ACTIVATION OF

THE DEEP ABDOMINALS

Is it more effective in standing or crook lying?
This article seeks to answer the question of whether activation of the deep abdominals is more
effective in a functional position such as standing or in a more traditional Pilates position of crook
lying. The study aimed to determine whether transversus abdominis (TrA) demonstrates greater
activity on lower abdominal hollowing (LAH) in standing compared with crook lying, and with greater
specificity in relation to the internal oblique (IO) and external oblique (EO). Subjects performed LAH in
crook lying and standing. Muscle activity of TrA, IO and EO was measured using real-time ultrasound
at rest and during LAH, and compared between the two postures. Changes in thickness due to
involuntary postural tone, with the subject at rest, were also compared between the two postures.
TrA showed significantly greater activity on LAH in standing compared with crook lying, and with
greater specificity in relation to IO and EO.
BY ROSIE MEW BSC, MSC, MCSP, MMACP
INTRODUCTION
Although the exact underlying mechanisms
remain unclear, in recent years there has been
increasing evidence to support Panjabis model
of spinal instability to explain the development
of lower back pain (LBP) (1). This proposed that
an inability of the spinal and paraspinal muscles
to maintain neutral vertebral alignment results in
a loss of segmental spinal stability leading to pain.
Richardson and colleagues suggest that this loss of
spinal stability is due to a dysfunction in the control
of the core stabilising muscles, such as transversus
abdominis (TrA) (2), and it has frequently been found in
people with LBP (3, 4). TrA activity has been found to
precede limb movement in normal people, suggesting it has
a protecting or stabilising function, preparing the spine before
loading, that is absent in people with LBP (5, 6).
As a result, over the past decade much LBP rehabilitation
12 sportEX medicine 2011;49(July):12-18 12
has been aimed at improving the activity of these stabilising
muscle groups. Exercises termed core stability
exercises have been developed to support the
spinal segment by enhancing muscle control to
compensate for any loss of segmental stability
due to injury or degenerative changes. Targeting
the core abdominal muscles using lower
abdominal hollowing (LAH) has been shown to
preferentially activate TrA relative to the more
superficial lateral abdominal muscles (7, 8). Core
stability exercises and the use of LAH have
been shown to be effective in the treatment of
LBP (9, 4), while OSullivan and colleagues found that
spinal stabilisation exercises significantly reduced LBP and
disability (10), and with fewer recurrences of LBP in the long
term (11, 12).
However, much of the early research into LAH used
positions such as supine, prone and four-point kneeling (13,
14), and therapists have often directly imitated this early
experimental work into their clinical practice. This, along
with the recent popularity and celebrity endorsement of
Pilates, has resulted in the majority of core stability work
often being practised in postures of greater support, such as
supine lying, crook lying and side lying. There is now growing
evidence to contradict this and support the theory that
postures of greater function, such as standing, provide more
effective activation of the deep abdominals (13). Urquhart and
colleagues observed delays in abdominal muscle activity
on arm movement in sitting when compared with the same
action in standing (15). Meanwhile, studies on the external
LAH IN STANDING PRODUCED
SIGNIFICANTLY GREATER
INCREASES IN TRANSVERSUS
ABDOMINIS THICKNESS COMPARED
WITH CROOK LYING
EVIDENCE UPDATE LBP REHABI LI TATI ON
obliques (EO) have highlighted delays in EO recruitment in
sitting in a study by Moore et al. (16) compared with a similar
activity in standing in a study by Hodges and Richardson (17).
There is, however, little research that directly compares TrA
function between different body positions or that investigates
which body position or posture is preferential for TrA
activation.
Due to its depth within the abdominal wall, reliable
evaluation of TrA activity is challenging. Fine-wire
electromyography (EMG) recordings are
impractical in the clinical setting, and TrA
cannot be isolated with surface EMG (14).
