Manual Therapy 16 (2011) 596e601

Contents lists available at ScienceDirect

Manual Therapy
journal homepage: www.elsevier.com/math

Original article

Ultrasound measurement of abdominal muscles activity during abdominal

hollowing and bracing in women with and without stress urinary incontinenceq
Amir Massoud Arab a, *, Mahshid Chehrehrazi b
a
Department of Physical Therapy, University of Social Welfare and Rehabilitation Sciences, Evin, Koodakyar Ave., P.O Box 1985713834, Tehran, Iran
b
Isfahan University of Medical Sciences, Isfahan, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Synergistic co-activation of the abdominal and pelvic floor muscles (PFM) has been reported in the
Received 3 March 2010 literature. Considering that PFM dysfunction is present in women with stress urinary incontinence (SUI),
Received in revised form altered abdominal muscle activation may also occur in incontinent women. The purpose of this study
28 April 2011
was to investigate the abdominal muscle activity during abdominal hollowing and bracing maneuver in
Accepted 6 June 2011
women with and without SUI using ultrasound. Convenience sample of 20 non-pregnant female
participated in the study. Subjects were categorized into two groups: continent females (N ¼ 10) and
Keywords:
females with SUI (N ¼ 10). The percentage of change in thickness of right transverse abdominals (TrA)
Abdominal muscles
Stress urinary incontinence
and internal obliques (IO) was measured during abdominal hollowing and bracing maneuver in both
Ultrasound groups. The result of two-way mixed-design ANOVA revealed no significant health status by maneuver
Hollowing interaction effect for ultrasound measurement of the percentage of change in thickness of TrA (P ¼ 0.66)
Bracing and IO (P ¼ 0.36). The main effect of health status on the percentage of the change in thickness of TrA
(P ¼ 0.52) or IO (P ¼ 0.84) was not statistically significant. In overall, no significant difference was found
in the percentage of changes in thickness of TrA and IO muscles during abdominal hollowing or bracing
maneuver between women with and without SUI.
Ó 2011 Published by Elsevier Ltd.

1. Introduction 2008). It is probable that this contributes to urinary continence.

Stress urinary incontinence (SUI) is a common health related
problem in women, involving 50% of women with urinary inconti-
nence (Abrams et al., 2003; DeLancey and Ashton-Miller, 2004). SUI
is defined as “the complaint of involuntary leakage on effort or
exertion, or on sneezing or coughing” (Abrams et al., 2003). For
urinary continence to be maintained, urethral pressure must be
greater than bladder pressure at all times. Under normal circum-
stances, pelvic floor muscles (PFM) contract to increase the pressure
of the urethra during the tasks that increase intra-abdominal pres-
sure. There is substantial evidence indicating PFM dysfunction in
women with SUI (Bø, 2003; Morin et al., 2004; Amaro et al., 2005).
Synergistic co-activation of the abdominal and PFM has been
reported in the literature with electromyographic (EMG) evidence
of this synergistic relationship (Sapsford et al., 2001; Sapsford and
Hodges, 2001; Neumann and Gill, 2002; Madill and McLean, 2006,
q This research was reviewed and was approved by the Human Subject
Committee at University of Social Welfare and Rehabilitation Sciences.
* Corresponding author. Tel./fax: þ98 21 22180039.
E-mail addresses: arabloo_masoud@hotmail.com, amarab@uswr.ac.ir (A.M. Arab).
Investigators attributed the generation of intra-vaginal pressure in
continent women to co-activation of PFM and abdominal muscles
(Madill and McLean, 2006). Neumann and Gill (2002) showed that
continent women were unable to fully perform PFM contraction
without simultaneous contraction of the transverse abdominals
(TrA) and the internal obliques (IO).
A significant difference in abdominal EMG amplitude during
maximal voluntary PFM contraction was found between healthy
continent women and those with severe SUI (Madill et al., 2009).
Some reports have also demonstrated less PFM activity and more
abdominal muscle activity during PFM contraction in the inconti-
nent women compared with asymptomatic women (Thompson
et al., 2006). It is thought that incontinent women can not perform
a correct PFM contraction using a localized muscle strategy and use
muscle substitution strategies and activate all the muscles of the
abdomino-pelvic cavity (Thompson et al., 2006). EMG studies have
found delayed abdominal muscle activity during arm movement
(Smith et al., 2007a), greater external oblique activation during
postural tasks (Smith et al., 2007b), and greater abdominal activa-
tion during balance tasks (Smith et al., 2008) in women with SUI.
Real-time ultrasound imaging is a reliable and valid technique
recently used by physical therapists to evaluate muscle structure,

