See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/8538362

Determining the Stabilizing Role of Individual

Torso Muscles During Rehabilitation Exercises
Article in Spine July 2004
Impact Factor: 2.3 DOI: 10.1097/00007632-200406010-00016 Source: PubMed

CITATIONS

READS

166

294

3 authors, including:
Sylvain G Grenier

Stuart M Mcgill

Laurentian University

University of Waterloo

32 PUBLICATIONS 1,059 CITATIONS

274 PUBLICATIONS 11,635 CITATIONS

SEE PROFILE

SEE PROFILE

Available from: Sylvain G Grenier

Retrieved on: 21 April 2016

SPINE Volume 29, Number 11, pp 12541265

2004, Lippincott Williams & Wilkins, Inc.

Determining the Stabilizing Role of Individual Torso

Muscles During Rehabilitation Exercises
Natasa Kavcic, MSc, Sylvain Grenier, PhD, and Stuart M. McGill, PhD

Study Design. A systematic biomechanical analysis

involving an artificial perturbation applied to individual
lumbar muscles in order to assess their potential stabilizing role.
Objectives. To identify which torso muscles stabilize
the spine during different loading conditions and to identify possible mechanisms of function.
Summary of Background Data. Stabilization exercises
are thought to train muscle patterns that ensure spine
stability; however, little quantification and no consensus
exists as to which muscles contribute to stability.
Methods. Spine kinematics, external forces, and 14
channels of torso electromyography were recorded for
seven stabilization exercises in order to capture the individual motor control strategies adopted by different people. Data were input into a detailed model of the lumbar
spine to quantify spine joint forces and stability. The EMG
signal for a particular muscle was replaced either unilaterally or bilaterally by a sinusoid, and the resultant
change in the stability index was quantified.
Results. A direction-dependent-stabilizing role was
noticed in the larger, multisegmental muscles, whereas a
specific subtle efficiency to generate stability was observed for the smaller, intersegmental spinal muscles.
Conclusions. No single muscle dominated in the enhancement of spine stability, and their individual roles
were continuously changing across tasks. Clinically, if the
goal is to train for stability, enhancing motor patterns that
incorporate many muscles rather than targeting just a few
is justifiable. [Key words: lumbar spine, spine stability,
modeling, muscles] Spine 2004;29:1254 1265

While muscles function to create torques, which support

postures and facilitate movement, they are also critical
for ensuring spine stability.1 Clinically, the question of
how to train lumbar spine stability requires knowledge
of how the various muscles contribute to ensuring stability. A common functional distinction used to classify the
role of the different muscles is that intersegmental or
local muscles are hypothesized to function primarily
as stabilizers and multisegmental or global muscles are
hypothesized to function primarily as moment producFrom the University of Waterloo, Faculty of Applied Health Sciences,
Waterloo, Ontario, Canada.
Acknowledgment date: May 21, 2003. First revision date: June 26,
2003. Acceptance date: August 6, 2003.
Supported by the National Science and Engineering Research Council
of Canada.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
Federal funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Address correspondence to Stuart M. McGill, PhD, Faculty of Applied
Health Science, University of Waterloo, Waterloo, Ontario, Canada
N2L 3G1; E-mail: mcgill@healthy.uwaterloo.ca

1254

ers.2 4 This distinction, formalized by Professor Anders

Bergmark,2 focused the early discussions on stability;
however, debate continues over which muscles are important stabilizers and how to best train the neuromuscular control system to ensure sufficient stability.
Researchers have used various techniques to investigate the question of which muscles stabilize the lumbar
spine. Electromyographic analysis of torso muscle onset
times to various perturbations has suggested that the
more internal muscles, particularly the transverse abdominis and internal obliques, behave in an anticipatory
manner, irrespective of loading condition, suggesting a
proactive control of spine stability.5,6 Others have observed a wasting of the multifidus muscle on the side of
the reported low back pain with MRI techniques,7 suggesting that in order to ensure a stable spine this muscle
requires specific training to return the cross-sectional
area of multifidus to normal levels.4 While these studies
did not quantify stability but rather relied on qualitative
intuition, other approaches have attempted to quantify
stability. For example, in vitro approaches have represented muscle forces with wire cables acting on cadaveric
lumbar spines. Through investigation of predominantly
small, local muscles, several researchers have found
that these muscles successfully increase the stiffness
within the spinal structure, critical for stability.8 10
While many believe that the local muscles are crucial for spine stability, others hypothesize that the
global, larger muscles play a role. Panjabi et al8 suggested that the role global muscles have in stabilizing the
lumbar spine comes from their efficient ability to impact
the stiffness of the entire spinal column, opposed to local
muscles that can only act on a few joints. Cholewicki and
McGill11 and Cholewicki and Van Vliet12 suggest from
the results of their biomechanical analyses, that no single
muscle, local or global, possesses a dominant responsibility for lumbar spine stability and therefore concluded
that training efforts should not focus on any single
muscle.
Contrasting results and descriptions for the neuromuscular control of spine stability have led to the development of various training theories. Patterns such as antagonist cocontraction as a method of increasing spine
stiffness has been confirmed through numerous studies1316; however, some argue that enhancing this response for therapeutic purposes to train spine stability
can lead to very high compressive load penalties.4 Some
advocate training isolated groups of muscles, primarily
local, with the goal to minimize global muscle activation and compressive loads. Identifying muscle impor-

