Physiotherapy Theory and Practice

An International Journal of Physical Therapy

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The effect of core stability and general exercise

on abdominal muscle thickness in non-specific
chronic low back pain using ultrasound imaging

MohammadBagher Shamsi, Javad Sarrafzadeh, Aliashraf Jamshidi, Vida

Zarabi & Mohammad Reza Pourahmadi

To cite this article: MohammadBagher Shamsi, Javad Sarrafzadeh, Aliashraf Jamshidi, Vida
Zarabi & Mohammad Reza Pourahmadi (2016) The effect of core stability and general exercise
on abdominal muscle thickness in non-specific chronic low back pain using ultrasound imaging,
Physiotherapy Theory and Practice, 32:4, 277-283, DOI: 10.3109/09593985.2016.1138559

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PHYSIOTHERAPY THEORY AND PRACTICE
2016, VOL. 32, NO. 4, 277–283
http://dx.doi.org/10.3109/09593985.2016.1138559

RESEARCH REPORT

The effect of core stability and general exercise on abdominal muscle thickness
in non-specific chronic low back pain using ultrasound imaging
MohammadBagher Shamsi, PT, PhDa, Javad Sarrafzadeh, PT, PhDb, Aliashraf Jamshidi, PT, PhDb, Vida Zarabi,
MDc, and Mohammad Reza Pourahmadi, PT, PhD Candidateb
a
Rehabilitation and Sport Medicine Department, School of Paramedicine, Kermanshah University of Medical Sciences, Kermanshah, Iran;
b
Physiotherapy Department, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran; cRadiology Department,
School of Medicine, Iran University of Medical Sciences, Tehran, Iran

ABSTRACT ARTICLE HISTORY

Background: There is a controversy regarding whether core stability exercise (CSE) is more Received 15 December 2014
effective than general exercise (GE) for chronic LBP. To compare different exercises regarding Revised 6 August 2015
their effect on improving back strength and stability, performance of abdominal muscles is a Accepted 11 August 2015
useful index. Ultrasound imaging for measuring muscle thickness could be used to assess KEYWORDS
muscle performance. Objective: The aim of this study was to compare CSE and GE in chronic Core stability exercise;
LBP using ultrasound imaging for measurement of thickness of the deep stabilizing and main general exercise; low back
global trunk muscles in non-specific chronic LBP. Methods: Each program included 16 training pain; muscle thickness;
sessions three times a week. Using ultrasound imaging, four transabdominal muscle thickness ultrasound imaging
were measured before and after the intervention. Disability and pain were measured as
secondary outcomes. Results: After the intervention on participants (n = 43), a significant
increase in muscle thickness (hypertrophy) was seen only in right and left rectus abdominis in
the GE group, but significant difference to the CSE group was only on the right side. Disability
and pain reduced within the groups without a significant difference in the change between
them. Conclusions: The present results provided evidence that only GE increased right and left
rectus muscle thickness. The only significant difference between CSE and GE groups was the
right rectus thickness. As rectus is a global muscle, the effect of GE on strength improvement
(one side stronger than the other) may have a negative effect on motor control of lumbopelvic
muscles and possibly increase the risk of back pain occurring or becoming worse, though this
was not observed in the present study.

Introduction for LBP has been noticed in recent years. The

basic rationale for CSE is the idea that the stability
Non-specific low back pain (LBP) which is known
and control of the spine are changed in people with
as symptoms without a clear specific cause (i.e., LBP
LBP (Costa et al, 2009). It is claimed that a co-
of unknown origin) constitutes up to 90% of LBP
activation pattern in the back muscles could be re-
patients (van Tulder and Koes, 2007). It is usually
educated, coordinated, and controlled and thus the
classified according to the duration as: acute (less
capacity of the trunk muscles be restored by this
than 6 weeks); sub-acute (between 6 weeks and 3
exercise (Hodges, 2003). Initial low-level isometric
months); or chronic (longer than 3 months) LBP
contraction of trunk stabilizing muscles (i.e., multi-
(Refshauge and Maher, 2006). Exercise is the main
fidus, transverses abdominis, and internal oblique)
choice for chronic low back pain (CLBP) treatment
and their progressive integration into functional
in most clinical practice guidelines (Costa et al,
tasks is important in CSE (Richardson, Hodges,
2009). Little evidence exists that a particular kind
and Hides, 2004). No agreement exists on super-
of exercise is any better than another (van Tulder,
iority of CSE over general exercise (GE) or other
Malmivaara, Esmail, and Koes, 2000). A common
therapies in treatment of CLBP. In a search in the
part of exercise programs for CLBP is trunk muscle
literature, five systematic reviews about CSE for
strengthening (Liddle, Baxter, and Gracey, 2004).
CLBP were found (Ferreira et al, 2007; Hauggaard
Core stability exercise (CSE) as a new treatment
and Persson, 2007; Macedo, Maher, Latimer, and

