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PM R 7 (2015) 479-484

www.pmrjournal.org

Original Research

Difference in Selective Muscle Activity of Thoracic Erector Spinae


During Prone Trunk Extension Exercise in Subjects With
Slouched Thoracic Posture
Kyung-hee Park, PhD, PT, Jae-seop Oh, PhD, PT, Duk-hyun An, PhD, PT,
Won-gyu Yoo, PhD, PT, Jong-man Kim, PhD, PT, Tae-ho Kim, PhD, PT,
Min-hyeok Kang, MSc, PT

Abstract

Background: The prone trunk extension (PTE) exercise is often used to strengthen the back extensors. Although altered trunk
posture is associated with movement impairment, the influences of a slouched thoracic posture on muscle activity of the thoracic
erector spinae and thoracic movement during the PTE exercise were overlooked in previous studies.
Objectives: To compare the muscle activity of the erector spinae muscles and the relative ratio of the thoracic and lumbar
erector spinae muscles during a PTE exercise in subjects with and without slouched thoracic posture.
Design: Cross-sectional.
Setting: University motion analysis laboratory.
Participants: The study included 22 subjects with slouched thoracic posture (defined as 40 ) and 22 age- and gender-matched
healthy subjects.
Methods: All participants performed the PTE exercise.
Main outcome measures: Bilateral surface electromyographic signals of the longissimus thoracis, iliocostalis lumborum pars
thoracis, and pars lumborum muscles were measured during PTE exercises. Thoracic kyphosis (the angle of T1 minus T12) and
lumbar lordosis (absolute value of the angle of L5 minus T12) were recorded using inclinometers during the PTE exercise.
Results: The results showed no difference in muscle activity of the erector spinae in subjects with slouched thoracic posture
versus those without during the PTE exercise. However, selective recruitment of the erector spinae pars thoracis was decreased
significantly, and the thoracic kyphotic angle and lumbar lordotic curve were increased, during the PTE exercise in subjects with a
slouched posture.
Conclusions: Although the PTE exercise has historically been a key component of correction of hyperkyphosis, the increased
spinal curvature inhibits muscle activation of the erector spinae pars thoracis in these individuals, thus limiting effective strength
gains. Therefore, modified methods to maintain a neutral posture of the spine and facilitate muscle activation of the erector
spinae pars thoracis are needed in these individuals.

Introduction such as thoracic flexion syndrome [3], osteoporotic


compression fractures of the spine [4], or impairment of
A slouched posture is commonly involved in daily shoulder flexion due to disturbances in scapular move-
sitting activities and is defined as a relaxed sitting ment [5,6]. It is likely beneficial to strengthen the
posture with a flexed thoracic and lumbar spine [1,2]. thoracic spine extensors and to correct excessive
An increased or prolonged slouched posture may cause thoracic kyphosis to reduce or prevent painful spinal
not only low-back pain (LBP) and movement-related disorders and other complications [3,7]; however, few
disorders in the lumbar spine, but it may also result in research studies have examined the thoracic versus the
thoracic spine pain or movement impairment syndrome lumbar spine.

1934-1482/$ - see front matter 2015 by the American Academy of Physical Medicine and Rehabilitation
http://dx.doi.org/10.1016/j.pmrj.2014.10.004
480 Muscle Activity of Thoracic Erector Spinae