Torso Muscles and Rehabilitation Exercises Kavcic et al 1255

Figure 1. Pictures of different stabilization exercises. A, Abdominal curl. B, Right side bridge. C, Sitting on a stool. D, Sitting on a gym ball.
E, Four-point kneeling with contralateral arm and leg extension. F, Four-point kneeling with single leg extension. G, Back bridge with single
leg extension. H, Back bridge.

tance during different loading conditions is necessary to

properly critique existing clinical practices for training
and restoring a healthy lumbar spine.
The purpose of this study is to use a highly sophisticated and detailed torso model, driven with biologic signals measured directly from each study participant, to
compute spine loads and stability. Each muscle was systematically adjusted to assess the impact on the stability
of the spine, thereby quantifying their contribution at a
specific instant in time. Furthermore, an attempt to identify the different mechanisms as to how the various muscles contribute to lumbar spine stability was performed.
Materials and Methods
Ten male study participants performed a series of eight different exercises (Figure 1) while electromyography, three-

dimensional lumbar motion, and external forces were measured. These data were input into a series of biomechanical
models in order to calculate a measure of lumbar joint forces
and spine stability. These methods are extremely detailed and
have already been published. While the interested reader can
refer to the manuscripts for details,11,17,18 the essential details
are documented here. A schematic of the protocol is shown in
Figure 2. All procedures were approved by the University Office
for Research Ethics.

Subjects. Ten male university students with an average age of

21 years (SD 3 years), height of 177.8 cm (SD 6.2 cm), and
weight of 80.2 kg (SD 12.1 kg) volunteered to participate in
this study. Subjects had no history of low back pain. Before
testing, study participants height, weight, and breadth dimensions at the feet, ankles, knees, hips, hands, wrists, elbows, and
shoulders were obtained while standing in anatomic position.

1256 Spine Volume 29 Number 11 2004

Figure 2. Flow chart of the various models used in the stability analysis.

Data Collection
Exercises. Each study participant performed a series of eight
exercises presented in random order. The exercises (shown in
Figure 1) include the abdominal curl (A), right side bridge (B),
sitting on a gym ball (D), four-point kneeling with a left arm

and right leg extension (E), four-point kneeling with right leg
extension (F), back bridging with right leg extension (G), and
back bridging (H). To act as a control trial for the gym ball
condition and allow for assessment of unstable support surfaces, study participants performed trials sitting on a stool (C).

Torso Muscles and Rehabilitation Exercises Kavcic et al 1257

Table 1. Summary of the support moments created at the

L4 L5 joint in order to perform the different exercises
Average L4L5 moment (Nm)
Bend ( 1 SD)
Abdcurl
1.30
Chair
0.54
Ball
0.72
Bridge
0.15
Bridge leg
8.42
Fpn_leg
4.84
Fpn_arm/leg 0.05
Side bridge 69.18

(1.9)
(0.5)
(1.0)
(3.9)
(5.0)
(2.9)
(5.1)
(21.9)

Twist

( 1 SD)

Flex

( 1 SD)

0.72
0.10
0.18
2.64
15.74
15.62
57.05
12.80

(0.99)
(0.3)
(0.5)
(7.6)
(7.6)
(8.1)
(14.6)
(3.9)

56.71
1.47
1.28
73.81
65.94
6.14
32.84
2.87

(7.0)
(0.5)
(0.5)
(32.7)
(33.3)
(25.3)
(23.2)
(3.4)

Average and standard deviations are listed. In the sagittal plane, flexion is
negative and extension is positive. In the frontal plane, right lateral bend is
positive and left lateral bend is negative. In the transverse plane, right axial
twist is negative and left axial twist is positive.

The stabilization exercises were chosen for ease of analysis as

well as to ensure moments to the spine in all three axes of
rotation (Table 1). Each exercise was performed with a neutral
lumbar spine position and controlled limb positioning. Limb
and/or pelvis position was controlled through the use of an
external frame with metal bars that was placed alongside body
segments to act as targets.
Each exercise was held isometrically for 2 seconds with an
isometric contraction of the abdominal muscles (termed abdominal brace).1 A brace is an isometric contraction of all the
muscles of the abdominal wall without any change in the position of the muscles. This is in contrast to the abdominal
hollow, described by Richardson et al,4 which is intended to
focus on the recruitment of the transverse abdominis while
minimizing activation of the rectus abdominis and the obliques. Bracing has been shown to be superior to hollowing for
enhancing lumbar stability.23 Subjects were shown the technique for performing both the hollow and brace abdominal contraction, and the instruction was to perform the
brace to the same perceived intensity as a hollow. Consequently, the intensity of the contraction was fairly low, however,
since the intensity was chosen subjectively, the stability demand of
some postures may have required that study participants brace
more intensively than originally instructed. Subjects were given an
unlimited number of practice trials and once comfortable with the
technique of performing each exercise with an abdominal brace,
three successive trials were measured.