CONTACT Mohammad Reza Pourahmadi, PT, PhD Candidate pasha_pourahmadi@yahoo.com Physiotherapy Department, School of Rehabilitation
Sciences, Iran University of Medical Sciences, Mohseni Square, Tehran, Iran.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iptp.
© 2016 Taylor & Francis
278 M. SHAMSI ET AL.
McAuley, 2009; Rackwitz et al, 2006; Wang et al,
2012). The positive effect of CSE on reducing pain
and disability is supported by almost all articles. But
it is a matter of controversy whether CSE is more
effective than other treatments and exercises. It has
been concluded in some articles that CSE is superior
to GE in the short term (Wang et al, 2012).
However, some studies conclude that both types of
exercise have equal benefits. These studies suggest
that improvements are due to the positive effects
that physical exercise may have on the patients
rather than on improvement in spinal stability
(Lederman, 2010). There is good evidence about
the benefits of exercise for CLBP (Hayden, Van
Tulder, Malmivaara, and Koes, 2005; Henchoz and
So, 2008), so general exercise was chosen as a con-
trol for the CSE group.
To compare different exercises regarding their effect
on improving back strength and stability, performance
of abdominal muscles after training period should be
assessed. Several techniques have been used to measure
muscle performance. In addition to measurement
methods for strength and endurance, fine-wire electro-
myography is a method that is less utilized due to its
invasive nature. Also, surface electromyography could
not differentiate between deep abdominal muscles.
Ultrasound imaging (USI) has recently been used as a
measure for muscle thickness (Rankin, Stokes, and
Newham, 2006). The reliability of USI in assessment
of abdominal muscle thickness has been reported as
good to excellent in different studies (Bunce, Moore,
and Hough, 2002; Kidd, Magee, and Richardson, 2002;
Teyhen et al, 2005). Hides et al. (2007) measured trans-
verses abdominis (TrA) muscle contraction, internal
oblique (IO) muscle contraction, and length of the
TrA muscle obtained by ultrasound imaging (USI),
and reported good correlation with the same measures
obtained by fine-wire EMG. In this study, during con-
tractions less than 20% of maximal voluntary contrac-
tion (MVC), a consistent correlation between: (1)
increases in thickness of the TrA and IO muscles and
changes in length of TrA muscle; and (2) changes in
ultrasonographic parameters were detected. The use of
USI to measure lateral abdominal muscle thickness has
been validated by other reference criterion measures
like MRI (Hides et al, 2006).
It is believed that after 8 weeks of training, over 95%
of increased strength is related to muscular factors and
hypertrophy and only 5% could be contributed to
neural factors (Lieber, 2010). The interventions period
(exercise program) for our study lasted about 6 weeks
and it is expected that strength increase would be
mostly due to hypertrophy than neural factors.
Therefore, in this study we used USI for measure-
ment of thickness of the deep stabilizing and main
global trunk muscles to assess whether CSE is more
effective than GE (as a control group) in achieving
changes in abdominal muscle thickness in CLBP. We
believe this measurement could offer an index to judge
the effectiveness of different exercises on LBP even
though it does not assess back stability directly.
Materials and methods
Study design
A quasi-randomized controlled trial was conducted (Trial
Registration number: IRCT201111098035N1). Approval
for the research was received from the ethics committee
of Iran University of Medical Sciences (IUMS).
Participants
Forty-eight non-specific CLBP patients enrolled in the
present study. Inclusion criteria were: (1) having LBP
for more than 3 months; (2) pain intensity from 3 to 6
on the visual analogue scale (VAS scale); and (3) age of
18 to 60 years. The age of the participants ranged from
19 to 60 years. Those with a history of having pathology
or anomaly in lower limbs such as malignancy, inflam-
matory diseases, severe osteoporosis, arthritis, or bone
diseases were excluded. Labelling participants as non-
specific CLBP was based on clinical examination. At the
time of admission, participants were assigned a number
in the order that they entered the study. Those with
odd numbers were selected to the core stability exercise
(CSE) group and those with even numbers to the gen-
eral exercise (GE) group. The participants were
instructed about the study at the first session and
their informed consent was obtained.
Interventions
This study was performed in the School of
Rehabilitation and Rasool Akram Hospital of Iran
University of Medical Sciences. Both programs had a
common component of warm-up (eight stretching
exercises and stationary bicycling for 5 minutes).
Based on previous recommendations two programs
with eight stages were performed (Koumantakis,
Watson, and Oldham, 2005). The difficulty of exercises
was increased progressively in each stage. An explana-
tion on how to perform the exercises was provided to
the participants in the first session. The intervention
was three times a week for a total of 16 sessions for
both groups.