Contraction of the muscle fibre results
in an increased cross-sectional area
and, due to the low forces involved
with LAH, will result in minimal tendon
stiffness and large changes in muscle
geometry (18), seen as increases in
muscle thickness (19). Measuring this change
in muscle thickness using real-time ultrasound
imaging has demonstrated consistent correlations with EMG
activity in TrA (19). Hodges and colleagues found consistent
correlations between ultrasound muscle thickness changes
and fine-wire EMG with sensitivity as low as 12% maximum
voluntary contractions (MVC) in TrA and 22% MVC in the
internal obliques (IO) but showed no such correlation for EO
(18). This recent growth in supporting evidence has resulted
in an increase in the use of ultrasound in the clinical setting
as a tool to examine changes in muscle function in response
to specific tasks such as LAH. However, to date much of the
available research has been done in crook lying and other
non-functional positions, and as yet there is little literature in
relation to more functional postures such as standing.
This investigation compares deep abdominal muscle
activity during LAH by measuring muscle thickness changes
with real-time ultrasound. The aim was to determine
whether TrA showed greater changes on activity in a
functional position, such as standing, compared with a less
functional but more supportive posture, crook lying, and with
greater specificity in relation to IO and EO. The aim was to
determine which posture showed greater changes in TrA
thickness between rest and during LAH, relative to IO and
EO. A secondary aim of this investigation was to compare
changes in resting involuntary postural tone between the two
postures.
METHOD
Subjects
A total of 28 healthy voluntary subjects were recruited
from staff and students of the University College London (14
females, 14 males, age 2142 years). An information sheet
was provided and all subjects signed informed consent.
Exclusion criteria were a history of pelvic or abdominal
surgery, current LBP and pregnancy. All subjects completed
a questionnaire recording their gender, age, height, weight,
level of physical activity, and a history of any previous LBP.
Of the 28 participants, 14 were noted to have some previous
experience of TrA training (trained subjects) and 14 had
none (untrained subjects); 6 subjects were noted to have
13 www.sportEX.net 13
POSTURES OF GREATER
FUNCTION, SUCH AS STANDING,
PROVIDE MORE EFFECTIVE ACTIVATION
OF THE DEEP
ABDOMINALS
14
a previous history of LBP. The study was approved by the
university research ethics committee.
Measurements
The two controlled postures compared were crook lying
(supine lying with neutral lumbar spine and 60 degrees
hip flexion) and standing (feet hip width apart and neutral
lumbar spine). The starting posture and starting muscle
state (i.e. resting or during LAH) were randomised each time.
Ultrasound imaging was performed using a high-frequency
(1022 MHz) 26-mm linear array transducer head (Diasus,
Livingston, UK). The transducer head location was marked
on the right-hand side of each subject midway between the
lowest rib and the apex of the ilium, which has been shown
to be the thickest point of TrA (20) and demonstrates the
clearest image of TrA, IO and EO simultaneously (14). Small
multidirectional movements ( 26mm) from this location were
permitted to optimise the scan image.
Relaxed muscle state imaging was collected at the end
of inspiration, when TrA is at its thinnest (21). The ultrasound
scan image was frozen and muscle thicknesses of TrA, IO
and EO were measured by a blinded reviewer with three
repeats in crook lying and standing. LAH was performed
following the guidelines of Richardson and Jull (3), by getting
subjects to gently draw in their lower abdomen. This was
performed in conjunction with a gentle pelvic floor initiation,
as this has been found to assist TrA activation (22). The
image was frozen again and muscle thicknesses measured
by a blinded reviewer with three repeats in crook lying and
standing.
Changes in the resting, relaxed muscle state thickness,
when the subjects were at rest, were also noted between
the two postures. Any change in muscle thickness between
the two postures should therefore be due to changes in
postural tone or involuntary activation alone in the three
muscles.
Data analysis
The changes in muscle thickness of TrA, IO and EO, between
rest and during LAH, were compared between crook lying
and standing. These changes were analysed using the paired
Student t-test. Changes in the resting muscle thickness
between the two postures due to involuntary postural
tone were also applied to the paired Student t-test. Where
changes in the three muscles were compared, significance
levels were adjusted to P0.017 (Bonferroni correction).
Demographic data regarding population group variances were
collected via questionnaires and analysed using the unpaired
t-test. Subgroup analysis also compared gender, trained
versus untrained subjects, and previous history versus no
previous history of LBP.