while in a sit-up position and manually braced by a research

assistant, produced a maximal isometric flexor moment followed sequentially by a right and left lateral bend moment and
then a right and left twist moment; little motion took place. For
the extensor muscles, a resisted maximum extension in the
Biering-Srensen position was performed with focus on quasistatic motion throughout neutral lordosis, which was found to
create larger neural drive. The EMG signal was normalized to
these maximal contractions, full wave rectified and low-pass
filtered with a second-order Butterworth filter. A cutoff frequency of 2.5 Hz was used to mimic the frequency response of
the torso muscles.11
Three-Dimensional Kinematic Positioning of the Lumbar
Spine. Lumbar spine kinematics was measured about three orthogonal axes using a 3 Space IsoTRAK, electromagnetic
tracking instrument (Polhemus Inc., Colchester, VT). This instrument consists of a single transmitter that was strapped to
the pelvis over the sacrum and a receiver strapped across the
ribcage, over the T12 spinous process. Thus, the position of the
ribcage relative to the sacrum was measured, isolating lumbar
motion. Overall rotation of the lumbar spine was normalized
relative to each study participants standing neutral spine posture. In this way, individual variance in the passive tissue contributions as a function of maximum range of motion was
represented. However, in this experiment, there was minimal
contribution of the passive tissue restorative moment because
of the neutral spine posture characteristic of the stabilization
exercises chosen.

Instrumentation

External Force Measures. For exercises requiring an inverse

dynamic load application, namely, the four-point kneeling exercises, back bridging exercises, and the side bridge, external
force measures were recorded using an AMTI force plate. The
signals were amplified to produce a peak to peak range of 20 V
( 10V) and then A/D converted with a 12-bit A/D converter at
1,024 Hz. Forces and moments were measured about three
axes and were used to calculate the external force center of
pressure values in the x, y, and z direction. For each exercise,
the study participant was instructed to position the contacting
segment on the force plate around the 0, 0, 0-reference point
located at the center of the force plate. Reaction forces were
measured at different parts of the upper body depending on the
exercise being performed (Figure 1). Force plate measures were
not recorded for the abdominal curl or ball sitting and chair
sitting exercises. The process of using whole body linked segment dynamics and measured external forces has been explained previously.11

Electromyography. Fourteen channels of EMG were collected from the following muscles bilaterally: rectus abdominis,
internal oblique, external oblique, latissimus dorsi, thoracic
erector spinae (longissimus thoracis and iliocostalis at T9),
lumbar erector spinae (longissimus and iliocostalis at L3), and
multifidus (1cm lateral to L5). We acknowledge the difficulty
in capturing multifidus with surface electrodes19 and therefore
assign validity of the EMG signal to the landmarked location
rather than to the multifidus muscle itself. Ag-AgCl surface
electrodes were positioned with an interelectrode distance of
about 3 cm. The EMG signals were amplified and then A/D
converted with a 12-bit, 16-channel A/D converter at 1,024
Hz. Each study participant was required to perform a maximal
contraction of each measured muscle for normalization of each
channel. For the abdominal muscles each study participant,

Kinematic Limb Positions. Kinematic marker data for each

exercise were measured from a single study participant, not
part of the group of 10 mentioned above. This study participant had a height of 178 cm and a weight of 79 kg. The external
segment kinematics were recorded for each exercise posture
with a single digital video image and guided by a space frame
jig. The isometric position of each exercise was used to analyze
the segment kinematics in the sagittal plane. The joints digitized for the kinematic analysis were the metatarsal, ankle, hip,
shoulder, elbow, wrist and hand bilaterally, as well as L4 L5
and C7T1. The kinematic posture obtained for each exercise
was controlled in the other 10 study participants with the external jig, and the marker data were scaled to the height of each
individual study participant. The joint locations about the zaxis, or in the frontal plane, were scaled to the breadth mea-

1258 Spine Volume 29 Number 11 2004

sures taken from each study participant. Since no exercise required deviations of the limbs from anatomic position in the
frontal plane, breadth measures were assumed to be constant
across exercises.

Table 2. Parameters used to calculate the contribution

of the psoas muscle to the support moment of the
extended leg for the back bridge with single leg
extension