The prone trunk extension (PTE) exercise is a familiar These subjects were selected from among 250 young
technique used to strengthen the erector spinae in the persons at 3 universities in South Korea. The criteria
treatment of weak and fatigue-sensitive back muscula- used to place the subjects into the slouched thoracic
ture; this exercise is typically recommended to prevent posture and control groups were based on data taken
the natural progression of kyphosis [7]. However, it is from 250 young persons whose mean kyphotic angle in a
questionable whether the PTE exercise is always relaxed standing posture was 30.2 (standard deviation
effective in individuals with a slouched thoracic posture [SD], 4.83 ). The slouched thoracic posture group was
[8-11]. A prolonged slouched posture has a tendency to defined as those subjects with a kyphotic angle 40 ,
induce excessive thoracic kyphosis according to the which represented the groups mean plus 2 SDs (30.2
directional susceptibility of movement [8]. Moreover, a [2  4.83 ]) [21]. A total of 22 age- and gender-matched
prolonged slouched posture may lengthen or stretch the participants with a kyphotic angle within the range of
erector spinae, which may decrease the position sense mean  1 SD were selected as the control group. These
[1,9,10]. The movements used in an attempt to participants reported no instance of LBP or thoracic pain
decrease the thoracic curve may cause pain or difficulty within the last year, no musculoskeletal disorders that
and may produce compensatory changes in the more would limit normal thoracic kyphosis, and no pain during
mobile lumbar region [3,11]. Therefore, lumbar exten- the test procedure.
sion may be performed to a greater degree than This study was approved by the human subjects
thoracic extension in these individuals during PTE committee of the University of Inje. Informed consent
exercises, and lumbar hyperextension exercises was obtained from all subjects.
accompanied by inordinate use of the lumbar erector
spinae musculature seem to be related to LBP due to Instrumentation
abnormal compressive and shear forces [12-16]. There-
fore, very careful observation and posture correction The angles of thoracic kyphosis and lumbar lordosis
are crucial to prevent hyperextension of the lumbar during the PTE exercise were measured using 2 gravity-
spine and to facilitate the thoracic erector spinae dependent inclinometers (Zebris Medical GmbH, Isny,
muscles in such patients during PTE exercises. Germany). The spinous processes of the first thoracic
Although synergistic activity of the erector spinae vertebra (T1), twelfth thoracic vertebra (T12), and fifth
pars thoracis and lumborum muscles is considered the lumbar vertebra (L5) were used as landmarks for posi-
main mechanism of trunk extension, these muscles do tioning the inclinometer sensors [6] (Figure 1). These
not comprise a homogeneous muscle mass, but have spinal levels were marked by palpation; the L5 spinous
anatomical and functional differences [17-20]. Knowl- process was identified above the sacrum, the T12
edge of the activity of the erector spinae in individuals spinous process was identified superiorly from the L5
with slouched thoracic posture during PTE exercises is point, and the T1 spinous process was identified inferi-
insufficient. The purpose of our research was to orly from the seventh cervical vertebra (designated as
compare the muscle activity of the erector spinae pars the most prominent spinal process) [6]. During PTE
thoracis and lumborum muscles and the relative ratio of exercise, the angle between T1 and T12 and between L5
the thoracic and lumbar erector spinae muscles in sub- and T12 were measured to assess thoracic kyphosis and
jects with a slouched thoracic posture. Because muscle lumbar lordosis, respectively, using the inclinometers.
activity of the erector spine influences trunk posture, a Surface electromyographic (EMG) signals were recor-
secondary purpose was to compare thoracic kyphosis ded for each subject using 8 preamplified (gain: 1000)
and lumbar lordosis in subjects with and without active surface electrodes (model DE-2.3; Delsys, Inc.,
slouched thoracic posture during the PTE exercise. Wellesley, MA). EMG signals from the recording sites
were band-pass filtered between 20 and 450 Hz, analog-
Methods to-digital converted at a sampling rate of 2048 Hz, and
stored on a computer hard disk for later analysis.
Study Participants The electrodes were positioned bilaterally on the
iliocostalis lumborum pars lumborum (right ICL and left
In total, 22 subjects (10 male and 12 female) with ICL) at the L3 level, midway between the lateral-most
thoracic slouched posture and 22 healthy subjects (10
male and 12 female) were selected from among 250
young persons engaged in desk work and computer use
for more than 5 hours per day. Participants with meta-
bolic, neuromuscular, or musculoskeletal disorders or a
history of spinal surgery were excluded. In the 22 sub-
jects with slouched thoracic posture, the thoracic spine
alignment tended to demonstrate excessive thoracic
kyphosis in a self-selected, relaxed standing position. Figure 1. Placements of the inclinometers.
K. Park et al. / PM R 7 (2015) 479-484 481