Core stability exercise
For CSE participants special instructions were applied.
Anatomy and function of local stabilizer muscles of
the back and the way they could be contracted was
explained. Cognition of contraction of local back mus-
cles was focused upon in the first four sessions in
order to improve awareness. Next the participants
were asked to do low levels of isometric contraction
of these muscles in minimally loading positions. In a
gradual manner, stabilizer muscle contraction was
integrated with dynamic function (activities requiring
spinal or limb movements) by adding co-contraction
of the local muscles into light functional tasks. In the
last six sessions of the CSE program, functional tasks
with heavier loads were performed. Exercises adminis-
tered were similar to those performed by the subjects
in GE group. To ensure correct contraction of the
transverses abdominis muscle, it was explained for
the participants that the lower part of the anterior
abdominal wall below the umbilical level needed to
be “drawn in.” The bulk of the multifidus muscle also
needed to be felt under the therapist’s fingers while
contracting. This was evaluated by placing fingers on
either side of the spinous processes of lumbar verteb-
rae directly over the belly of this muscle, while the
therapist palpated to detect a contraction (Richardson,
Hodges, and Hides, 2004).
General exercise
The focus of exercises in the GE group was on activating
the extensor (paraspinals) and flexor (abdominals) muscle
groups. Pure exercise times per session for CSE and GE
groups were 20 and 14 minutes, respectively. A previous
study was used in order to balance the groups regarding the
amount of estimated total force output of the trunk mus-
cles in response to the exercises and thus the amount of
exercise time duration (Danneels et al, 2001). Subjects were
excluded from the study if they had three consecutive or
five intermittent sessions of absence. An experienced phy-
siotherapist was responsible for managing both groups to
perform the exercises perfectly in the exact time duration.
Outcome measures
Ultrasound measurement of the abdominal muscle
thickness
Ultrasound Measurements were obtained before and
after the training using a portable ultrasound unit
(Sonoscape, S8, China) with a 15 MHz linear transducer.
The participants were positioned in supine lying with
arms crossed over the chest (Figure 1). Following a
deep inspiration, at the end of a forced expiration, they
PHYSIOTHERAPY THEORY AND PRACTICE 279
Figure 1. The participant’s position for ultrasound measurement.
were asked to continue to breathe out (further expira-
tion). The images were collected during this period.
Four transabdominal muscle thicknesses including: (1)
rectus abdominis (RA); (2) external oblique (EO); (3) inter-
nal oblique (IO); and (4) transverse abdominis (TrA), were
investigated. In order to achieve accurate and repeatable
ultrasound measurements, the position of the transducer
needs to be consistent. For RA, the transducer was placed
3 cm above the umbilicus, 3 cm from the midline. Images
of the anterolateral abdominal wall for EO, IO, and TrA
were obtained along a line midway between the inferior
angle of the rib cage and the iliac crest (Teyhen et al, 2007).
The ultrasound transducer was placed perpendicular to the
anterolateral abdominal muscles.
On-screen caliper measurements of muscle thickness
were done by drawing the caliper perpendicular inside
the hyper-echoic region between adjacent fascial bor-
ders (Figure 2). Muscle thickness was measured before
and after the training. The operator was unaware of the
previous measures.
To assess reliability of measurement, the main
researcher and another ultrasonographer performed
the measurement of abdominal muscles on 10 healthy
people through three repetitions, two times on one day
and the other on another day.
Disability and pain
Persian translated version of Oswestry disability ques-
tionnaire (Mousavi et al, 2006) (0 = no disability, 100 =
totally disabled) were filled by the participants and their
pain intensity were measured by VAS (0 = no pain, 100
= pain as bad as it could be). Pain and disability were
measured before and after the training.
280 M. SHAMSI ET AL.