Data Analysis
Muscle

Calculating a Stability Index. The analysis of stability was

performed using a method documented by Cholewicki and
McGill11 and involved three cascading and interdependent
models. For the interested reader, these models are described in
detail by Cholewicki and McGill,11 McGill and Norman,17
and McGill18; however, a brief description is provided here
(Figure 2, flow chart showing the modeling process for the
stability analysis).
The first model is an 8-segment link segment model that uses
external force measures recorded from the forceplate, study
participant kinematics, and anthropometrics of height and
weight to calculate reaction forces and moments acting at each
of the 6 lumbar intervertebral joints through a top-down, inverse dynamics approach. The L4 L5 moments calculated
from this linked-segment model are used to ultimately drive the
EMG-assisted optimization routine that determines the muscle
force profiles; however, this will be described in more detail
later in this section.20 The reaction forces from the link segment
model calculations are used to determine the shear and compression forces at the L4 L5 joint.
The second model is the lumbar spine model, which consists of an anatomically detailed, three-dimensional ribcage,
pelvis/sacrum, and five intervening vertebrae. More than 100
laminae of muscle and the passive tissues, which are represented as a lumped parameter of torsional stiffness, are modeled about each axis. This model uses the measured threedimensional relative spine motion data from the 3-space
IsoTRAK system and assigns the appropriate rotation to each
of the lumbar vertebral segments based on findings from White
and Panjabi.21 Muscle lengths and velocities are determined from
their motions and attachment points on the dynamic skeleton of
which the motion is driven from the directly measured lumbar
kinematics obtained from the study participant. As well, the orientation of the vertebral segments along with stress/strain relationships of the passive tissues was used to calculate the restorative
moment created by the spinal ligaments and discs.
The third model, termed the distribution-moment model,22 is used to calculate the muscle force and stiffness profiles
for each of the muscles. The model uses the normalized EMG
profile of each muscle along with the calculated values of muscle length and velocity of contraction to calculate the active
muscle force and any passive contribution from the parallel
elastic components. When input to the spine model, these muscle forces are used to calculate a moment for each of the 18 df
of the six intervertebral joints. The objective function for the
EMG-assisted optimization routine is to match the moments
with a minimal amount of change to the EMG driven force
profiles. In this way, biologic validity of using EMG is preserved while mathematical validity is addressed with achieving
balanced moments. The adjusted muscle force and stiffness
profiles are then used in the calculations of L4 L5 compression
and shear, as well as in calculating spine stability. The most
recent updates to the model, specifically regarding the much
improved representation of the transverse abdominis, are documented by Grenier and McGill.23
The value for stability, or stability index, was obtained by

Psoas
Iliacus
Rectus Femoris

Peak isometric
muscle force (N)*

Moment
arm (cm)

Relative proportion of
total hip-flexion
moment

370
430
780

2.9
3.0
4.2

0.19
0.23
0.58

* From Delp et al.26

Moment arms are measured at the hip during the mid stance phase of gait.
Arnold et al.27

calculating a level of potential energy in the spinal structure for

each of the 18 df (three rotational axes at six lumbar joints)
resulting from the combined potential energy existing in both
the active and passive spinal structures, minus any work done
from external loads. The 18 values of potential energy were
formed into an 18 18 Hessian matrix and diagonalized. The
determinant of this matrix represented an index of spine stability.
For a more detailed description of the mathematical procedures,
refer to Cholewicki and McGill11 and for sensitivity testing and
mathematical validity of the approach see Howarth et al.24
Before inputting data into the link-segment model, certain
modifications were made to both the data and the model so to
enable accurate calculations of spine load and stability for certain exercise postures. They are noted as follows:
Abdominal curl. When performing this exercise, study participants were directed to perform a curl-up such that rotation
of the upper body occurred about the base of the rib cage.
Consequently, the weight supported consisted of the head and
neck, thorax, and arms. Calculating moments about the L4 L5
joint would consider the entire torso mass and result in an
overestimation of the flexor moment required by the muscles.
To consider the true axis of rotation, the L4 L5 marker was
shifted up along the long axis of the spine to accurately represent a rotation of the thorax opposed to the trunk. A thorax
distance of 0.4 m, which is characteristic of a 75 percentile male
was used. The mass proportion assigned to the thorax was
0.216 of body mass.25 For this exercise only, the abdomen
segment was considered a rigid segment and the thorax moment was then translated to the L4 L5 joint, recognizing that
the rectus abdominis carries equal loading along its length.
Bridging with single leg extension. In this exercise, the internal oblique activation profile did not accurately represent that
of the psoas muscle because of the extended leg. To account for
the extra force necessary to support the extended leg, the psoas
force in the lifted leg was calculated as a proportion of the
moment supporting the leg, which was assumed to be primarily
generated from combined action of the rectus femoris, iliacus,
and psoas. The moment arms and peak isometric muscle forces
used to calculate the proportions for the three listed muscles
were obtained from the literature (Table 2).26,27 Then, for each
study participant, the support moment required to maintain
the posture of the lifted leg was calculated. This moment was
then multiplied by a proportionality constant for psoas and
divided by its moment arm. The resulting force value was input
into the 18 df lumbar spine model (Figure 2) by adding it
directly to the compressive force acting on the spine, consistent
with the psoas line of action.28

Torso Muscles and Rehabilitation Exercises Kavcic et al 1259

Figure 3. Sinusoidal muscle activation profile from 0 to 100%

MVC (A) and the associated
change in the stability index
when manipulating each muscle
EMG profile (B). RL corresponds
to the muscle on both the right
and left side. Rect rectus abdominis; Ext external oblique;
Int internal oblique; Pars
pars lumborum fibers of longissimus thoracis and iliocostalis
lumborum; Ilio thoracic fibers
of iliocostalis lumborum; Long
thoracic fibers of longissimus
thoracis; Quad quadratus lumborum; Lat latissimus dorsi;
Mult multifidus; Trans
transversus abdominis.