1356-689X/$ e see front matter Ó 2011 Published by Elsevier Ltd.

doi:10.1016/j.math.2011.06.002
 A.M. Arab, M. Chehrehrazi / Manual Therapy 16 (2011) 596e601 597

function and activation patterns. This method allows for real time
study of the muscles as they contract. This is especially important
when the activation pattern of deep muscles such as deep
abdominal muscles is investigated (Teyhen et al., 2007; Costa et al.,
2009). Changes in thickness of the TrA and IO muscles are
measured as an indicator of muscle activity in ultrasound imaging
(Critchley and Coutts, 2002; Ferreira et al., 2004; Henry and
Westervelt, 2005; Ainscough-potts et al., 2006; Teyhen et al.,
2007; Costa et al., 2009). The reliability of this method for
measuring changes in TrA muscle thickness has been established
previously (Costa et al., 2009). Validity studies have compared
ultrasound measurements with those obtained using fine wire
EMG (Hodges et al., 2003; McMeeken et al., 2004).
McMeeken et al. (2004) found good to high correlation between
the needle EMG recordings of TrA and ultrasound changes in
thickness of the muscle at all activity level. Hodges et al. (2003)
compared the thickness changes in the abdominal muscles in
real-time ultrasound and EMG activity. They found that change in
thickness and EMG activity of the TrA and IO muscles were linearly
related at low contraction levels. However, these researchers found
that the external oblique muscle behaved differently from the TrA
and IO in that there was no consistent relationship between muscle
thickness and EMG activity of external oblique and this muscle did
not become thicker when it contracted.
These findings support the use of ultrasound imaging as a non-
invasive technique to measure TrA and IO muscle thickness and
estimate relative muscle activity.
Recent studies have demonstrated a link between low back pain
and genito-urinary dysfunction such as SUI (Finkelstein, 2002;
Pool-Goudzwaard et al., 2005; Smith et al., 2006). There is
substantial evidence indicating that a primary muscular impair-
ment in patients with lumbopelvic pain is dysfunction of deep
abdominal muscles (Hodges, 1999; Richardson et al., 1999; Jull and
Richardson, 2000) and major muscular impairment in subjects
with SUI is PFM dysfunction (Bø, 2003; Morin et al., 2004; Amaro
et al., 2005). Considering these findings, altered abdominal
muscle activation may also occur in women with SUI.
The abdominal hollowing and bracing maneuvers are
commonly used to assess and rehabilitate abdominal muscles
(Allison et al., 1998; Richardson et al., 1999; Jull and Richardson,
2000; Beith et al., 2001). The abdominal hollowing maneuver is
performed to activate deep abdominal muscles (TrA and IO) and
involves gently drawing the lower abdominal wall in toward the
spine. The abdominal bracing maneuver is performed with
emphasis on the activation of all the antero-lateral abdominal
muscles. This is achieved by instructing the subjects to tighten
their abdominal wall and increase the lateral diameter of the
waist (Allison et al., 1998; Richardson et al., 1999; Jull and
Richardson, 2000; Beith et al., 2001). Changes in thickness of