Table 1. Participants’ characteristics.

Core stability exercise group General exercise group
N = 22 N = 21
Male: 7 Male: 6
Female: 15 Female: 15
Characteristic Mean SD SEM Mean SD SEM
Age (year) 39.2 11.7 2.5 48.0 10.2 2.2
Height (cm) 166.4 9.1 1.9 163.7 8.1 1.8
Weight (kg) 70.1 15.1 3.2 74.3 10.5 2.3

Table 2. ICC measures for inter-rater reliability in four muscle

images.
Muscle ICC 0.95% Confidence interval SEM
Rectus abdominis 0.90 0.72–0.97 0.17
External oblique 0.87 0.66–0.96 0.23
Internal oblique 0.96 0.89–0.99 0.14
Transverse abdominis 0.96 0.89–0.99 0.09
Figure 2. Three transabdominal muscles in ultrasound imaging.

Statistical analysis from intervention and 43 remained (22 subjects in CSE

Interrater reliability of ultrasound imaging measurements
were examined using model 2 intraclass correlation coeffi-
cient (ICC) (using a two factor mixed effects model and
type consistency) and standard error of measurement
(SEM = pooled SD × [1 – ICC] 1/2). Independent-samples
t-test was used to compare ultrasound imaging muscle
thickness, disability level, and pain intensity of the subjects
between the two groups: (1) at the start of the study to
confirm equality of samples; and (2) at the end of the study
to assess whether the changes in these variables during
intervention were statistically different in the two groups.
A paired t-test was used to investigate whether the three
variables were changed by the intervention. A two-way
ANOVA test was used to understand whether there was
an interaction between treatment group and time of mea-
surement (before or after the intervention).
Results
Five out of 48 participants fulfilling inclusion criteria
were excluded during the study due to their absence
and 21 in GE group). The participants’ characteristics
are presented in Table 1.
The average ICC measures for inter-rater reliability
in four muscles images were from 0.87 to 0.96 with a
95% confidence interval from 0.66–0.96 to 0.89–0.99
and SEMs were from 0.09 to 0.23 (Table 2).
There was no statistically significant differences
between the groups on entry to the trial in ultrasound
imaging muscle thickness (p = 0.14 to p = 0.95), dis-
ability (p = 0.97), and pain (p = 0.61).
Statistical analysis revealed a significant increase in
muscle thickness (hypertrophy) only for the right and
left rectus abdominis in the GE group after the training
period. No significant change was seen in other muscles
in either groups. After training, disability and pain
reduced within the groups (Table 3).
With regard to changes in outcomes (the difference
between before and after treatment values), the only
significant difference between CSE and GE group was
seen in right rectus abdominis muscle thickness change.
No significant difference in other measures was seen

Table 3. Statistical analysis showing comparison between and within groups.