Reliability testing
Good intra-rater reliability was demonstrated for the three
blinded repeat muscle thickness measurements for each
muscle, while relaxed and during LAH, and in both postures
in six sets of data, with intraclass correlation coefficient
(ICC) results between 0.98 and 0.99, and a standard error
of measurement of 0.26mm. Varying the order of the
starting posture or muscle state demonstrated no significant
difference (range of P-values 0.980.99).
RESULTS
Lower abdominal hollowing
Greater changes in TrA thickness from rest to during LAH
were seen in standing by 54% (+0.88mm 0.12mm) over
crook lying (Table 1, Figures 1 and 2). Meanwhile, IO and
EO demonstrated greater thickness changes on LAH in
Mean muscle
thickness (mm)
Crook Standing Difference SEM P
lying
3.71 4.48
5.34 7.00
1.63 2.51 0.88 0.12 0.0000002

8.02 8.85
9.33 9.57
1.31 0.72 0.59 0.08 0.00101

5.76 5.83
6.13 5.32
0.37 0.51 0.87 0.12 0.00003
TrA At rest
During LAH
Change in
thickness
IO At rest
During LAH
Change in
thickness
EO At rest
During LAH
Change in
thickness
TABLE 1: MEAN MUSCLE THICKNESSES AT REST AND DURING
LOWER ABDOMINAL HOLLOWING (LAH) IN TRANSVERSUS
ABDOMINIS (TRA), INTERNAL OBLIQUE (IO) AND EXTERNAL
OBLIQUE (EO) IN CROOK LYING AND STANDING (N=28), WITH
CHANGE IN MUSCLE THICKNESS, DIFFERENCE BETWEEN
STANDING AND CROOK LYING, STANDARD ERROR MEAN (SEM)
AND P-VALUE.
Figure 1: Ultrasound image of right lateral abdominal wall (a) relaxed state (b)
contracted state during lower abdominal hollowing
(a) (b)
THESE FINDINGS HAVE
SIGNIFICANT IMPORTANCE FOR
FUTURE ABDOMINAL CORE STABILITY
RETRAINING FOR PEOPLE WITH
LUMBOPELVIC DISORDERS.
sportEX medicine 2011;49(July):12-18
crook lying (+0.59mm 0.08mm and 0.87mm 0.12mm,
respectively), with a thinning of EO noted on LAH in standing.
The means of TrA, IO and EO were significantly different
between crook lying and standing (P<0.001).
Resting involuntary postural tone
All three muscles demonstrated a greater resting involuntary
postural tone thickness in standing compared with crook
lying (Table 1, Figures 1 and 3). TrA increased by 20.7%
(+0.77mm 0.10), IO by 10.3% (+0.83mm 0.11), and EO by
1.2% (+0.07mm 0.01) (Table 1, Figure 3). Significant difference
was demonstrated between TrA and EO (P=0.004) but not
between TrA and IO, or IO and EO.
Population variances
No significant differences were noted with any of the
variances within the population group, including age, height,
weight and level of physical activity; or between the different
subgroups of gender, trained and untrained subjects, and
previous history and no history of LBP. No significant
difference to the results obtained was seen by completely
removing subjects with a history of LBP from the study
(P=0.71).
A previous history of LBP seems to correlate with a
slightly reduced resting TrA thickness (0.22mm), but there
was no significant difference seen with these subjects
during LAH (0.80mm and 0.99mm, P=0.53). Subjects with
previous training in LAH showed a greater mean increases
in TrA thickness than untrained subjects. but not significantly
(1.10mm and 0.66mm, respectively, P=0.09), and no
significance was seen with IO (0.56mm and 0.62mm, P=0.85)
and EO (0.81mm and 0.94mm, P=0.72). Male subjects had
a slightly larger resting TrA thickness than female subjects
(0.08mm), but no significant difference was seen on LAH
(males 0.93mm, females 0.85mm, P=0.74).
DISCUSSION
Lower abdominal hollowing
Lower abdominal hollowing in standing produced significantly
greater increases in TrA thickness, with reduced thicknesses
in both IO and EO, compared with crook lying. If changes
in muscle architecture or thickness can be an indicator
of muscle function or activity, then this suggests that
LAH in standing produces a greater activation of TrA and
with greater specificity to TrA, resulting in less IO and EO
activation, compared with crook lying.