the TrA and IO muscles during abdominal maneuvers are
measured using ultrasound imaging to indicate abdominal muscle
activity (Critchley and Coutts, 2002; Ferreira et al., 2004; Henry
and Westervelt, 2005; Ainscough-potts et al., 2006; Teyhen
et al., 2007).
To our knowledge, no study has directly evaluated abdominal
2. Material and methods
2.1. Subjects
A cross sectional study design was used to compare abdominal
muscle activity in two groups of women: women with SUI and
continent women. A total of 20 non-pregnant females participated
in the study. The subject population in this study was a sample of
convenience made up of subjects who were between the ages of 25
and 50 years. An equal number of women (N ¼ 10) were allocated
to each group. The subjects with SUI had been diagnosed by
a urogynaecologist as having symptoms of SUI. The type of urinary
incontinence had also been assessed using a urinary symptoms
questionnaire (Ishiko et al., 2000). Inclusion criteria were willing-
ness to participate, having had urine leakage on coughing,
sneezing, laughing, lifting and any activity that increases the intra-
abdominal pressure, premenopausal or under hormone replace-
ment therapy. Asymptomatic females, matched in age, body mass
index (BMI) and parity, were also evaluated by urogynaecologist
and found to have no symptoms of urinary incontinence. Exclusion
criteria were pregnancy and having given birth in previous 12
months, known neurological or respiratory disorders, low back
pain in previous six months, prolapse of the pelvic organs greater
than the second degree, and major surgery of the abdominal or
pelvic regions. All the participants signed an informed consent
form approved by the human subjects committee at the university
of Social Welfare and Rehabilitation Sciences before participating in
the study. Physical characteristics of the subjects can be seen in
Table 1.
2.2. Ultrasound measurement of the abdominal muscle thickness
A diagnostic ultrasound imaging unit set in B-mode (Ultra-
sonix-ES500, Canada) with a 7.5 MHz linear head transducer was
used to measure the changes in thickness of the abdominal
muscles (TrA, IO) during abdominal hollowing and bracing
maneuver based on the method explained by others (Critchley and
Coutts, 2002; Ferreira et al., 2004; McMeeken et al., 2004; Henry
and Westervelt, 2005; Ainscough-potts et al., 2006; Teyhen et al.,
2007). The measurements were made on the right side of the
abdominal wall at the end of expiration. The participants were
tested in supine position with one pillow underneath the head and
knee. The lumbar spine was positioned in neutral. The abdominal
wall was exposed. The ultrasound transducer was transversely
located across the abdominal wall over the anterior axillary line
midway between the 12th rib and the iliac crest to obtain a clear
image of the three antero-lateral abdominal muscle layers. Prior to
testing, participants were trained by a physiotherapist to perform
the abdominal maneuvers correctly. A pressure biofeedback device
was used to standardize each maneuver (Allison et al., 1998;
Table 1
Descriptive statistics for the subjects and the thickness of the TrA and IO at rest in
each group (Mean  SD).