Core stability group General exercise group
Outcome p-value for p-value for p-value for difference between
measures Before After difference Before After difference groups
Rt Rec Abd 8.21 (1.4) 8.16 (1.6) 0.82 7.85 (1.8) 8.86 (2.0) 0.003 0.009
Lt Rec Abd 7.95 (1.4) 8.17 (2.0) 0.41 7.94 (1.9) 8.54 (1.4) 0.024 0.29
Rt EO 4.64 (1.3) 4.83 (1.3) 0.57 4.79 (1.3) 4.77 (1.2) 0.96 0.62
Lt EO 4.42 (1.5) 4.55 (1.1) 0.73 4.76 (1.1) 5.07 (1.5) 0.25 0.68
Rt IO 5.17 (1.4) 5.85 (2.0) 0.08 5.95 (2.0) 5.88 (1.8) 0.76 0.09
Lt IO 5.26 (1.9) 5.40 (1.8) 0.59 5.84 (2.1) 5.79 (1.8) 0.85 0.60
Rt TrA 3.39 (1.2) 3.38 (1.0) 0.95 3.37 (0.8) 3.18 (0.6) 0.31 0.59
Lt TrA 3.30 (1.2) 3.32 (1.2) 0.92 3.20 (0.6) 3.27 (0.8) 0.72 0.89
OS 50.5 (12.1) 32.8 (10.5) <001 50.1 (11.3) 37.6 (10.9) <001 0.16
VAS 51.3 (9.8) 15.1 (11.8) <001 52.9 (9.0) 15.1 (13.8) <001 0.73

