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Ito Test: Does Height of The Pad Affect Back Muscle Endurance?
Ito Test: Does Height of The Pad Affect Back Muscle Endurance?
ENDURANCE?
ABSTRACT
Background: Decreased back muscle endurance is sometimes associated with high rates of low back
pain. Ito test is a safe and reliable test for assessing trunk extensor muscle endurance, however it limits
recognition due to lack of studies and absence of standardized testing procedure. Hence this study
aims to find out whether the height of the pad that is to be used while performing the test has any effect
on back muscle endurance in normal healthy individuals. Methodology: 84 healthy college volunteers
were recruited in the study. A pilot study was conducted to find out the optimal height of pad that can
be used for conducting Ito test. Back extensor endurance was evaluated using a foam pad of height 5,
6.5 and 8 centimeters. Results: There was no significant difference in trunk extensor endurance with
different height of the foam pad. Conclusion: Any height of the pad ranging from 5 to 8 centimeters
can be used for assessing back muscle endurance, however the self reported comfortable height of the
pad was 5 centimeters for most of the healthy participants.
Keywords: Ito test, back endurance, low back pain
INTRODUCTION
Muscular endurance is the ability of an isolated sustain a contraction over time at a certain level
muscle group to perform repeated contractions (static endurance)1,2. Decreased static
over a period of time (dynamic endurance) or endurance in back extensors is sometimes
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associated with high rates of low back pain, 1981.10 To overcome these disadvantages Ito et
decreased proprioceptive awareness, poor al developed a new method based on Sorensen
balance, decreased productivity at work place, test and studied its reliability, safety in
increased muscular fatigability and overload on application of this method and established its
soft tissues and passive structures of the spine.3 validity by evaluating the endurance using this
Therefore, measurement of trunk muscle test in 190 healthy individuals and in
endurance is potentially important for individuals with chronic low back pain. The
identifying the risk factors, as prognostic reliability of this test in healthy individuals is,
indicators, for planning treatment goals and ICC= 0.97 for trunk extensor muscles.8 Also,
measuring patient’s progress.4 Hansen JW maximal neck flexion and gluteal muscle
developed the first test for evaluating isometric contraction included in the test procedure are
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back extensor endurance. Troup and Chapman supposed to be the most optimal position for
evaluated muscle fatigability by surface decreasing lumbar lordosis and for activating
electromyography in patients during this test.6 the lumbar erector spinae muscle to the
After a study of Bieiring- Sorensen in 1984, maximum.11 Muller et al in his study showed
which was published in the Spine journal, this that Ito test has a good criterion validity and it
test came to be known as Sorensen test can assess back extensor muscle endurance
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structures of the spine . more specifically as compared to Sorensen
Although there are no gold standards for test.12
measurement of trunk endurance, Sorensen test Although, Ito test had a very high test-retest
is the most popular method of assessing trunk reliability and did not seem to induce pain or
extensor endurance. However there are some increase spinal loads the factors that limit the
disadvantages pertaining to the use of this test recognition of Ito test includes lack of studies,
in patients with chronic low back pain.8 It absence of standardized test procedures like the
increases the lumbar lordosis because of type of pad used and extent of raising the upper
extended hip and knee during the test which body and theoretical risk of exaggerating the
can produce bulging of intervertebral disc and lumbar lordosis.8,10 Hence our study aims at
buckling of ligamentum flavum followed by determining the most appropriate height of pad
reducing the intervertebral foramen. The to assess back muscle endurance during Ito test
hyperextension of lumbar spine may aggravate in normal healthy individuals.
pain.9 Also a study by Callaghan et al,
estimated that the compression load imposed on METHODOLOGY
spine during Sorensen test was 4000N, slightly Eighty-four healthy college volunteers (53
above the value recommended by the National females and 31 males) between 18 – 25 years
Institute of Occupational Safety and Health in of age who volunteered for the study from
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Scientific Research Journal of India ● Volume: 3, Issue: 2, Year: 2014
College Of Physiotherapy, Pravara Institute of encouraged to clarify their queries, if any and
Medical Sciences, Loni were recruited. The all queries were addressed for complete
study was conducted from March 2013 till June familiarization of the test. For evaluating the
2013. The participants were selected by back extensor endurance the participants were
convenience sampling and were screened based asked to lie in prone position with a foam pad
on the exclusion criteria by physiotherapist who (figure 1) under the lower abdomen.
later were involved with data collection.
