EO, thickness of the external oblique muscle; IO, thickness of the internal oblique muscle; TrA, thickness of the transversus
abdominis muscle.

A B C

Fig. 2. Ultrasound imaging of the lateral abdominal wall. A. natural, B. hollowing, C. bracing; EO; external oblique, IO; internal oblique, TrA;
transversus abdominis.

2.4.2. Angular displacement of whole body segments
To identify the body sway during the support sur-
face translation, we analysed an angular displacement
of whole body segment [25,29]. Subsequent data pro-
cessing used CORTEX 1.0 software (Motion Anal-
ysis Corporation, Santa Rosa, CA, USA). The anal-
ysed body segments were upper thoracic, lower tho-
racic, lumbopelvis, thigh, shank, and foot. The right
side was analysed between both lower extremities. The
angular displacement was determined by subtraction of
the minimum to maximum values for 100 ms before
and 1.5 s after onset of the moving platform. Figure 3
presents trajectories of the angular displacement of the
inter-spinal segments during the forward translation.
2.5. Statistical analysis
The measured values were averaged over the 3 tri-
als of each of the 3 strategies. To assess a normal dis-
tribution, the Shapiro-Wilk test was conducted. Relia-
bility of the ultrasonography image was calculated for
the repeat measures of thickness of TrA, EO, and IO
of each of the 3 strategies using the intra-class corre-
lation coefficient (ICC3,1 ). Additionally, one-way re-
peated measures analysis of variance was used to iden-
tify differences in the absolute thickness of EO, IO, and
TrA and angular displacement of the whole body seg-
ments among the 3 strategies. The difference in change
ratio of TrA and EO + IO between the hollowing and
bracing were analysed by the one-way repeated mea-
sures analysis of variance. Post hoc analysis was con-
ducted using Tukey’s honest significant difference. In
this study, the significance level was set at alpha =
0.05.
3. Results
3.1. Thickness of abdominal muscles
Each of the values of ICC and absolute thickness of
EO, IO, and TrA in the 3 strategies are demonstrated
in Table 1. In the change ratio of TrA, hollowing was
greater than bracing by 20.87% (F = 15.187, p =
0.001). In case of the change ratio of EO + IO, bracing
was significantly greater than hollowing by 8.98% (F
= 6.348, p = 0.021) (Table 2).
3.2. Angular displacement
During the backward translation, the angular dis-
placements of the trunk were significantly different
 M. Kim et al. / Abdominal hollowing and bracing strategies increase joint stability 321

Table 2
Change ratio of abdominal muscle thickness from the natural strategy at hollowing and bracing
Hollowing Bracing F (p-value) p-value
Thickness change (%)
TrA 45.22 ± 26.71 24.35 ± 18.69 15.187 0.001∗
EO + IO 21.59 ± 13.38 31.55 ± 14.33 7.166 0.015∗
Values represent mean ± SD. Asterisk indicate that the difference is statistically significant. EO,
external oblique muscle; IO, internal oblique muscle; TrA, transversus abdominis muscle.

A B

C D

Fig. 3. The trajectory of inter-spinal segments during forward translation. A. linear displacement of the moving platform; B. angular displacement
of the upper trunk; C. angular displacement of the lower trunk; and D angular displacement of the lumbopelvis.