palpable border of the erector spinae and a vertical line MVIC testing. The normalized LT:ICL and ICT:ICL ratios
through the posterosuperior iliac spine [17,19,22]; on the were calculated to measure the selective recruitment of
longissimus thoracis (right LT and left LT) at the T9 level, the thoracic erector spinae.
midway between a line through the spinous process and a Inclinometer markers to compare the angles of
vertical line through the posterosuperior iliac spine, thoracic kyphosis and lumbar lordosis were placed over
located approximately 5 cm laterally [19,22]; and on the T1, T12, and L5 and were simultaneously measured in
iliocostalis lumborum pars thoracis (right ICT and left ICT) the isometric PTE position with a surface EMG signal. In
at the T10 level, midway between the lateral-most a previous study, intrarater and interrater reliability
palpable border of the erector spinae and a vertical line were concurrently established during PTE exercises in
through the posterosuperior iliac spine [17,23-25]. 15 participants and were found to be highly correlated
Skin impedance was reduced by shaving excess body (intraclass correlation coefficient [ICC] [1,2] 0.97, ICC
hair if necessary, by gently abrading the skin with fine- [2,1] 0.91).
grade sandpaper, and wiping the skin with alcohol swabs. Clockwise rotation of the indicator (toward the
extension direction) represented positive values, and the
Procedures opposite rotation represented negative values. The angle
of T1 minus T12 was the value of thoracic kyphosis, and
The subjects were asked to perform a body the absolute value of the angle of T12 minus T1 was the
weightedependent isometric back extension exercise in angle of thoracic extension. The angle of lumbar lordosis
the prone position. The PTE exercise was performed was the absolute value of the angle of L5 minus T12.
with the iliac crests aligned with the table edge and the
subjects arms crossed at the chest and lower limbs Statistical Analysis
fixed by nonelastic straps at the hip, knees, and ankles.
While looking downward at a visual fixation point, the The KolmogoroveSmirnov test was used to assess
subjects were instructed to raise their trunk to hori- homogeneity of variance of the % MVIC of each muscle
zontal (parallel to the ground) and maintain this posi- and the LT:ICL and ICT:ICL ratios. An independent t-test
tion for 5 seconds [26] (Figure 2). The exercises were was performed to evaluate the differences between the
taught to each subject before data collection; 2 prac- right and left erector spinae EMG data. Because no
tice sessions were allowed to achieve proper perfor- significant differences were found, EMG data of the
mance. A bar indicator was positioned approximately at right and left erector spinae were averaged and are
the T6 level for feedback about the horizontal position. reported. Independent t-tests were then performed to
The procedure was repeated 3 times with a 3-minute investigate the effect of slouched thoracic posture on
recovery period between trials. the normalized EMG activity of the erector spinae
The maximum voluntary isometric contraction (MVIC) (% MVIC), the selective recruitment of the thoracic
of the erector spinae was used for normalization. To erector spinae (LT:ICL and ICT:ICL ratios), the angle of
measure the MVIC of the ES pars thoracis and lumborum, thoracic kyphosis in a standing posture, and the angle of
the subjects, lying in a prone position, placed their thoracic kyphosis and the angle of lumbar lordosis
hands on their head with their legs strapped to the during the PTE exercise. All statistical analyses were
table. Back extension was performed with maximum performed with the statistical software package SPSS
isometric effort against resistance by the experimenter version 18.0 (SPSS Inc., Chicago, IL), and the level of
on the angular inferior aspect of both scapulae [18,25]. statistical significance was set at P < .05.
This was repeated 3 times, with a 30-second rest period
between sessions. Results
A root mean square (RMS) processing method was
executed on 250-millisecond (512 points) successive The subjects in the slouched thoracic posture group
time windows; EMG signals from the 3 middle seconds of were a mean ( SD) age of 27.54  4.29 years; their
the 5-second isometric contraction during the PTE ex- mean height was 169.37  8.57 cm, body weight 63.25 
ercise and MVIC testing were used. The data obtained 8.79 kg, and thoracic kyphotic angle 44.25  4.14
were normalized (% MVIC) by the mean RMS value during while standing (Table 1). The subjects in the control

Table 1
Thoracic kyphotic angles in subjects with and without slouched
thoracic posture in a standing posture
With Slouched Without Slouched
Posture (n 22) Posture (n 22) P Value
44.25  4.14 30.05  4.72 <.001
Figure 2. Prone trunk extension exercise. Data for angles are given in degrees ( ).
482 Muscle Activity of Thoracic Erector Spinae

Table 2
Differences in normalized EMG activity of each segment in the erector spinae muscles and selective recruitment of the longissimus thoracis and
iliocostalis pars thoracis to iliocostalis pars lumborum during the PTE exercise in participants with and without a thoracic slouched posture
Variable Muscles With Slouched Posture Without Slouched Posture P Value
Muscle activity (% MVIC) Both LT 37.80  14.52 37.84  16.51 .933
Both ICT 40.93  18.38 39.48  20.91 .701
Both ICL 56.28  21.90 52.36  22.75 .151
Ratio to ICL Both LT 0.72  0.25 0.82  0.37 .040*
Both ICT 0.78  0.20 0.88  0.31 .024*
EMG electromyography; PTE prone trunk extension; LT longissimus thoracis; MVIC maximum voluntary isometric contraction;
ICT iliocostalis lumborum pars thoracis; ICL iliocostalis lumborum pars lumborum.
*
P < .05.