These findings may be explained by a greater
gravitational pull upon the abdomen in standing than in crook
lying. This may result in increased feedback from TrA muscle
stretch receptors, so raising the excitability of its motor
neuron pool, resulting in TrA recruitment on LAH (13). In crook
lying with hip flexion, this gravitational pull will be reduced,
so making recruitment of TrA and IO in isolation more
demanding, and therefore possibly increasing the need for
EO recruitment to assist in LAH. Meanwhile, EO, being a more
global mobilising muscle, will be less responsive to the low
forces involved with LAH, and the passive stretch in standing
could instead result in a lengthening and thinning of EO.
Due to the constraints of the ribs and iliac crest, increased
EVIDENCE UPDATE LBP REHABI LI TATI ON
C
h
a
n
g
e

i
n

m
u
s
c
l
e

t
h
i
c
k
n
e
s
s

(
m
m
)
Lying Standing
TrA 1o E
3.0
2.5
2.0
1.5
1.0
-1.0
0.5
-0.5
0.0
Figure 2: Change in
muscle thickness
during lower
abdominal hollowing
(LAH) in transversus
abdominis (TrA),
internal oblique
(IO) and external
oblique (EO) in
crook lying and
standing (n=28).
Error bars show
standard error
mean (SEM)
15 www.sportEX.net
10
9
8
7
6
5
4
3
2
1
0
M
u
s
c
l
e

t
h
i
c
k
n
e
s
s

(
m
m
)
Crook lying Standing
TvA IO EO
Figure 3: Muscle
thickness (mm)
of transverse
abdominis (TrA),
internal oblique (IO)
and external oblique
(EO) at rest in crook
lying and standing
(n=28). Error bars
show standard error
mean (SEM)
POSITIONS OF GREATER FUNCTION
APPEAR TO PROVIDE MORE
EFFECTIVE ACTIVATION OF TRA
TrA and IO thickness on LAH could also create a relative
crushing force upon the more passive EO, resulting in
this apparent thinning.
These findings appear to support the initial
theory of this present investigation that LAH in
standing is more specific to TrA, and possibly
IO, with less EO involvement. However, although
Hodges and colleagues found that TrA and IO
showed consistent thickness changes with
incremental changes in activity less than 20%
MVC (18), EO showed no such correlation, implying
that it does not get thicker on contraction at low-
level MVC. Hodges and colleagues proposed that
although transversely oriented abdominal muscles may
experience greater shortening, the more oblique orientation
of EO may result in less shortening on isometric contraction,
or it may increase in breadth rather than thickness. They
therefore suggested that their findings in relation to EO
were non-conclusive and should be ignored. Hodges and
colleagues study, however, was performed on only three
subjects, and possible correlations between low-level EO
activity and muscle length can be noted in one of the three
subjects. Therefore, more research is required in this area
before we can conclude that there is no correlation between
EO muscle thickness and its activity levels.
The increase in TrA thickness by 54% on LAH in
standing is similar to recent abdominal ultrasound studies.
Springer and colleagues observed a 52% increase in mean
TrA thickness during abdominal drawing-in (7). Teyhan and
colleagues found a two-fold increase in TrA thickness at
pre-training and post-training of LAH and on follow-up 4 days
later (8). The relative lack of change in IO and EO seen in
their study further validates the use of LAH as a fundamental
component of core stability retraining when preferentially
activating TrA.
Resting involuntary postural tone
TrA demonstrated the greatest increase in involuntary postural
tone (Figures 1 and 3), supporting current beliefs that it is
a primary postural muscle that increases its activity when
the challenge to stability is increased. EO demonstrated
the least increase in involuntary postural tone in standing
and was significantly different from TrA. This reinforces the
theory that EO is a mobilising muscle initiated with higher
levels of force, less affected by postural changes, and with
little stabilising function. Beith and colleagues found similar
changes in the relaxed muscle thickness of TrA and IO in
standing but not with EO (23), suggesting that at rest EO
plays no role in stabilising the spine. Meanwhile, IO showed no
significant difference from either TrA or EO, suggesting that
it may possess some dual stabilising and mobilising roles.