Determining a Muscles Impact on Spine Stability. The

contribution of each individual muscle to spine stability was
evaluated in the following way. A value of external force and
muscle activation for each muscle was taken at a point in time
corresponding to the 1-second point of each 2-second trial.
This profile was then frozen and extended for the entire
duration of the 2-second trial. The activation profile for all
fascicles of a single muscle of interest, or target muscle, was
then replaced by a sinusoid wave that varied from 0% to 100%
MVC (Figure 3A), and the analysis was run with the new muscle profile. A sinusoid wave was originally chosen as an input
because it was thought that some muscles would demonstrate
more control over stability than others. Control of spine stability would be reflected by a strong correlation between
changes in stability with changes in muscle activation. In those
muscles that had little control over spine stability, the sinusoidal pattern would be less evident in the stability output. A

sinusoid was chosen as a very specific input that could be identified in the output. Through a pilot analysis, however, there
appeared to be no significant difference in how closely stability
followed muscle activation across the various muscles tested;
therefore, this analysis was not performed.
The specific target muscles assessed were the rectus abdominis, external oblique, internal oblique, pars lumborum fibers of
longissimus thoracis and iliocostalis lumborum, thoracic fibers
of iliocostalis lumborum, longissimus thoracis, quadratus lumborum, latissimus dorsi, multifidus, and transverse abdominis.
This analysis was systematically repeated for each muscle, one
at a time, both unilaterally and bilaterally. To isolate the effect
of each target single muscle at this level of analysis, the EMGassisted optimization routine (Figure 2), used to balance the
moments, was not used. This prevented the force and stiffness
profiles of the other muscles from changing. In effect, this pro-

1260 Spine Volume 29 Number 11 2004

Figure 4. A, Increase in stability

index resulting from activating a
muscle bilaterally to 100% MVC.
B, Decrease in stability index resulting from turning a muscle off
bilaterally to 0% MVC. Across
tasks there is no consistent pattern in the ability of the different
muscles to affect stability. However, it appears as though,
across the larger muscles, increased activation of the moment antagonist enhances stability and decreased activation of
the moment agonist reduces
stability.
cedure allowed each muscle to be rattled and the subsequent
effect of this perturbation on the spine assessed.
The artificial sinusoidal activation profile impacted many
variables within the analysis; however, the effect was only
quantified in certain variables of interest: namely, muscle force,
muscle stiffness, spine loads, and the stability index. The maximum increase and decrease in these variables, resulting from
the sinusoidal manipulation, were computed and compared to
a nonmanipulated control trial.
In an attempt to better understand the different mechanical
advantages for each of the muscles to stabilize, the RMS difference was calculated across each stability index curve resulting
from the manipulated muscle activation profile, as well as
across the corresponding muscle force curve. The RMS difference was used to quantify of the magnitude of fluctuation
within the particular curve. The force RMS difference was then
divided into the stability index RMS difference. In this sense, an

efficiency ratio was created to describe the coupling between

the fluctuations in the force of a particular muscle and the
corresponding fluctuations in spine stability.

Results
The effect of the sinusoidal EMG activation profile on the
calculated stability index is shown for each muscle in
Figure 3B The stability index for each manipulated muscle is superimposed on the same graph.
Assessing the Absolute Impact of a Single Muscle on
Lumbar Spine Stability
The effect of increasing each muscle activation profile to
100% MVC on increasing the stability index is shown in
Figure 4A, whereas the effect from decreasing muscle
activation to 0% MVC is shown in Figure 4B. A major

Torso Muscles and Rehabilitation Exercises Kavcic et al 1261

finding in the analysis is that, between the different tasks,

there is no consistent pattern across muscles in their ability to affect stability. This is particularly evident with
some of the larger muscles, such as the rectus abdominis
and the lumbar and thoracic extensors. In contrast, the
quadratus lumborum, latissimus dorsi, multifidus, and
transverse abdominis demonstrated only small changes
in their relative patterns in terms of both increasing and
decreasing stability.
Quantification of each muscles absolute impact on
the stability index shows that, compared with the rectus
abdominis, obliques, and lumbar and thoracic extensors,
the quadratus lumborum, latissimus dorsi, multifidus,
and transverse abdominis each created minimal changes.
In contrast, both the internal and external obliques consistently demonstrated a large impact on both increasing
and decreasing stability irrespective of the task condition. Between the two muscles, a more dramatic effect
was produced from the internal obliques. One important
note is that in the stabilization exercises assessed, no
individual muscle, either unilaterally or bilaterally, when
artificially reduced in activation, created an unstable
situation.
An interesting result is that certain muscles demonstrated a direction-dependent effect on lumbar spine stability. Specifically, coactivation of what would be considered an antagonist, in a torque context, enhances
stability. Compare the rank order of the predominant
flexor: rectus abdominis versus the major lumbar extensors, pars lumborum, iliocostalis lumborum, and longissimus thoracis. In the abdominal curl, which is a flexion
dominant task (Table 1), the three extensor muscles
demonstrate a greater effect on increasing the stability
index compared with the rectus abdominis. However,
this pattern is reversed when quantifying each muscles
ability to reduce spine stability. In contrast, during the
extension dominant tasks (Table 1), the rectus abdominis creates a greater increase in stability over the pars
lumborum and longissimus thoracis. For the iliocostalis,
lumborum, this pattern is not so evident; however, careful examination shows that across the extension dominant tasks, as the required support moment increases,
the relative difference between the effects of the rectus
abdominis and the iliocostalis lumborum decreases. As
with the abdominal curl, when the activation levels are
reduced to 0% MVC, the pattern between the flexors
and extensors reverses.
The same association observed between the flexor and
extensor muscle groups is observed between certain right
versus left muscle groups during asymmetric tasks such as
the four-point kneeling tasks and side bridge (Figure 5).
It should be noted that the above results refer to group
means calculated from the 10 study participants. Across
the individual study participants, the pattern of muscle
impact on stability was not consistent for any given task;
however, the direction-dependent effect observed among
the group means exists at an individual level as well.