muscle activity in women with and without SUI using ultrasound Variables Continent Incontinent P-
measurements. The purpose of this study was to investigate the (n ¼ 10) (n ¼ 10) value
changes in the thickness of the TrA and IO muscles during Age (years) 38.47  5.23 41.66  6.44 0.15
abdominal hollowing and bracing maneuvers using ultrasound in Weight (kg) 67.20  9.36 69.35  10.52 0.56
Height (cm) 160.53  6.78 158.14  4.72 0.78
women with and without SUI. 2
BMI (kg/m ) 25.61  3.50 27.52  4.14 0.67
The hypothesis of this study is as follows: Parity 2.40  0.94 2.84  1.26 0.22
Thickness of the TrA at rest 3.49  0.78 3.72  0.75 0.51
- The percentage of thickness change in TrA and IO muscles (mm)
during abdominal hollowing or bracing maneuvers is signifi- Thickness of the IO at rest (mm) 6.02  0.82 5.89  1.18 0.78

cantly different between women with and without SUI. TrA ¼ Transverse abdominis; IO ¼ Internal oblique.
598 A.M. Arab, M. Chehrehrazi / Manual Therapy 16 (2011) 596e601

Cairns et al., 2000). For this purpose, the pillow pressure was
placed under the lumbar curve, between first lumbar and second
sacral vertebrae, and then inflated until 40 mmHg when the
subjects were at rest. The participants were asked to gently drawin
the lower abdominal wall toward the spine for abdominal hol-
lowing maneuver and to tighten their abdominal wall and increase
the lateral diameter of the waist for abdominal bracing maneuver
(Allison et al., 1998; Richardson et al., 1999; Jull and Richardson,
2000; Beith et al., 2001). All contractions were performed while
breathing normally and without visible movement of the lumbar
spine, pelvis, or rib cage. Subjects were not allowed to increase the
pressure more than 10 mmHg for both hollowing and bracing
maneuvers (Allison et al., 1998; Cairns et al., 2000). The cursor
points measured the muscle thickness between the fascial bands
in ultrsonography. The image was frozen on the screen and the
muscle thickness was measured in millimeter (mm) by the marker
(Fig. 1). The ultrasound transducer was not displaced during the
testing procedure. The participants performed three abdominal
muscles contractions and the mean value of three contractions
was measured for the analysis. To assure reliability, all measure-
ments were performed by one examiner. However, using 10
volunteers, we assessed within-day intra-tester reliability of the
ultrasound measurement. For this purpose, the whole procedure
was performed twice in one day. At first the examiner completed
the ultrasound measurements during abdominal maneuvers in
a subject and then after 30 min repeated the measurement
randomly in the subjects in the same procedure to reduce the
memory effect.
2.3. Data analysis
The change in thickness of each abdominal muscle during each
maneuver was expressed as a percentage of thickness at rest. Kol-
mogroveSmirnov test was utilized to assess the normality of
distribution for tested variables. Normal distribution was observed
for variables in both groups. The intra-class correlation coefficient
(ICC), two-way mixed effect model, was used to assess intra-
examiner reliability of the measurements. We calculated the ICC
(3,1) as described by Shrout and Fleiss (1979), because only one
judge evaluated the same population of subjects. The 95% limits of
agreements method of reliability assessment with a confidence
level of 95% was calculated using a BlandeAltman plot to assess
absolute reliability. Independent t-test was used to compare age,
height, weight and BMI among the two groups. A two-way mixed-
Table 2
Intra-class correlation coefficient (ICC) values for intra-examiner reliability of the
ultrasound measurements performed in pilot study (N ¼ 10).
Muscle Maneuver ICC (3,1)
TrA Abdominal Hollowing 0.92
Abdominal Bracing 0.80
IO Abdominal Hollowing 0.84
Abdominal Bracing 0.84
TrA ¼ Transverse abdominis; IO ¼ Internal oblique.
design ANOVA, accounting for health status (continent vs. incon-
tinent), maneuvers (abdominal hollowing vs. bracing) and inter-
action of maneuvers and health status effects, was applied to test
the ultrasound measurement of each abdominal muscle activity
during maneuvers between groups.
Statistical significance was set at P ¼ 0.05.
3. Results
Descriptive statistics for the subjects and the thickness of the
TrA and IO at rest in each group is presented in Table 1. Statistical
analysis (independent t-test) revealed no significant difference in
subjects’ age (p ¼ 0.15), height (p ¼ 0.78), weight (p ¼ 0.56) and BMI
(p ¼ 0.67) among the two groups.
Table 2 presents the ICC for repeat measures of the ultrasound
measurement for TrA and IO taken in the pilot study. All ICC values
were greater than 0.80 (Table 2). It indicates high intra-tester
reliability for the measurements. The BlandeAltman plot of
agreement in ultrasound measurement of the TrA during abdom-
inal hollowing between test and retest is shown in Fig. 2. The
BlandeAltman plot demonstrated that 95% of the observations fall
between the limits of agreement for test and retest for all ultra-
sound measurements (TrA and IO during hollowing or bracing). The
limits of agreement are from 1.04 mm to þ2.20 mm.
No significant difference was found in the thickness of the TrA
(p ¼ 0.51) and IO (p ¼ 0.78) at rest between women with and
without SUI. Fig. 3 depicts the percentage of changes in thickness of
abdominal muscle in women with and without SUI during
abdominal hollowing and bracing maneuver respectively. Detailed
descriptive statistics (Mean  SD) are presented in Table 3. The
result of two-way mixed-design ANOVA revealed no significant
health status by maneuver interaction effect for ultrasound
2.5
+1.96 SD
2.20
2.0