between the two groups. The two-way ANOVA
revealed no interaction between treatment group and
time of measurement for eight abdominal muscles
(before or after the intervention) (from p = 0.16 for
right RA to p = 0.93 for left TrA).
Discussion
The novelty of our study was comparing CSE and GE
based on change in trunk muscle thickness. We com-
pared these two types of exercise in patients with
chronic non-specific LBP. A course of 16 training ses-
sions showed an increment only in right and left rectus
abdominis muscle thickness in the GE group and a
decrement in disability and pain in both groups. But
the overall group effect could be seen only on right
rectus abdominis thickness increment in the GE group.
Core stability exercises have been suggested to improve
the muscular control required around the lumbar spine
to maintain functional stability (Richardson, Hodges,
and Hides, 2004). In our study, general exercise was
chosen as a control because the exercises activate the
same trunk muscles. Yet, unlike core stability exercise,
these general exercises are less likely to result in motor
control improvement and synergy of local and global
muscles and focus only on the strength of the muscles
(Sharrock et al., 2011).
Muscular control required around the lumbar spine
to maintain functional stability needs core strengthen-
ing. Comprehensive strengthening of these core mus-
cles has been suggested for prevention of various
lumbar spine and musculoskeletal disorders (Akuthota
and Nadler, 2004). As hypertrophy is one of character-
istics of muscle strength, trunk muscle thicknesses were
measured.
Our results are in agreement with a similar study
(Vasseljen and Fladmark, 2010) which investigated the
effects of three exercise programs of 8 weeks duration
including: (1) high load stability exercises; (2) low load
stability exercises; and (3) general exercise (i.e., trunk,
leg, and back muscle strengthening exercises) on
abdominal muscle thickness. In this study there was
no difference in EO, IO, or TrA resting thickness before
and after exercise period (RA muscle was not mea-
sured). The values for muscle thickness change in the
present study was similar to that noted in the Vasseljen
and Fladmark (2010) study. In another recent study
(Park and Yu, 2013) compared abdominal draw-in
maneuver and core exercises using ultrasonography
for muscle thickness measurement. After 4 weeks of
training, thickness of IO and EO muscles in both
groups and TrA in the drawing-in group increased
significantly, but the increase in TrA thickness in the
PHYSIOTHERAPY THEORY AND PRACTICE 281
core exercise group was not significant. Comparing the
two groups, changes made in EO and TrA in drawing-
in and change made in IO in the core exercise group
were more pronounced.
It has been claimed that motor control of transab-
dominal muscles in patients with LBP is altered (Hides
et al, 2009) concluding that these muscles are important
for spinal stability in LBP (Hides et al, 2009; Hodges
and Richardson, 1996). This claim is supported by the
finding that LBP is reduced by TrA strengthening
exercise (O’Sullivan, Twomey, and Allison, 1997).
Regarding these findings, an increase in thickness of
TrA as an index of both strength and neuromuscular
activation of this muscle, may have benefits for LBP
patients (Noormohammadpour, Kordi, Dehghani, and
Rostami, 2012).
In order to enhance motor control and strength of
the trunk region, in LBP patients, trunk strengthening
and trunk stabilization exercise programs (which target
deep abdominal muscles) are used. Generally there are
a variety of exercises (e.g., lumbar stabilization training,
Pilates, yoga, and motor control training), the purpose
of which is to improve local muscular and functional
control of the lumbopelvic region by targeting muscles
that surround the lumbar region (Teyhen et al, 2008).
Basically core strengthening improves the muscular
control required around the lumbar spine to maintain
functional stability (Akuthota and Nadler, 2004).
Core strength may be assessed in different ways.
Muscle thickness as a measure of muscle function
could be suggested as an index that affects stability.
Neural adaptation and increased central drive are the
reasons for early increase in contraction force observed
within days to a few weeks of initiating training
(Vasseljen and Fladmark, 2010). The later increase in
force is due to muscular hypertrophy. Though muscle
hypertrophy is typically found after 8–12 weeks of
intensive strength training, some evidence indicates
that it may be seen only after 3 weeks (Seynnes, de
Boer, and Narici, 2007).
Regarding the nature of rectus abdominis, which is
a global torque generating trunk muscle, increase in
thickness of this muscle after 16 sessions of general
exercise in our study is reasonable. As it was men-
tioned before, exercises performed by GE group were
of strengthening type compared with those of the
CSE group, so it is possible that hypertrophy
occurred only in the GE group. Significant increase