Assessment of a Potential Mechanical Stabilizing

Mechanism for Each of the Different Muscles
The cost of certain muscles to stabilize is demonstrated in
Figure 6. These figures show that the larger muscles, such
as the rectus abdominis, obliques, and upper and lower
erectors, impose larger changes in L4 L5 load compared
with the other muscles tested. Given this, the final analysis assesses the efficiency with which each muscle can
translate their respective generated force to spine stability (Figure 7). Those muscles with higher values of the
efficiency ratio have a greater normalized contribution
to spine stability for a given change in muscle force. In
contrast to the absolute impact of the various muscles to
spine stability, large efficiency ratios were observed in the
multifidus, quadratus lumborum and transverse abdominis, internal and external oblique, and iliocostalis lumborum produced. Relatively smaller values were observed in the rectus abdominis, pars lumborum,
longissimus thoracis, and latissimus dorsi.
Discussion
Clearly, there is no single muscle that is superior at enhancing spine stability. In addition, the muscle manipulation method described here has provided insight into
the potential neuromuscular control of lumbar spine stability. Results of this analysis indicate that muscles in the
trunk play several roles at once and that their roles depend on the instantaneous demand placed on the spinal
column. Generally, those muscles that were antagonist to
the dominant moment of the task were most effective at
increasing stability. This finding supports the directiondependent cocontraction pattern that has been reported
in the more global muscles during different tasks.14,29,30
The greatest reductions in stability were observed when
muscles that opposed the dominant destabilizing forces
were inactivated. For example, in a lateral bending task
such as the right side bridge, the dominant external force
at the spine is the ground reaction force acting at the
forearm that forces the L4 L5 joint in a left lateral bend.
The right abdominal muscles are activated not only to
oppose the left lateral bend moment to support the totalbody posture, but at the level of a single lumbar joint,
they potentially also protect against an instantaneous
instability resulting from an excessive rotation in lateral
bend. During an in vivo study by Cholewicki and
McGill,31 the authors observed a temporary excessive
vertebral flexion in a powerlifter who incurred an injury
while lifting. The authors hypothesized that a motor control error in a crucial back muscle may have been responsible for the excessive flexion instability. These temporary reductions may prevent those muscles, whose job
during a particular task is to oppose crucial destabilizing
forces and rotational instabilities, from controlling vertebral motion. As the destabilizing forces on the spine
change through different postures, so do the muscles that
are able to oppose these forces.

1262 Spine Volume 29 Number 11 2004

Figure 5. Increase in stability index resulting from activating a

muscle unilaterally to 100% MVC.
A, Results are shown for two
asymmetrical tasks. B, Decrease
in stability index resulting from
turning a muscle off bilaterally to
0% MVC. Results are shown for
two asymmetrical tasks. The
same pattern observed between
agonist and antagonist muscles
noted in Figure 4 is observed between right and left muscles during asymmetrical tasks. R corresponds to the muscle on the right
side; L corresponds to the muscle on the left side.

Across the various torso muscles, the mechanical advantage to provide stability to the lumbar spine varies
depending on the muscle. It appears as though, on average, the larger, more global muscles are better able to
alter spine stability than the smaller, intersegmental muscles. This is most likely because of the larger forcegenerating potential in these muscles and their ability to
generate higher levels of L4 L5 compression, translating
to higher levels of spine stiffness. As well, their larger
moment arms enhance their ability to act as guy wires.
Interestingly, the increase in compressive loads on the
spine that result from muscular cocontraction has been
estimated to increase stability at a higher rate than the
additional compression. Specifically, Granata and Marras32 have estimated that stability is enhanced threefold

for a given increase in compression, whereas Grenier and

McGill23 have computed the enhancement to be at least
twofold. It would appear that the qualitative assumption
that activating muscles that impose low compressive
loads as prime stabilizers is problematic when evaluating
a quantitative stability analysis. Among the more local
muscles, it is interesting to observe the minor ability of
the transverse abdominis to alter spine stability when
manipulated through its entire force- and stiffnessgenerating abilities.
The mechanical advantage for the smaller, intersegmental muscles, particularly the multifidus, and quadratus lumborum, appears to come from their efficient translation of generated force to spine stiffness and stability.
These results can potentially be explained by a phenom-

Torso Muscles and Rehabilitation Exercises Kavcic et al 1263

Figure 6. A, Increase in L4 L5 compression resulting from activating a muscle bilaterally to 100% MVC. B, Decrease in L4 L5 compression
resulting from turning a muscle off bilaterally to 0% MVC. The larger, multisegmental muscles stabilize through their ability to generate
high levels of L4 L5 compression, which is associated with increased levels of spine stiffness, together with their action as guy wires
enhancing the systems potential energy.