among the 3 strategies (upper thoracic: F = 13.758,
p < 0.001; lower thoracic: F = 8.477, p = 0.001;
and lumbopelvis: F = 8.651, p = 0.001). In the upper
thoracic, the post hoc analysis showed that the angu-
lar displacement of hollowing and bracing decreased
by 25.15% (p = 0.002) and 32.70% (p = 0.002)
compared with the natural strategy, respectively. In the
lower thoracic, the angular displacement of hollowing
and bracing decreased by 36.36% (p = 0.006) and
31.66% (p = 0.041) compared with the natural strat-
egy, respectively. In the lumbopelvis, the angular dis-
placement of the hollowing and bracing decreased by
27.62% (p = 0.029) and 25.81% (p = 0.006) com-
pared with the natural strategy, respectively. In the
lower extremity segments, there was a decreased an-
gular displacement from 1% to 24% for hollowing and
bracing, respectively, but there were no significant dif-
ferences among the 3 strategies.
322 M. Kim et al. / Abdominal hollowing and bracing strategies increase joint stability
A B
Fig. 4. The average and standard errors of angular displacement in natural, hollowing, and bracing for the inter-spinal segments and lower
extremities during forward (A) and backward (B) translations.
During the forward translation, only the lower tho-
racic presented different angular displacement among
the 3 strategies (F = 7.640, p = 0.002). Post hoc anal-
ysis showed that the angular displacement of bracing
decreased by 33.48% (p = 0.003) compared with the
natural strategy. Additionally, angular displacement of
hollowing and bracing tended to decrease the angu-
lar displacement of the lower extremities by −0.04 to
20%, but there was no significant difference among the
3 strategies (Fig. 4).
4. Discussion
The purpose of this study was to demonstrate the ef-
fects of AAS on body sway in the standing position. To
achieve the purpose, it was important to identifying the
successful hollowing and bracing strategy. Ultrasonog-
raphy was used to confirm the contraction of abdomi-
nal muscles during hollowing and bracing. Ultrasonog-
raphy is a reliable and valid tool for assessing mus-
cle thickness [30–32] and it has been frequently used
to evaluate muscle activation based on muscle thick-
ness change [18,26]. Additionally, all ICC values of
this study were acceptable. Also, both our results and
previous studies showed similar results regarding the
change ratio of TrA during hollowing, which was ap-
proximately 21% greater than the bracing, and change
ratio of EO + IO during the bracing was around 9%
greater than the hollowing [26]. These findings indi-
cated that the hollowing and bracing were performed
properly.
The current results showed that the AAS achieved
a greater decrease of the sway in the trunk region
compared with the natural strategy. During the hol-
lowing and bracing, we instructed the subjects to per-
form a contraction of the abdominal muscles before
we applied the sudden perturbation. As a result, there
was a decrease of body sway of 25–36% in the inter-
spinal segments of our subjects. These results concur
with those of a previous study that reported that pre-
activation of abdominal muscles reduced the move-
ment of the lumbar spine response to forced perturba-
tion [7]. For trunk stability, the preparatory muscle re-
cruitment and a neuromuscular reflex response are re-
quired [33–36]. Our results supported the concept that
according to pattern of recruitment, such as hollowing
or bracing, rather than the effect of pre-activation of the
abdominal region, could increase trunk stability. Thus,
to increase trunk stability, early activation of abdomi-
nal muscles might be more important than the intensity
of the contraction of abdominal muscles.
The body sway during hollowing and bracing was
different depending on the direction of the translation.
During backward translation, when inducing anterior
body sway, hollowing and bracing achieved a greater
reduction of the amount of angular displacement of
the all the inter-spinal segments compared with the
natural strategy. Conversely, when inducing posterior
body sway during forward translation, only bracing
achieved a greater reduction of the lower thoracic sway
compared with the natural strategy. These results are
consistent with those reported by previous study that
showed that the direction of perturbation strongly af-
fected the balance response [37]. These differences of
postural response might relate with the required dif-
ferential extent of effort to stabilize the body sway.
 M. Kim et al. / Abdominal hollowing and bracing strategies increase joint stability
One previous study reported that “unnecessary” step-
ping occurred much more frequently during posterior
body sway. This might be the effect of non-mechanical
factors, such as the greater fear of falling or the mis-
perception of the safety related to the posterior body
sway [20]. Moreover, Henry et al. (1998) suggested
that the overall magnitude of response increased more
during the posterior body sway as the base of support
is smaller and it is generally considered the most dif-
ficult perturbation. We speculated based on those pre-
vious studies and our present results that bracing was
a far superior strategy for the reduction of the sway of
the trunk regardless of the direction of the perturbation
than hollowing. However, our results lack for evidence
to determine the predominance of bracing over hollow-
ing.
There were no significant differences between hol-
lowing and bracing during forward and backward
translations. However, previous studies have reported
that bracing was better for trunk stabilization than
hollowing during sudden trunk perturbation [7,8,10].
These different findings might be explained by the
posture adopted when the body is perturbed suddenly
and the type of perturbation imposed. Differences in
the experimental setup could influence the perturbed
motion, and the associated proprioceptive, visual, and
vestibular stimuli could be influenced by the postural
response [38]. The current study induced the whole
body sway in the standing position, but the previous
studies applied external loading on the upper trunk di-
rectly in a semi-seated position. This position might
increase the compressive pressure on the inter-spinal
segments as well as contribute to discriminate the dif-
ferential effect between hollowing and bracing [8]. In
case of the support surface translation while standing,
an automatic postural adjustment is triggered to stabi-
lize body sway [39]. In this process, much more joints,
such as ankle, knee, and hip, might contribute to com-
pensate and stabilize body sway than in the sitting po-
sition.
Additionally, the current study hypothesized that the
AAS alters movement of the lower extremities dur-
ing sudden perturbation, but the results indicated no
changes in sway of thigh, shank, and foot. However,
previous studies reported a clear relationship between
the muscle activity of the trunk and the lower extrem-
ity movements [15,16,40]. Although they postulated
that trunk stability is the base of body movements by
means of pre-activation of trunk muscles before the
limb movement, the participants of previous studies
mainly performed internal perturbation tasks, which
323
are different from the external perturbation tasks ap-
plied in the current study. Thus, no changes in the
lower extremity stability might suggest that the influ-
ence of trunk muscle activation is different between
proactive and reactive responses. These results might
be translate into important clinical implications regard-
ing the paradigm of balance exercise, in which core sta-
bility is a critical factor for balance enhancement while
in standing position.
The limitation of the study was the small number of
subjects. In addition, body sway may not directly in-
dicate the level of stability, but is one of the indicat-
ing factors. The current study demonstrated that AAS
increased trunk stability during external perturbation.
In cases of external perturbation similar to that of fall,
further study is needed to determine whether increased
trunk stability could positively influence the risk of
falling.
5. Conclusion
The aim of this study was to investigate the effec-
tiveness of AAS to decrease the body sway during sud-
den perturbation. Our findings supported the hypothe-
sis that hollowing and bracing achieve a decrease in the
sway of the trunk more effectively than natural strategy
in the standing position. Further, bracing decreases the
sway of the lower thoracic regardless of the direction
of the sudden perturbation in comparison with the nat-
ural strategy. These results demonstrated that AAS ef-
fectively increases the trunk stability, but does not af-
fect the stability of the lower extremities. The low im-
pact of AAS on lower extremities gives rise to doubts
concerning the importance of core stability for stand-
ing balance.
Acknowledgements
This research was supported by the R & D grant of
rehabilitation services by the Korea National Rehabili-
tation Centre Research Institute, Ministry of Health &
Welfare.
Conflict of interest
None of the authors have any conflicts of interest to
report.
324 M. Kim et al. / Abdominal hollowing and bracing strategies increase joint stability
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