in right rectus thickness compared with the left side
in GE may be related to the fact that most people are
right handed and performing the exercises cause
more stress on the right side. As rectus abdominis is
a global muscle, the effect of GE on uneven (side to
282 M. SHAMSI ET AL.
side) strength improvement may have a negative
effect on motor control of lumbopelvic muscles and
possibly increase the risk of back pain occurring or
becoming worse, though this was not the case in the
present study.
As deep abdominal muscles (particularly TrA) are
proposed to contribute to lumbar segmental stabiliza-
tion (Hodges, 2003) and are not torque generators, we
do not expect hypertrophy following training. Thus
insignificant thickness increment in IO, EO, and TrA
muscles could be attributed to low-level activation of
these muscles. From the results obtained, no preference
for either type of exercise could be concluded for redu-
cing pain and disability in chronic LBP patients. This
has been concluded in many similar studies (Macedo,
Maher, Latimer, and McAuley, 2009; Wang et al, 2012).
Clinical implications
The implication to consider from these data is that
apart from rectus abdominis both exercises could be
used to treat chronic LBP patients with similar effects.
Limitations
Small sample size was a limitation of the study. The mean
age was higher in GE (47.9) than CSE (39.2) group (p =
0.013), which can be considered as a drawback of sys-
tematic sampling (alternative allocation of participants in
two groups). It was difficult for the patients to attend the
long 16 treatment sessions regularly and keep them per-
forming exercises exactly perfect. Some participants had
a thick layer of fat in their abdomen and it was difficult to
perform sonography examination. As sonography is a
highly sensitive technique to visualize sub-cutaneous tis-
sues and a small change in probe position may alter the
image, more attention should be paid to use accurate
positions for all participants.
Conclusion
The present results provided evidence that only general
exercise impacted right and left rectus abdominis mus-
cle thickness in patients with chronic non-specific LBP.
The only significant difference between core stability
and general exercise groups was seen in a change in
right rectus abdominis thickness.
Acknowledgments
The authors thank Dr. Ali Amiri and his colleagues in the
Physiotherapy Department of Rasool Akram Hospital
(Tehran, Iran) for their cooperation, Dr. Vida Zarabi (clinical
radiologist) for her guidance and help, Dr. Amir Hosein
Hashemian for his statistical advice, and Dr. Bahman
Mehraban for his grammatical correction on the manuscript.
Funding
This work was supported by grants from Iran University of
Medical Sciences.
Declaration of interest
The authors report no declarations of interest.
References
Akuthota V, Nadler SF 2004 Core strengthening. Archives of
Physical Medicine and Rehabilitation 85(3 Suppl 1): S86–
S92.
Bunce S, Moore A, Hough AD 2002 M-mode ultrasound: A
reliable measure of transversus abdominis thickness?
Clinical Biomechanics 17: 315–317.
Costa LO, Maher CG, Latimer J, Hodges PW, Herbert RD,
Refshauge KM, McAuley JH, Jennings MD 2009 Motor
control exercise for chronic low back pain: A randomized
placebo-controlled trial. Physical Therapy 89: 1275–1286.
Danneels LA, Vanderstraeten GG, Cambier DC, Witvrouw
EE, Bourgois J, Dankaerts W, De Cuyper HJ 2001 Effects
of three different training modalities on the cross sectional
area of the lumbar multifidus muscle in patients with
chronic low back pain. British Journal of Sports Medicine
35: 186–191.
Ferreira PH, Ferreira ML, Maher CG, Herbert RD, Refshauge
K 2007 Specific stabilisation exercise for spinal and pelvic
pain: A systematic review. Australian Journal of
Physiotherapy 52: 79–88.
Hauggaard A, Persson AL 2007 Specific spinal stabilisation
exercises in patients with low back pain: A systematic
review. Physical Therapy Reviews 12: 233–248.
Hayden JA, Van Tulder MW, Malmivaara AV, Koes BW
2005 Meta-analysis: Exercise therapy for nonspecific low
back pain. Annals of Internal Medicine 142: 765–775.
Henchoz Y, Kai-Lik So L 2008 Exercise and nonspecific low
back pain: A literature review. Joint, Bone, Spine 75: 533–
539.
Hides JA, Belavy DL, Cassar L, Williams M, Wilson SJ,
Richardson CA 2009 Altered response of the anterolateral
abdominal muscles to simulated weight-bearing in subjects
with low back pain. European Spine Journal 18: 410–418.
Hides JA, Miokovic T, Belavý DL, Stanton WR, Richardson
CA 2007 Ultrasound imaging assessment of abdominal
muscle function during drawing-in of the abdominal
wall: An intrarater reliability study. Journal of
Orthopaedic and Sports Physical Therapy 37: 480–486.
Hides JA, Wilson S, Stanton W, McMahon S, Keto H,
McMahon K, Bryant M, Richardson C2006 An MRI inves-
tigation into the function of the transversus abdominis
muscle during “drawing-in” of the abdominal wall. Spine
31: E175–E178.
Hodges PW 2003 Core stability exercise in chronic low back
pain. Orthopedic Clinics of North America 34: 245–254.