Demographic questionnaire data
No significant differences were noted due to previous TrA
training or LBP, gender, height, weight, age or exercise
frequency within the population group. Therefore, efforts
to separate the subgroups beyond checking for significant
differences were not undertaken. Subjects within the
untrained and trained subgroups had equal proportions of
males to females, and equal proportions of subjects with
previous LBP and subjects without previous LBP.
Males demonstrated a slightly larger resting muscle
thickness than females. Rankin and colleagues (24)
and Springer and colleagues (7) reported similar
abdominal musculature differences with gender.
However, in this present investigation, difference
due to gender was not significant at rest or
during LAH.
The slightly reduced resting TrA muscle
thickness in the LBP group may have been
predicted due to deconditioning or pain inhibition,
as has been found in lumbar multifidus (25, 26).
Cairns and colleagues also found that subjects who
have previously had LBP can present with deep abdominal
muscular dysfunctions even when asymptomatic (27).
However, in the present investigation this difference was not
significant at rest or during LAH.
The trained group demonstrated greater increases in TrA
thickness on LAH in standing, suggesting previous exposure
to LAH techniques gave them a slight advantage, but this
was not enough to be significant.
Methodological considerations
Single-side-only studies such as this do not allow for any
variance between left and right, as has been found in lumbar
multifidus (26). However, Springer and colleagues showed no
side-to-side difference of TrA at rest or on activity (7).
Although they only imaged a small proportion of the
muscle, Beith and colleagues showed minimal differences
at three points on TrA (23), indicating that activity is
similar throughout the muscle length. Scanning over the
thickest point of TrA has also been shown to demonstrate
the clearest image of TrA, IO and EO simultaneously (14).
However, when activated excited muscle fibres slide over
each other, creating shorter thicker muscles, by only imaging
the middle we cannot comment on these more distal
portions. Although the lower fibres of IO run more parallel
to TrA, suggesting that they function in a similar fashion, the
upper fibres run more obliquely, implying that they may have
a very different role from both the lower fibres and TrA. This
transducer head location scans only the upper fibres of IO,
and therefore any conclusion made in relation to IO in this
present investigation can refer only to the upper fibres.
A frequency lower than 1022MHz may have been more
appropriate for the depth of the abdominal muscles, giving
better-quality images and reducing possible human error in
measuring muscle thickness. Previous studies have used as
low as 5MHz (18), 25MHz (8) and 7.5MHz (28). However, in
the present investigation, good resolution was maintained as
none of the subjects had muscle thickness measurements
greater than 30mm; this was further minimised by
sportEX medicine 2011;49(July):12-18 16
THESE FINDINGS MAY BE
EXPLAINED BY A GREATER
GRAVITATIONAL PULL UPON THE
ABDOMEN IN STANDING
EVIDENCE UPDATE LBP REHABI LI TATI ON
demonstrating good intra-related reliability on measuring.
Many studies have attempted to normalise the data to
gain a representation of a change in muscle activity; this
is usually done by expressing the data as a percentage
of their maximum (19, 23). In the present investigation
attempts to normalise the data were done by expressing
the increase in thickness on LAH as a percentage of the
increase in thickness during MVC. MVC recordings were
measured in 23 of the subjects (82%) during a maximal
clench of the abdomen. Mean MVC thicknesses of TrA, IO
and EO were 7.17mm (1.95), 11.16mm (2.93) and 5.53mm
(1.44), respectively. However, when analysed with the paired
Student t-test, the change in muscle thickness between
the two postures was less significant (P<0001, P=0.01, P<0.1,
respectively). Cholewicke and McGill suggest that muscle
forces even as low as 13% MVC may be sufficient for
segmental stability (29). Therefore, comparing low-level core
muscle activity of TrA and IO with MVC may be inappropriate.
Also, it is not entirely appropriate to normalise all three
muscles against the same task, because although MVC in
standing is optimal for TrA, MVC in rotation would have been
more suitable for IO and EO. Furthermore, without twitch
interpolation the author cannot state that actual MVC was
produced but rather maximal effort, and this could further
account for less significant results obtained. Hodges and
colleagues demonstrated that TrA and IO muscle thickness
increased incrementally only with activity less than 20%
MVC (18). During low-level activation small changes in muscle
activity can produce relatively large changes in muscle
thickness; however, at higher levels of activation, these
thickness changes increase in relatively small amounts,
suggesting that ultrasound can only reliably detect thickness
changes at low-level activity, with less accuracy at higher-
level contraction or near MVC.