1.5
TrA1-hollow - TrA-2 Hollow

1.0

Mean
0.5 0.58

0.0

-0.5

-1.0 -1.96 SD
-1.04

-1.5
-4 -2 0 2 4 6 8 10
AVERAGE of TrA1-hollow and TrA-2 Hollow

Fig. 2. The BlandeAltman plot for ultrasound measurement of the TrA during abdominal
hollowing maneuver. The mean of the test (TrA1-hollow) and retest (TrA2-hollow)
scores is plotted on the X axis and the differences between two scores on the Y axis. The
Fig. 1. Ultrasound measurement of the abdominal muscles thickness. horizontal interrupted lines represent the limits of agreement.
 A.M. Arab, M. Chehrehrazi / Manual Therapy 16 (2011) 596e601 599

pelvic floor on attempting a PFM contraction, EMG activity of the

external oblique muscle was greater than in controls.
It is thought that co-activation of pelvic floor and abdominal
muscles, contributes to the generation of intra-vaginal pressure to
maintain urinary continence in situations of increased intra-
abdominal pressure (Madill and McLean, 2006). Thompson et al.
(2006) believe that incontinent women are unable to perform
a correct PFM contraction using a localized muscle strategy,
therefore, use muscle substitution strategies and activate all of the
abdomino-pelvic cavity muscles. To our knowledge, the present
study is the first to directly assess the abdominal muscles activation
during specific tasks in stress incontinent women compared to
those without SUI using ultrasound measurement. However, what
we measured in this study was a voluntary contraction and not the
automatic recruitment during functional tasks.
The abdominal hollowing with the aim of deep abdominal
muscles activation and abdominal bracing maneuver with emphasis
on the activation of all antero-lateral abdominal wall muscles are
commonly used to activate abdominal muscles (Ferreira et al., 2004;
Henry and Westervelt, 2005; Teyhen et al., 2007).
Considering that performing different abdominal muscle
contractions (hollowing or bracing) increases intra-abdominal pres-
sure in a different way (Richardson et al., 1999; Junginger et al., 2010),
we assessed the abdominal muscle activation during both abdominal
hollowing and bracing maneuvers in women with SUI.
Changes in thickness of the TrA and IO muscles during abdom-
Fig. 3. The percentage of change in thickness of TrA and IO muscles during abdominal
hollowing or bracing maneuver in continent and incontinent women. TAUS ¼ inal maneuvers are measured using ultrasound imaging to indicate
Transabdominal Ultrasound a): During abdominal hollowing TAUS ¼ Transabdominal abdominal muscle activity (Critchley and Coutts, 2002; Ferreira
Ultrasound b): During abdominal bracing. et al., 2004; Henry and Westervelt, 2005; Ainscough-potts et al.,
2006; Teyhen et al., 2007). The reliability of this method in different
measurement of the percentage of change in thickness of TrA positions has been established previously (Costa et al., 2009).
(P ¼ 0.66) and IO (P ¼ 0.36) at a ¼ 0.05. The main effect of health Ultrasound measurement of the change in thickness of TrA and IO
status on the percentage of change in thickness of TrA (P ¼ 0.52) muscle has been shown to have good to high correlation with EMG
and IO (P ¼ 0.84) was not statistically significant. The percentage of amplitude of the muscles at low levels of contraction (Hodges et al.,
changes in thickness of TrA (p ¼ 0.96) and IO (p ¼ 0.53) during 2003) or at all activity levels (McMeeken et al., 2004).
abdominal hollowing was not significantly different in women with The percentage of changes in thickness of TrA during abdominal
SUI compared to those without SUI. No significant difference was hollowing was 51.66% and 52.96 in continent and incontinent
also found in the percentage of thickness change in TrA (p ¼ 0.50) women respectively. In contrast, Teyhen et al. (2009) found that the
and IO (p ¼ 0.48) during abdominal bracing between continent percent change in thickness of the TrA was 20.9% less in subjects
women and those with SUI (Table 3). with lumbopelvic pain compared to the control group. This
controversy may be due to the fact that we excluded the subjects
with current low back pain. Stuge et al. (2006) found no significant
4. Discussion
difference in TrA and IO thickness in women with long lasting
pelvic girdle pain and women who had recovered from PGP. The