enon known as the follower load, described by Patwardhan et al.33,34 According to this theory, those muscles that insert onto the spinal segments are better able to
translate their generated force along the compressive axis
of the spine or tangent to the curve of the lumbar spine.
It is important to note that previous work by Crisco and
Panjabi10 reported the opposite, in that the more multisegmental muscles are more efficient at creating a critical
level of lumbar spine stiffness over the intersegmental
muscles. The discrepancy in findings, however, is consistent with the different models used. In their study, the
lumbar spine was modeled as a straight elastic column
with motion restrained to the frontal plane. With such a
linear model, a given level of activation in the multisegmental muscles would impact many joints, whereas the

intersegmental muscles may only affect one or two joints,

as they described. In our analysis, the spine was modeled
with a natural lordotic curvature and motion existed in a
total of 18 df The ability of the intersegmental muscles to
follow the curvature of the spine and direct a large component of force along the compressive axis is how the
efficiency of these muscles dominated over the more multisegmental muscles.
When attempting to apply the results of this study to
clinical practice, consideration of the physiologic relevance of this technique is necessary. In a human neuromuscular system, muscle synergies exist, where changes
in a given muscle activation level rarely occur in isolation
but rather are associated with changes in that of other
muscles. For example, Richardson and Jull35 reported

1264 Spine Volume 29 Number 11 2004

Figure 7. RMS of stability curve normalized to RMS of muscle force curves. One mechanism explaining how the smaller, intersegmental
muscles stabilize could result from their ability to efficiently translate their respective generated force to spine stability.

that activation of the multifidus is linked to that of the

transverse abdominis. In order to accurately assess the
stabilizing role of a given muscle and represent physiologic reality, synergistic patterns need to be considered.
Since this study examined the effect of changing a single
muscle, this could be considered a limitation in terms of
assessing synergies. Assessing the consequence of synergies is much more difficult given the many roles each
component muscle plays, but it is our objective to examine this in the future. The benefit of this analysis, however, is to address the clinical misconception that at any
given moment a single muscle can provide the necessary
stability to the lumbar spine. One finding observed in this
analysis was that no single muscle, when manipulated
from 0% to 100% MVC, created an unstable spine. It
does not seem reasonable then that any one muscle in
isolation has the capabilities to dramatically impact
spine stability, at least in the stability exercises tested
here, although we have found some low challenge tasks
where this is not the case. This study showed that as
loads are applied to the spine there is an integration of
the many different muscles in order to balance the stability and moment demands, and these patterns change as
the spine loading patterns change.
One feature of this technique was that it was successful
at identifying the total contribution that each muscle can
make to stability, relative to the other torso muscles tested.
In this light, it is noticed that the smaller muscles have a
stabilizing role through their efficient generation of force,
however, as loads increase the need for the stronger global
muscles is required. One important note is that only the
contributions of the muscles force profiles to stability were
assessed. Other potential roles that influence stability such
as proprioceptive integration or passive-elastic link with
intra-abdominal pressure were not assessed.

Another benefit of manipulating a muscle in isolation

is that the changes created in stability can be associated
with only the manipulated muscle. Allowing an optimization routine to balance the muscle force moments to
the external moments would have caused changes in the
force profiles of various muscles, and associating these
changes to that observed in the stability index would be
a difficult task.
Many assumptions were made in this study as a result
of the biomechanical modeling procedure used. Assumptions made in the biomechanical models used in this
analysis have been documented previously,11 and while
great attempts were made to achieve biofidelity, this
highly complex analysis could not be performed without
them. Lastly, the conclusions of this work are limited to
the contrived stability exercises tested. One important
note is that in the abdominal curl exercise, the actual
torque is generated at the level of the midthoracic spine;
however, in this analysis, in order to assess the stabilizing
ability of the different muscles in the lumbar spine during
a flexion task, the moment created at the thoracic level
was translated to the lumbar spine. Given that the study
participants were fully supported laying supine on the
floor, the individual muscle contributions to lumbar
spine stability during the type of abdominal curl performed here remain unknown.
In terms of the practical application of the findings in
this study pertaining to prevention and rehabilitation,
the clinical practice of isolated training of a specific muscle or group of muscles in attempts to reduce the compressive costs must be questioned. According to the results of this study, it appears justifiable to train motor
patterns that involve the contribution of many of the
potentially important lumbar spine stabilizers. This seems
to be the case since although some of the highly regarded

Torso Muscles and Rehabilitation Exercises Kavcic et al 1265

local muscles can create stability very efficiently, their absolute contribution is not dominating and may not be sufficient during functional tasks. Focusing on a single muscle,
or only a few, appears to be misdirected clinical effort if the
goal is to ensure a stable spine.
Key Points
Using various assumptions and variations to a
biomechanical model, assessment of the stabilizing
role of different muscles was quantified for different
loading scenarios.
The role of each individual lumbar muscle
changes as the loads placed on the spine changes.
Consideration should be given to each potential
stabilizer when designing exercise programs intended to increase spine stability.

