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ITO TEST: DOES HEIGHT OF THE PAD AFFECT BACK MUSCLE

ENDURANCE?

Juanita E. Soans*, Keerthi Rao**, Chandra Iyer***, Dnyanda Newasekar****


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
muscle group to perform repeated contractions
over a period of time (dynamic endurance) or
sustain a contraction over time at a certain level
(static endurance)
1,2
.

Decreased static
endurance in back extensors is sometimes
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32
associated with high rates of low back pain,
decreased proprioceptive awareness, poor
balance, decreased productivity at work place,
increased muscular fatigability and overload on
soft tissues and passive structures of the spine.
3
Therefore, measurement of trunk muscle
endurance is potentially important for
identifying the risk factors, as prognostic
indicators, for planning treatment goals and
measuring patients progress.
4
Hansen JW
developed the first test for evaluating isometric
back extensor endurance.
5
Troup and Chapman
evaluated muscle fatigability by surface
electromyography in patients during this test.
6

After a study of Bieiring- Sorensen in 1984,
which was published in the Spine journal, this
test came to be known as Sorensen test
structures of the spine
7
.
Although there are no gold standards for
measurement of trunk endurance, Sorensen test
is the most popular method of assessing trunk
extensor endurance. However there are some
disadvantages pertaining to the use of this test
in patients with chronic low back pain.
8
It
increases the lumbar lordosis because of
extended hip and knee during the test which
can produce bulging of intervertebral disc and
buckling of ligamentum flavum followed by
reducing the intervertebral foramen. The
hyperextension of lumbar spine may aggravate
pain.
9
Also a study by Callaghan et al,
estimated that the compression load imposed on
spine during Sorensen test was 4000N, slightly
above the value recommended by the National
Institute of Occupational Safety and Health in
1981.
10
To overcome these disadvantages Ito et
al developed a new method based on Sorensen
test and studied its reliability, safety in
application of this method and established its
validity by evaluating the endurance using this
test in 190 healthy individuals and in
individuals with chronic low back pain. The
reliability of this test in healthy individuals is,
ICC= 0.97 for trunk extensor muscles.
8
Also,
maximal neck flexion and gluteal muscle
contraction included in the test procedure are
supposed to be the most optimal position for
decreasing lumbar lordosis and for activating
the lumbar erector spinae muscle to the
maximum.
11
Muller et al in his study showed
that Ito test has a good criterion validity and it
can assess back extensor muscle endurance
more specifically as compared to Sorensen
test.
12

Although, Ito test had a very high test-retest
reliability and did not seem to induce pain or
increase spinal loads the factors that limit the
recognition of Ito test includes lack of studies,
absence of standardized test procedures like the
type of pad used and extent of raising the upper
body and theoretical risk of exaggerating the
lumbar lordosis.
8,10
Hence our study aims at
determining the most appropriate height of pad
to assess back muscle endurance during Ito test
in normal healthy individuals.

METHODOLOGY
Eighty-four healthy college volunteers (53
females and 31 males) between 18 25 years
of age who volunteered for the study from
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33
College Of Physiotherapy, Pravara Institute of
Medical Sciences, Loni were recruited. The
study was conducted from March 2013 till June
2013. The participants were selected by
convenience sampling and were screened based
on the exclusion criteria by physiotherapist who
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
hip extensor muscles, a history of
cardiovascular disease representing
contraindications to exercise or any disability
limiting the ability to exercise. The participants
were informed about the study and a written
consent was obtained before any measurements
were taken. Anthropometric data like height,
weight, BMI and abdominal girth of the
participants were calculated. Height was
measured using a stadiometer to the nearest 0.1
cm. Body weight was taken with light clothes
and measured to nearest 0.1 kg using a
weighing scale caliberated from 0-120 kgs with
the participant in standing position and shoes
off. BMI was calculated using the above data.
Abdominal girth was calculated using a
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
encouraged to clarify their queries, if any and
all queries were addressed for complete
familiarization of the test. For evaluating the
back extensor endurance the participants were
asked to lie in prone position with a foam pad
(figure 1) under the lower abdomen.

Figure 1: Foam pad used for the test
This foam is medium rubber, high density and
has a medium to soft feel depending on the
body weight of the sleeper. It offers a high
degree of comfort and will retain its shape and
density. Participants were made to perform the
test in the following manner. The foam pad was
first placed below the lower abdomen of the
participants and they were asked to lift the
sternum off the plinth and hold the position as
long as they could upto a maximum of 300
seconds
8
. While performing the test participants
were asked to maintain maximum flexion at
cervical spine with pelvic stabilization through
contraction of glutei, the most optimal position
for reducing lumbar lordosis and activating the
lumbar erector spinae (Figure 2).
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Figure 2: Participant performing ITO test
The pattern of selection of height of the foam
pad with which the participants were to start the
test was done by block randomization method
which was computer generated. The time for
which the participants could hold the test
position with the height of the foam pad was
measured in seconds using a stop watch. After
a rest period of 10 minutes, the test was
repeated with the same height of the pad and
similarly 2 readings were taken. An average of
the two readings was calculated and
documented for that height of the foam pad to
obtain highest accuracy and decrease any
manual error. The criteria for stopping the tests
were trick movements, altered pain sensation
and pain tolerance. The participants were called
the next day and the same procedure was
repeated with the other height of the foam pad
on the consecutive day. The main purpose of
taking two readings was to decrease fatigability
and for obtaining the best value for each height
of the pad. Before starting with the data
collection a pilot study was conducted with ten
participants to find out the optimal height of the
pad that can be used as reference for this study.
For any height below 5 cms in height, the
participants reported an absence of fulcrum
through which they could maintain the upper
body in the desired position, and for any height
above 8 cms the participants felt excessive
pressure on their abdomen and pain in the low
back which averaged 5.3 on VAS. Any height
greater than 8 cms was also flattening the
lumbar lordosis more than that required while
performing the Ito test. The criteria for stopping
the test were trick movements, altered pain
sensations, and pain tolerance.
Based on the results obtained, the participants
performed the test with a foam pad of 5, 6.5
and 8 centimeters in height. All the tests were
performed two hours after the last meal taken
by the participants. After each test the
participants were asked to rate their level of
discomfort on VAS so as to find out the height
of foam pad which was most comfortable.