Our data showed that the percentage of thickness change in TrA
percentage of changes in TrA muscle thickness was greater than the
and IO muscles during abdominal hollowing and bracing maneuver
IO muscle during both maneuvers for both groups (Table 3). Similar
was not significantly different between women with and without
finding has been reported in subjects with and without lumbo-
SUI. Thompson et al. (2006) studied the muscle activation patterns
pelvic pain (Teyhen et al., 2009).
of the abdomino-pelvic region during PFM contraction and Valsalva
Madill et al. (2009) compared the abdominal EMG amplitude
maneuver in 13 incontinent women compared to 13 healthy
during maximal voluntary PFM contractions between women with
continent women. They found no significant difference in EMG
and without SUI and showed no significant difference in EMG
amplitude of the IO muscles between two groups during Valsalva
amplitudes of the abdominal muscles between two groups.
maneuver. They also showed that in women who depressed the
However, when they categorized the women with SUI to those with
mild or severe symptoms, a significant difference was found in
Table 3 abdominal EMG amplitude between continent women and those
The (Mean  SD) for the percentage of increase in thickness of abdominal muscles with severe SUI. In the present study, we did not classify the
during abdominal hollowing or bracing maneuver in women with and without SUI. incontinent women to those with different severity of SUI
Maneuver Muscle Group P- depending on the severity of the leakage as the number of subjects
With SUI (N ¼ 10) Without SUI (N ¼ 10)
value was too small. We suggest that this study could be repeated on
continent women and subjects with different severity of SUI to
Abdominal TrA 51.66  22.79 52.96  15.2 0.96
Hollowing IO 12.38  14.29 9.18  6.5 0.53 provide more insight regarding the abdominal muscle activity in
Abdominal Bracing TrA 23.15  20.25 31.55  29.02 0.50 women with SUI.
IO 14.06  13.4 18.95  16.55 0.48 Investigators attributed SUI to differences in activation timing of
TrA ¼ Transverse abdominis; IO ¼ Internal oblique; SUI ¼ Stress urinary abdominal muscles and PFM and suggested that in treatment
incontinence. protocols for women with SUI more focus should be placed on
600 A.M. Arab, M. Chehrehrazi / Manual Therapy 16 (2011) 596e601
restoring the normal order of abdominal and PFM activation than
amplitudes (Madill et al., 2009). Although Smith et al. (2007a)
showed no decrease in amplitude of IO muscle activity during
arm movement in incontinent women compared with asymp-
tomatic women; they found a trend for delayed activity of IO
muscle in women with SUI. It seems that timing of abdominal
muscle activation is more compromised rather than amplitude of
muscle activation in women with SUI compared with those without
SUI. Delay in onset of abdominal muscle EMG activity in response to
arm movement in women with SUI (Smith et al., 2007a) occurred
only in IO muscle and with shoulder movement in one direction. It
seems that there is variation in abdominal muscle responses and
the abdominal muscle group should not be considered as a single
functional unit. Considering the results of Hodges et al. (2003), the
EMG changes found by Thompson et al. (2006) and Smith et al.
(2007a) can not be correlated with ultrasound changes for
external obliques during the tasks performed in this study.
However, we acknowledge several important limitations. One of
the limitations and weakness of this study was the sample size. We
excluded the subjects with urge or mixed urinary incontinence in
order to assess the correlation in a more homogenous population of
incontinence. Since our inclusion criteria was specific, the acces-
sible population, that is women with SUI and no other type of
incontinence, was limited to a relatively small group of patients for
the time frame this study was conducted.
Ultrasound measurement may be criticized because of the
difficulty of accurately measuring the muscle width due to the
spread of the fascial bands.
Considering deep abdominal muscle dysfunction and smaller
thickness change of TrA during the abdominal drawing-in
maneuvers in subjects with current lumbopelvic pain, we
excluded the subjects with low back pain in the previous six