group were a mean ( SD) age of 26.15  5.34 years; erector spinae muscles (LT:ICL and ICT:ICL ratios), and
their mean height was 168.25  7.46 cm, body weight thoracic and lumbar spine movements during PTE ex-
61.92  9.17 kg, and thoracic kyphotic angle 30.05  ercise. Although there was no difference in the muscle
4.72 while standing (Table 1). activity of the erector spinae muscles in subjects with
No difference in the muscle activity of the erector and without a slouched thoracic posture, a significant
spinae (% MVIC) was found between the 2 groups, but decrease in the relative ratio of the thoracic to lumbar
significant differences in both LT:ICL and ICT:ICL ratios erector spinae muscles was found in the slouched
between the groups were found during PTE exercise. posture group versus the control group. In addition, the
The LT:ICL and ICT:ICL ratios were significantly lower in thoracic kyphotic angle and lumbar lordotic curve were
the slouched thoracic posture group (0.72  0.25 and greater during the PTE exercise in these subjects than in
0.78  0.20, P .040 and .024, respectively) than in the the control group.
control group (0.82  0.37 and 0.88  0.31, respec- An increased kyphoticelordotic curve of the spine
tively) (Table 2). could be explained by the decreased activity of the
In the slouched thoracic posture group, the upper erector spinae pars thoracis and increased activity of
thoracic spine (T1) was significantly flexed 3.83  8.03 the erector spinae pars lumborum. Although the erector
(P < .001), and the lower thoracic spine (T12) was spinae pars thoracis and lumborum produce forces syn-
significantly extended 12.17  7.70 (P .026), but the ergistic with the trunk extension force, the lumbar
extension movement of L5 during the PTE exercise was extensors are more naturally suited to spinal stability;
not significantly different between groups (P .666) the thoracic extensors, located more superficially, are
during the PTE exercise. Kyphosis of the thoracic spine designed for higher loads [13,18,19]. Our results showed
and lordosis of the lumbar spine were significantly higher no significant difference in muscle activity itself, but
at 16.00  10.36 and 25.13  6.30 , respectively, in the the LT:ICL and ICT:ICL ratios were decreased in the
slouched thoracic posture group than in the control group slouched posture group. To the best of our knowledge,
during PTE exercise (7.21  9.90 and 22.05  7.20 ; few studies have investigated the activities of the LT
P <.001 and .045, respectively) (Table 3). and ICT during extension exercises or their activity
relative to that of the ICL. The level of erector spinae
Discussion pars thoracis muscle activity (37%e41% MVIC) in the
current study was lower than that in previous studies
The present study was designed to investigate the (41%e74% MVIC) [12,18,22]. The muscle activity of the
influence of slouched thoracic posture on the level of erector spinae pars lumborum in the current study
activity (%MVIC) of the erector spinae muscles (pars was 52%e56% MVIC, which is similar to some previous
thoracis and lumborum), the balance between these results (55%e57% MVIC) [12,22] and lower than others

Table 3
Differences in thoracic and lumbar spine movement during the PTE exercise in participants with and without habitual slouched posture
Degree of Trunk Extension ( )
Variable With Slouched Posture Without Slouched Posture P Value
T1 3.83  8.03 2.98  9.95 <.001*
T12 12.17  7.70 10.20  3.85 .026*
L5 11.95  6.40 11.85  7.01 .666
Kyphosis of thoracic spine 16.00  10.36 7.21  9.90 <.001*
Lordosis of lumbar spine 25.13  6.30 22.05  7.20 .045*
PTE prone trunk extension.
*
P < .05.
K. Park et al. / PM R 7 (2015) 479-484 483