Implications for future practice
When rehabilitating patients with LBP, the clinician needs
to ensure that the best exercise in the best position is
chosen to achieve optimum outcome (30). Much of the early
research into core abdominal exercises used positions such
as supine, prone and four-point kneeling (13, 14). This has
filtered through relatively unchallenged into present clinical
practice. As therapists, we are at risk of directly imitating
these early experimental works by initiating core abdominal
rehabilitation in positions of greater support and less function.
The present investigation builds on growing evidence
suggesting that positions of greater function provide a more
effective activation of TrA. Beith and colleagues found that
TrA activity can be isolated more often and more consistently
in four-point kneeling than in prone (13). Using ultrasound,
Ainscough-Potts and colleagues compared abdominal activity
in lying, relaxed sitting, sitting on a gym ball, and sitting on a
gym ball with the left foot raised off the floor (28). They found
that increasing the challenge to stability by lifting one foot off
the floor was the only way to initiate significant increases in
TrA and IO activity. Van Vilet and Heneghan discussed how
cortical mapping studies demonstrate that neural pathways
even in healthy subjects adapt according to what is practised
(31). They recommend that to improve motor control it
is essential to incorporate functionally oriented exercise
early into management to re-educate this feed-forward
mechanism to improve spinal stability.
The present investigation demonstrated that LAH in a
weight-bearing posture of greater function produces greater
TrA activity and with greater specificity, compared with a
posture of less function. The reduction in EO activity during
LAH in standing will be specifically beneficial in rehabilitating
people with LBP who have substitution strategies of
excessive EO activity during LAH (3, 32).
These findings support OSullivans theory that non-
weight-bearing postures such as prone or supine should be
used for core stability retraining only if accurate contraction
cannot be facilitated in weight-bearing postures such as
sitting or standing (30). OSullivan further stresses the
importance of treating patients in their pain-provocation
positions (33), usually positions of greater function, and
progressing rehabilitation with movement into the direction
of pain provocation, so preventing maladaptive movement
patterns that can result in ongoing pain and disability.
CONCLUSION
Standing produces a statistically more significant effect upon
increasing TrA activity on LAH compared with crook lying,
and with greater specificity to TrA, seen as a reduction in IO
and EO activity. These findings have significant importance
for future abdominal core stability retraining for people with
lumbopelvic disorders. Therapists must therefore ensure that
they further develop their rehabilitation strategies by using
positions of greater function to ensure that they optimise
core abdominal rehabilitation.
www.sportEX.net 17
18 sportEX medicine 2011;49(July):12-18
THE AUTHOR
Rosie Mew qualified from the Royal London Hospital and has
remained in London ever since. She has a masters degree,
is trained in acupuncture, is a qualified Pilates instructor and
was awarded a Gold ACPSM Accreditation in 2008. Rosie has over 13
years of specialist sports experience, working for a variety of sports and
national teams, including England and GB Hockey, GB Table Tennis, GB
Bobsleigh, GB Masters Athletics, British Association of Ski and Snowboard
Instructors, Circus Space performance artists, London Irish RFU, and elite
triathletes and marathon runners. She has worked in a headquarters
environment for the British team at the European Youth Olympics, the
Australian Youth Olympic Festival, the World Masters Games, three World
University Summer Games and two World University Winter Games. She
went to Beijing as part of the GB Paralympic Medical team and is now
the lead physiotherapist for ParalympicsGB, in charge of selecting and
developing a team for 2012. She is also the lead physiotherapist for
British Universities & Colleges Sport, selecting the physiotherapy teams
for the World University Summer and Winter Games.
ACKOWLEDGEMENTS
The author would like to thank the considerable time,
patience and advice of Professor Bruce Lynn and Dr Andrew
Dilley.
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TEST YOUR
LEARNING
nAre therapists continuing to ignore
the recent evidence by still initiating
the deep abdominals in crook lying?
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