months before study. At the time of data collection, none of the
participants had current lumbopelvic pain. However, the subjects
were not asked about the history of lumbopelvic pain before six
months prior to study during their lifetime.
Another area of concern in our study was that we measured
voluntary contraction and not automatic, involuntary activity at
subconscious level. This is only one aspect of the muscle function.
Other factors such as endurance, strength and power of muscle
activity are necessary for muscle function.
This study did not, therefore, demonstrate conclusively that
contractile ability per se? was normal in the SUI group. Therefore,
the automatic activity and other aspects of the abdominal muscles
activity could be abnormal and further studies are needed to
investigate other aspects of the abdominal muscle activity in
women with SUI. For example, involuntary abdominal muscle
activity could be examined during more functional tasks such as
hip movement.
5. Conclusion
Our data showed that the percentage of thickness change in TrA
and IO muscles during abdominal hollowing and bracing maneuver
was not significantly different between continent and incontinent
women. These findings indicate no significant difference in TrA and
IO voluntary muscle activity among two groups but automatic
activity during tasks and other characteristics of muscle function
have yet to be investigated.
Acknowledgment
The authors would like to thank Dr. Mahtab Zargham (an uro-
gynecologist) for assisstance in slecting the subject with symptoms
of SUI.
References
Abrams p, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U. The standardisation of
terminoligy in lower urinary tract function: report from the standardisation sub-
committee of the International Continence Society. Urology 2003;61:37e49.
Ainscough-potts AM, Morrissey MC, Critchley D. The response of the transverse
abdiominis and internal oblique muscle to different postures. Manual Therapy
2006;11:54e60.
Allison GT, Godfrey P, Robinson G. EMG signal amplitude assessment during
abdominal bracing and hollowing. Journal of Electromyography and Kinesiology
1998;8:51e7.
Amaro JL, Moreira EC, De Oiliveira Orsi Gameiro M, Padovani CR. Pelvic floor muscle
evaluation in incontinent patients. International Urogynecology Journal and
Pelvic Floor Dysfunction 2005;16:352e4.
Beith ID, Synnott RE, Newman SA. Abdominal muscle activity during the abdominal
hollowing manoeuvre in the four point kneeling and prone positions. Manual
Therapy 2001;6:82e7.
Bø K. Pelvic floor muscle strength and response to pelvic muscle training for stress
urinary incontinence. Neurourology and Urodynamics 2003;22:654e8.
Cairns MC, Harrison K, Wright C. Pressure biofeedback: a useful tool in the quan-
tification of abdominal muscular dysfunction? Physiotherapy 2000;2000(86):
127e38.
Costa LO, Maher CG, Latimer J, Hodges PW, Shirley D. An investigation of the
reproducibility of ultrasound measures of abdominal muscle activation in
patients with chronic non-specific low back pain. European Spine Journal 2009;
18:1059e65.
Critchley DJ, Coutts FJ. Abdominal muscle function in chronic low back pain
patients: measurements with real-time ultrasound scanning. Physiotherapy
2002;88:322e32.
DeLancey J, Ashton-Miller J. Pathophysiology of adult urinary incontinence.
Gastroenterology 2004;126:S23e32.
Ferreira PH, Ferreira ML, Hodges PW. Changes in recruitment of the abdominal
muscles in people with low back pain: ultrasound measurement of muscle
activity. Spine 2004;29:2560e6.
Finkelstein MM. Medical conditions, medications and urinary incontinence: anal-
ysis of a population-based survey. Canadian Family Physician 2002;48:96e101.
Henry SM, Westervelt KC. The use of real-time ultrasound feedback in teaching
abdominal hollowing exercises to healthy subjects. Journal of Orthopaedic and
Sports Physical Therapy 2005;85:338e45.
Hodges PW. Is there a role for transversus abdominis in lumbo-pelvic stability?
Manual Therapy 1999;4:74e86.
Hodges PW, Pengel LMH, Herbert RD, Gandevia SC. Measurement of muscle
contraction with ultrasound imaging. Muscle Nerve 2003;27:682e92.
Ishiko O, Hirai K, Sumi T, Nishimura S, Ogita S. The urinary incontinence score in the
diagnosis of female urinary incontinence. International Journal of Gynaecology