Hodges PW, Richardson CA 1996 Inefficient muscular stabi-
lization of the lumbar spine associated with low back pain:
A motor control evaluation of transversus abdominis.
Spine 21: 2640–2650.
Kidd AW, Magee S, Richardson CA 2002 Reliability of real-
time ultrasound for the assessment of transversus abdo-
minis function. Journal of Gravitational Physiology: 9:
131.
Koumantakis GA, Watson PJ, Oldham JA 2005 Trunk mus-
cle stabilization training plus general exercise versus gen-
eral exercise only: Randomized controlled trial of patients
with recurrent low back pain. Physical Therapy 85:
209–225.
Lederman E 2010 The myth of core stability. Journal of
Bodywork and Movement Therapies 14: 84–98.
Liddle SD, Baxter GD, Gracey JH 2004 Exercise and chronic
low back pain: What works? Pain 107: 176–190.
Lieber RL 2010 Skeletal Muscle Structure, Function, and
Plasticity: The Physiological Basis of Rehabilitation.
Baltimore, MD, Wolters Kluwer Health/Lippincott
Williams & Wilkins.
Macedo LG, Maher CG, Latimer J, McAuley JH 2009 Motor
control exercise for persistent, nonspecific low back pain:
A systematic review. Physical Therapy 89: 9–25.
Mousavi SJ, Parnianpour M, Mehdian H, Montazeri A,
Mobini B 2006 The Oswestry disability index, the
Roland–Morris disability questionnaire, and the Quebec
back pain disability scale: Translation and validation stu-
dies of the Iranian versions. Spine 31: E454–459.
Noormohammadpour P, Kordi R, Dehghani S, Rostami M
2012 The effect of abdominal resistance training and
energy restricted diet on lateral abdominal muscles thick-
ness of overweight and obese women. Journal of Bodywork
and Movement Therapies 16: 344–350.
O’Sullivan PB, Twomey LT, Allison GT 1997 Evaluation of
specific stabilizing exercise in the treatment of chronic low
back pain with radiologic diagnosis of spondylolysis or
spondylolisthesis. Spine 22: 2959–2967.
Park SD, Yu SH 2013 The effects of abdominal draw-in
maneuver and core exercise on abdominal muscle thick-
ness and Oswestry disability index in subjects with chronic
low back pain. Journal of Exercise Rehabilitation 9: 286–
291.
Rackwitz B, De Bie R, Limm H, von Garnier K, Ewert T, Stucki
G 2006 Segmental stabilizing exercises and low back pain.
What is the evidence? A systematic review of randomized
controlled trials. Clinical Rehabilitation 20: 553–567.
PHYSIOTHERAPY THEORY AND PRACTICE 283
Rankin G, Stokes M, Newham DJ 2006 Abdominal muscle
size and symmetry in normal subjects. Muscle and Nerve
34: 320–326.
Refshauge K, Maher C 2006 Low back pain investigations and
prognosis: A review. British Journal of Sports Medicine 40:
494–498.
Richardson C, Hodges PW, Hides J 2004 Therapeutic exer-
cise for lumbopelvic stabilization: A motor control
approach for the treatment and prevention of low back
pain, 2nd edn. Edinburgh, Churchill Livingstone.
Seynnes OR, de Boer M, Narici MV 2007 Early skeletal
muscle hypertrophy and architectural changes in response
to high-intensity resistance training. Journal of Applied
Physiology 102: 368–373.
Sharrock C, Cropper J, Mostad J, Johnson M, Malone T 2011
A pilot study of core stability and athletic performance: Is
there a relationship? International Journal of Sports
Physical Therapy 6: 63–74.
Teyhen DS, Gill NW, Whittaker JL, Henry SM, Hides JA,
Hodges P 2007 Rehabilitative ultrasound imaging of the
abdominal muscles. Journal of Orthopaedic and Sports
Physical Therapy 37: 450–466.
Teyhen DS, Miltenberger CE, Deiters HM, Del Toro YM, Pulliam
JN, Childs MJ, Boyles RE, Flynn TW 2005 The use of ultra-
sound imaging of the abdominal drawing-in maneuver in
subjects with low back pain. Physical Therapy 35: 346–355.
Teyhen DS, Rieger JL, Westrick RB, Miller AC, Molloy JM,
Childs JD 2008 Changes in deep abdominal muscle thick-
ness during common trunk-strengthening exercises using
ultrasound imaging. Journal of Orthopaedic and Sports
Physical Therapy 38: 596–605.
van Tulder M, Koes B 2007 Spinal imaging. In: Evidence-
Based Medicine for Low Back pain, pp 111–125. Germany,
Springer Berlin Heidelberg.
van Tulder M, Malmivaara A, Esmail R, Koes B 2000 Exercise
therapy for low back pain: A systematic review within the
framework of the Cochrane Collaboration Back Review
Group. Spine 25: 2784–2796.
Vasseljen O, Fladmark AM 2010 Abdominal muscle contrac-
tion thickness and function after specific and general exer-
cises: A randomized controlled trial in chronic low back
pain patients. Manual Therapy 15: 482–489.
Wang XQ, Zheng JJ, Yu ZW, Bi X, Lou SJ, Liu J, Cai B, Hua
YH, Wu M, Wei ML, Shen HM, Chen Y, Pan YJ, Xu GH,
Chen PJ 2012 A meta-analysis of core stability exercise
versus general exercise for chronic low back pain. PloS
One 7(12): e52082.