(70% MVIC) [18]. The main reason for this is that the PTE spine [1,9]. Thus, these individuals may also have diffi-
exercise was performed in a different way in the pre- culty recognizing their abnormal movement patterns
vious studies, with both arms raised to the head instead and correcting their increased thoracic kyphosis and
of folded at the chest or with participants instructed to lumbar lordosis angles to achieve a neutral curve [30].
achieve an intensity of 60% of 1 repetition maximum The first limitation of the current study is that we
(RM). Notably, the muscle activity of the erector spinae examined a young healthy population; thus, the results
pars thoracis in the slouched thoracic posture group was cannot be generalized to elderly individuals or to pa-
lowest, and decreased activation was not enough to tients with LBP. Second, only a single exercise (PTE) was
straighten the thoracic spine. used. Third, although the main function of the erector
The PTE exercise is beneficial in strengthening spinae is to maintain an erect posture, the endurance of
the erector spinae for the treatment of weak and the erector spinae muscles was not tested. Future
fatigue-sensitive back musculature [7]. However, an research should use various exercises and resistances
appropriate spinal curve should be considered when and compare the muscle endurance of the erector spi-
performing the PTE exercise, because maintenance of a nae muscles in individuals with and without slouched
stable neutral zone in the spine is assumed to be safe thoracic posture. In addition, differences in the diam-
and to diminish the stress on the spine [12,22,27]. That eter and contractility of erector spinae muscles be-
is, the PTE exercise with increased thoracic kyphosis tween persons with and without a slouched thoracic
and lumbar lordosis may be less effective and may posture should be measured using real-time ultrasound
produce pain because of greater disk loading, in a future study. Finally, we measured only the thoracic
compression force, and shearing force caused by an kyphotic angle in this study. To fully understand
increased spinal curve in the sagittal plane [28,29]. In thoracic mobility and the influence of thoracic kyphosis
the present study, the slouched thoracic posture group on adjacent joints, the mobility of the rib cage and
showed increases in the lumbar lordotic and thoracic thoracic facet joints and the alignment of the cranio-
kyphotic curves during the PTE exercise. Considering cervical junction should also be assessed in future
directional susceptibility to movement, namely, studies.
compensatory movement in a specific direction or a
stress applied in a specific direction [8], persons with
Conclusion
slouched thoracic posture are accustomed to a thoracic
flexed posture not only during standing but also during
In this study the muscle activity relative ratio of the
other positions, and even during the PTE exercise. Also,
thoracic to lumbar erector spinae muscles decreased
thoracic kyphosis in a relaxed standing posture was
significantly, whereas the angle of kyphosis and lumbar
greater in the slouched thoracic posture group than in
lordosis increased significantly, during the PTE exercise
the control group in this study. It is inferred that soft
in the slouched thoracic posture group compared with
tissues allow greater flexibility, together with less
the control group. The increased spinal curve in the
stiffness, going into thoracic flexion in the slouched
sagittal plane and decreased selective activation of the
thoracic posture group than in the control group, which
erector spinae pars thoracis induced during this exercise
may lead to a greater thoracic kyphotic angle in the
could have a negative impact on the spine. Thus, careful
slouched thoracic posture group, even with no signifi-
observation and modified methods (eg, support of the
cant difference in muscle activity of the erector spinae
lower trunk to prevent compensatory lumbar lordosis) to
between the groups during the PTE exercise. Individuals
maintain a neutral posture of the spine and to facilitate
with a slouched thoracic posture have decreased
muscle activation of the erector spine pars thoracis are
thoracic extension range of motion [11,30] and may
needed in these individuals.
compensate for this by increasing their lumbar lordotic
curve instead of increasing thoracic extension during
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Disclosure

K.P. Department of Physical therapy, Masan University, Changwon, South Korea J.K. Department of Physical Therapy, Jeonju Univerisy, Jeonju, South Korea
Disclosure: nothing to disclose Disclosure: nothing to disclose

J.O. Department of Physical Therapy, College of Biomedical Science and Engi- T.K. Department of Physical Therapy, Daegu University, Daegu, South Korea
neering, INJE University 607 Obang-dong, Gimhae-si, Gyeongsangnam-do, South Disclosure: nothing to disclose
Korea, 621-749. Address correspondence to: J.-s.O.; e-mail: ysrehab@inje.ac.kr
Disclosure: nothing to disclose M.K. Department of Physical Therapy, Graduate School, INJE University,
Gimhae, South Korea
D.A. Department of Physical Therapy, INJE University, Gimhae, South Korea Disclosure: nothing to disclose
Disclosure: nothing to disclose
Submitted for publication March 17, 2014; accepted October 5, 2014.

W.Y. Department of Physical Therapy, INJE University, Gimhae, South Korea


Disclosure: nothing to disclose