& Obstetrics 2000;68:131e7.
Jull GA, Richardson CA. Motor control problems in patients with spinal pain: a new
direction for therapeutic exercises. Journal of Manipulative and Physiological
Therapeutics 2000;23:115e7.
Junginger B, Baessler K, Sapsford R, Hodges PW. Effect of abdominal and pelvic floor
tasks on muscle activity, abdominal pressure and bladder neck. International
Urogynecology Journal 2010;21:69e77.
Madill SJ, McLean L. Relationship between abdominal and pelvic floor muscle
activation and intravaginal pressure during pelvic floor muscle contraction in
healthy continent women. Neurourology and Urodynamics 2006;25:722e30.
Madill SJ, McLean L. Quantification of abdominal and pelvic floor muscle synergies
in response to voluntary pelvic floor muscle contractions. Journal of Electro-
myography and Kinesiology 2008;18:955e64.
Madill SJ, Harvey MA, McLean L. Women with SUI demonstrate motor control
differences during voluntary pelvic floor muscle contractions. International
Urogynecology Journal and Pelvic Floor Dysfunction 2009;20:447e59.
McMeeken JM, Beith ID, Newham DJ, Milligan P, Critchley DJ. The relationship
between EMG and changes in thickness of transverses abdominis. Clinical
Biomechanics 2004;19:337e42.
Morin M, Bourbonnais D, Gravel D, Dumoulin D, Lemieux M. Pelvic floor muscle
function in continent and stress urinary incontinent women using dynamo-
metric measurements. Neurourology and Urodynamics 2004;23:668e74.
Neumann P, Gill V. Pelvic floor and abdominal muscle interaction: EMG activity and
intra-abdominal pressure. International Urogynecology Journal and Pelvic Floor
Dysfunction 2002;13:125e32.
Pool-Goudzwaard AL, Slieker ten Hove MC, Vierhout ME, Mulder PH, Pool JJ,
Snijders CJ, et al. Relations between pregnancy-related low back pain, pelvic
floor activity and pelvic floor dysfunction. International Urogynecology Journal
and Pelvic Floor Dysfunction 2005;16:468e74.
Richardson CA, Jull GA, Hodges PW, Hides JA. Therapeutic exercise for spinal
segmental stabilization in low back pain. Scientific basis and clinical approach.
Edinburgh: Churchill Livingstone; 1999.
Sapsford R, Hodges P, Richardson A, Cooper D, Markwell S, Jull G. Co-activation of
the abdominal and pelvic floor muscles during voluntary exercise. Neuro-
urology and Urodynamics 2001;20:31e42.
Sapsford R, Hodges P. Contraction of pelvic floor muscle during abdominal
maneuvers. Archives of Physical Medicine and Rehabilitation 2001;82:1081e8.
Shrout PE, Fleiss JL. Intraclass correlation: use in assessing rater reliability.
Psychological Bulletin 1979;86:420e8.
 A.M. Arab, M. Chehrehrazi / Manual Therapy 16 (2011) 596e601
Smith M, Russell A, Hodges PW. Disorders of breathing and continence have
a stronger association with back pain than obesity and physical activity.
Australian Journal of Physiotherapy 2006;52:11e6.
Smith MD, Coppieters MW, Hodges PW. Postural activity of the pelvic floor muscles
is delayed during rapid arm movements in women with stress urinary incon-
tinence. International Urogynecology Journal and Pelvic Floor Dysfunction
2007a;18:901e11.
Smith MD, Coppieters MW, Hodges PW. Postural response of the pelvic floor and
abdominal muscles in women with and without incontinence. Neurourology
and Urodynamics 2007b;26:377e85.
Smith MD, Coppieters MW, Hodges PW. Is balance different in women with and
without stress urinary incontinence? Neurourology and Urodynamics 2008;27:
71e8.
601
Stuge B, MØrkved S, Dahl HH, VØllestad N. Abdominal and pelvic floor muscle
function in women with and without long lasting pelvic girdle pain. Manual
Therapy 2006;11:287e96.
Teyhen DS, Gill NW, Whittaker JL, Henry SM, Hides JA, Hodges P. Rehabilitative
ultrasound imaging of the abdominal muscles. Journal of Orthopaedic and
Sports Physical Therapy 2007;37:450e66.
Teyhen DS, Bluemle LN, Dolbeer JA, Baker SE, Molloy JM, Whittaker J, et al. Changes
in lateral abdominal muscle thickness during the abdominal drawing-in
maneuver in those with lumbopelvic pain. Journal of Orthopaedic and Sports
Physical Therapy 2009;39:791e8.
Thompson JA, O’Sullivan PB, Briffa NK, Neumann P. Altered muscle activation
patterns in symptomatic women during pelvic floor muscle contraction and
Valsalva manouevre. Neurourology and Urodynamics 2006;25:268e76.