STATISTICAL ANALYSIS:
The statistical analysis was done using Graph
Pad Instat Trial Version 13.3. ANOVA with
repeated measures was used for data analysis
and p<0.05 was considered to be statistically
significant.

RESULTS:
The baseline data for participants are as follows
and represented in table 1.
Participants
Males
(n= 31
Females
(n=53)
Age
(years)
21.20 2.31 21.9 1.97
Scientific Research Journal of India Volume: 3, Issue: 2, Year: 2014
35
BMI
(kg/m
2
)
20.26 3.49 20.19 2.84
Abdominal
girth
(cms)

87.12 10.31

76.18
12.83
Table 1: Baseline demographic data of
participants
BMI of all participants were 20.26 3.49
kg/m
2
and 20.26 3.49 79 10.3 kg/m
2
for
male and female participants respectively and
did not show co-relation to discomfort
experienced by them while performing the test
with different heights of the foam pad. The
abdominal girth for both male and female
participants were 87.12 10.31 and 76.18
12.83 centimeters respectively. The mean
holding time of all participants with pad height
of 5, 6.5 and 8 centimeters were 69.54 36.79,
70.20 44.96 and 68.78 33.79 seconds
respectively.(figure 3)

Figure 3: Mean Holding Time
Statistical analysis was done using ANOVA
with repeated measures with p < 0.05. This
shows that results obtained were not
statistically significant leading us to conclude
that height of foam pad does not actually alter
the endurance. It was found that 72% of
participants self reported that a height of 5
centimeters of pad was most comfortable while
performing the test as compared to 6.5 and 8
cms.

DISCUSSION:
The results of the present study show that there
was n significant alteration in back muscle
endurance with different height of foam pads.
Also, most participants reported that 5
centimeter height of foam pad was most
comfortable. In our opinion the height of the
foam pad did not vary much with respect to
each other in order to change the kinematics or
coupled movements of the muscles. Time, as a
measure of endurance of low back musculature,
varies with intensity of loading and with
posture. The Ito test, as compared to Sorensen
test is safe, reliable and easy to perform and
doesnt require any other equipment apart from
a foam pad. In the present study, a pilot study
was initially conducted to find out the optimum
height of the pad that can be used. The height
of the pad was kept between 5cms and 8cms
beyond which the participants reported
discomfort while performing the test. On
interrogation participants reported that
increased height of the foam pad placed below
the lower abdomen created excessive
compression which made it difficult for them
to breathe and reduced their performance. In
our opinion this is because a trunk extension
from 45 degrees of trunk flexion needs
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36
dynamic pelvic and trunk movement. The leg
muscle will extend the pelvis, and the lumbar
muscles will stabilize and extend the lumbar
region on the pelvis whereas thoracic muscles
will lift the trunk.
13
Therefore more the height
of the pillow the glutei muscles have to contract
more in order to stabilize the pelvis and the
thoracic muscles will work in order to clear the
sternum off the plinth during extension. Also
lesser the height of the pillow the compression
on the lower abdomen is less thus reducing the
discomfort in breathing. In another study
conducted by Muller et al, an EMG study to
find out the criterion validity of Ito test, a foam
roll of 0.2 m in diameter, the density of which
was not stated in the study was used to evaluate
the trunk extensor endurance.
12
However, in
our study participants felt abdominal
discomfort and pain with any height above 8
centimeters. Another interesting observation
was that participants with greater abdominal
girth reported more comfort with a greater
height of the pad as compared to other
participants however the co-relation of this was
beyond the scope of this study.
The participants in the study were healthy
young adults hence the results cannot be
generalized to population with low back pain.
Evaluating back endurance muscle in patients
with low back pain using different height of
pad would have been difficult for the patients
because of repeated test procedures resulting in
aggravation of pain, hence this study was
conducted on normal individuals to find out the
optimal length of pad that can be used while
performing the test which would be
comfortable to the patients. Future scope of the
study may include finding the co-relation
between the height of the pad and abdominal
girth. Lastly as proposed in the original study
lumbar lordosis during the test should be
evaluated either by radiography or by using a
flexicurve.

CONCLUSION:
It can be concluded that any height of the foam
pad made of medium rubber and high density
having soft feel 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.

ACKNOWLEDGEMENT:
We would like to thank the participants in the
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.