References
1. McGill S. Low Back Disorders: Evidence-Based Prevention and Rehabilitation. Champaign, IL: Human Kinetics, 2002:143.
2. Panjabi MM, Abumi K, Duranceau J, et al. Spinal stability and intersegmental muscle forces: a biomechanical model. Spine. 1989;14:194 200.
3. Bergmark A. Stability of the lumbar spine: a study in mechanical engineering.
Acta Orthop Scand Suppl. 1989;60:154.
4. Richardson C, Jull G, Hodges P, et al. Therapeutic exercise for spinal segmental stabilization. In: Lower Back Pain. London: Harcourt Brace, 1999.
5. Hodges PW, Richardson CA. Feedforward contraction of transverse abdominis is not influenced by the direction of arm movement. Exp Brain Res.
1997;114:362370.
6. Hodges PW, Richardson CA. Delayed postural contraction of transverse
abdominis in low back pain associated with movement of the lower limb.
J Spinal Disord. 1998;1:46 56.
7. Hides JA, Stokes MJ, Saide M, et al. Evidence of lumbar multifidus muscle
wasting ipsilateral to symptoms in patients with acute/subacute low back
pain. Spine 1994;19:165172.
8. Panjabi M, Abumi K, Duranceau J, et al. Spine stability and intersegmental
muscle forces: a biomechanical model. Spine. 1989;14:194 200.
9. Wilke HJ, Wolf S, Claes LE, et al. Stability increase of the lumbar spine with
different muscle groups: a biomechanical In vitro study. Spine. 1995;20:192
198.
10. Crisco JJ, Panjabi M, The intersegmental and multisegmental muscles of the
lumbar spine: a biomechanical model comparing lateral stabilizing potential.
Spine 1991;16:793799.
11. Cholewicki J, McGill S. Mechanical stability of the In vivo lumbar spine:
implications for injury and chronic low back pain. Clin Biomech. 1996;11:
115.
12. Cholewicki J, VanVliet J IV. Relative contribution of trunk muscles to the
stability of the lumbar spine during isometric exertions. Clin Biomech. 2002;
17:99 105.

13. Cholewicki J, Simons A, Radebold A. Effects of external trunk loads on

lumbar spine stability. J Biomech. 2000;33:13771385.
14. Gardner-Morse M, Stokes I. Trunk stiffness increases with steady-state effort. J Biomech. 2001;34:457 463.
15. Gardner-Mores M, Stokes I. The effects of abdominal muscle coactivation on
lumbar spine stability. Spine. 1998;23:86 92.
16. Granata K, Orishimo K. Response of trunk muscle coactivation to changes in
spinal stability. J Biomech. 2001;34:11171123.
17. McGill S, Norman R. Partitioning of the L4 L5 dynamic moment into disc,
ligamentous and muscular components during lifting. Spine. 1986;11:666
677.
18. McGill S. A myoelectrically based dynamic three-dimensional model to predict loads on lumbar spine tissues during lateral bending. J Biomech. 1992;
25:395 414.
19. Stokes I, Henry S, Single R. Surface EMG electrodes do not accurately record
from lumbar multifidus muscles. Clin Biomech. 2003;18:9 13.
20. Cholewicki J, McGill S. Relationship between muscle force and stiffness in
the whole mammalian muscle: a simulation study. J Biomech Eng. 1995;117:
339 342.
21. White A, Panjabi M. Clinical Biomechanics of the Spine. Philadelphia: Lippincott, 1978:79.
22. Ma SP, Zahalak GI. A distribution-moment model of energetics in skeletal
muscle. J Biomech. 1991;24:2135.
23. Grenier S, McGill S. Lumbar spine stability from hollowing vs. bracing:
the transverse abdominis is no more important than any other muscle to
ensure lumbar stability. Submitted.
24. Howarth S, Allison A, Grenier S, et al. On the implications of interpreting the
stability index: a spine example. J Biomed. In press.
25. Winter DA. Biomechanics and Motor Control of Human Movement, 2nd ed.
Toronto: John Wiley and Sons, 1990:56 57.
26. Delp SL, Loan JP, Hoy MG, et al. An interactive graphics-based model of the
lower extremity to study orthopaedic surgical procedures. IEEE Trans
Biomed Eng 1990;37:757759.
27. Arnold A, Salinas S, Asajawa D, et al. Accuracy of muscle moment arms
estimated from MRI-based musculoskeletal models of the lower extremity.
Comput Aided Surg 2000;5:108 119.
28. Santaguida PL, McGill SM. The psoas major muscle: a three-dimensional
geometric study. J Biomech. 1995;28:339 345.
29. Thomas JS, Lavender SA, Corcos DM, et al. Trunk kinematics and trunk
muscle activity during a rapidly applied load. J Electromyogr Kinesiol. 1998;
8:215225.
30. McGill S. Electromyographic activity of the abdominal and low back musculature during generation of isometric and dynamic axial trunk torque:
implications for lumbar mechanics. J Orthop Res. 1991;9:91103.
31. Cholewicki J, McGill S. Lumbar posterior ligament involvement during extremely heavy lifts estimated from fluoroscopic measurements. J Biomech.
1992;25:1728.
32. Granata KP, Marras WS. Cost-benefit of muscle cocontraction in protecting
against spinal instability. Spine. 2000;25:1398 1404.
33. Patwardhan AG, Harvey R, Ghanayem A, et al. A follower load increases the
load-carrying capacity of the lumbar spine in compression. Spine. 1999;24:
10031009.
34. Patwardhan AG, Meade KP, Lee B. A frontal plane model of the lumbar
spine subjected to a follower load: implications for the role of muscles.
J Biomech Eng. 2001;123:212217.
35. Richardson C, Jull G. Muscle control-pain control: what exercises would
you prescribe? Man Ther. 1995;1:210.