Exclusion criteria were a history of
symptomatic low back pain within one year to
the time of the study, any obvious spinal
deformity, individuals participating in high-
intensity regular exercise or elite sports at
competitive level or individuals involved in any
prior systematic exercise program of lumbar or
Figure 1: Foam pad used for the test
hip extensor muscles, a history of
This foam is medium rubber, high density and
cardiovascular disease representing
has a medium to soft feel depending on the
contraindications to exercise or any disability
body weight of the sleeper. It offers a high
limiting the ability to exercise. The participants
degree of comfort and will retain its shape and
were informed about the study and a written
density. Participants were made to perform the
consent was obtained before any measurements
test in the following manner. The foam pad was
were taken. Anthropometric data like height,
first placed below the lower abdomen of the
weight, BMI and abdominal girth of the
participants and they were asked to lift the
participants were calculated. Height was
sternum off the plinth and hold the position as
measured using a stadiometer to the nearest 0.1
long as they could upto a maximum of 300
cm. Body weight was taken with light clothes
seconds8. While performing the test participants
and measured to nearest 0.1 kg using a
were asked to maintain maximum flexion at
weighing scale caliberated from 0-120 kgs with
cervical spine with pelvic stabilization through
the participant in standing position and shoes
contraction of glutei, the most optimal position
off. BMI was calculated using the above data.
for reducing lumbar lordosis and activating the
Abdominal girth was calculated using a
lumbar erector spinae (Figure 2).
measuring tape at the level of the umbilicus to
the nearest 0.1 cm.
Before taking the readings the participants were
demonstrated the procedure of the test and were
also asked to perform it themselves. They were
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Scientific Research Journal of India ● Volume: 3, Issue: 2, Year: 2014
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ISSN: 2277-1700 ● Website: http://srji.drkrishna.co.in ● URL Forwarded to: http://sites.google.com/site/scientificrji
dynamic pelvic and trunk movement. The leg Evaluating back endurance muscle in patients
muscle will extend the pelvis, and the lumbar with low back pain using different height of
muscles will stabilize and extend the lumbar pad would have been difficult for the patients
region on the pelvis whereas thoracic muscles because of repeated test procedures resulting in
will lift the trunk.13 Therefore more the height aggravation of pain, hence this study was
of the pillow the glutei muscles have to contract conducted on normal individuals to find out the
more in order to stabilize the pelvis and the optimal length of pad that can be used while
thoracic muscles will work in order to clear the performing the test which would be
sternum off the plinth during extension. Also comfortable to the patients. Future scope of the
lesser the height of the pillow the compression study may include finding the co-relation
on the lower abdomen is less thus reducing the between the height of the pad and abdominal
discomfort in breathing. In another study girth. Lastly as proposed in the original study
conducted by Muller et al, an EMG study to lumbar lordosis during the test should be
find out the criterion validity of Ito test, a foam evaluated either by radiography or by using a
roll of 0.2 m in diameter, the density of which flexicurve.
was not stated in the study was used to evaluate
the trunk extensor endurance.12 However, in CONCLUSION:
our study participants felt abdominal It can be concluded that any height of the foam
discomfort and pain with any height above 8 pad made of medium rubber and high density
centimeters. Another interesting observation having soft feel ranging from 5 to 8 centimeters
was that participants with greater abdominal can be used for assessing back muscle
girth reported more comfort with a greater endurance however the self reported
height of the pad as compared to other comfortable height of the pad was 5
participants however the co-relation of this was centimeters for most of the healthy participants.
beyond the scope of this study.
The participants in the study were healthy ACKNOWLEDGEMENT:
young adults hence the results cannot be We would like to thank the participants in the
generalized to population with low back pain. study for their kind co-operation.
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CORRESPONDING AUTHOR:
*Final year M.P.Th (Orthopaedics) student, College of Physiotherapy, Pravara Institute of Medical
Sciences(DU), Loni, Maharashtra, India. Email Id: soans_juanita@yahoo.co.in
**M.P.T, Associate Professor, College of Physiotherapy, Pravara Institute of Medical Sciences(DU),
Loni, Maharashtra, India.
***M.P.T, Assistant Professor, College of Physiotherapy, Pravara Institute of Medical Sciences(DU),
Loni, Maharashtra, India.
****B.P.Th, College of Physiotherapy, Pravara Institute of Medical Sciences(DU), Loni, Maharashtra,
India.
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