Journal of Sport Rehabilitation, 2012, 21, 151-160

2012 Human Kinetics, Inc.

The Effect of Traditional Bridging or Suspension-Exercise

Bridging on Lateral Abdominal Thickness
in Individuals With Low Back Pain
Rebecca J. Guthrie, Terry L. Grindstaff, Theodore Croy,
Christopher D. Ingersoll, and Susan A. Saliba

Context: Individuals with low back pain (LBP) are thought to benefit from interventions that improve motor
control of the lumbopelvic region. It is unknown if therapeutic exercise can acutely facilitate activation of
lateral abdominal musculature. Objective: To investigate the ability of 2 types of bridging-exercise progres-
sions to facilitate lateral abdominal muscles during an abdominal drawing-in maneuver (ADIM) in individu-
als with LBP. Design: Randomized control trial. Setting: University research laboratory. Participants: 51
adults (mean SD age 23.1 6.0 y, height 173.6 10.5 cm, mass 74.7 14.5 kg, and 64.7% female) with
LBP. All participants met 3 of 4 criteria for stabilization-classification LBP or at least 6 best-fit criteria for
stabilization classification. Interventions: Participants were randomly assigned to either traditional-bridge
progression or suspension-exercise-bridge progression, each with 4 levels of progressive difficulty. They per-
formed 5 repetitions at each level and were progressed based on specific criteria. Main Outcome Measures:
Muscle thickness of the external oblique (EO), internal oblique (IO), and transversus abdominis (TrA) was
measured during an ADIM using ultrasound imaging preintervention and postintervention. A contraction
ratio (contracted thickness:resting thickness) of the EO, IO, and TrA was used to quantify changes in muscle
thickness. Results: There was not a significant increase in EO (F1,47 = 0.44, P = .51) or IO (F1,47 = .30, P =
.59) contraction ratios after the exercise progression. There was a significant (F1,47 = 4.05, P = .05) group-by-
time interaction wherein the traditional-bridge progression (pre = 1.55 0.22; post = 1.65 0.21) resulted in
greater (P = .03) TrA contraction ratio after exercise than the suspension-exercise-bridge progression (pre =
1.61 0.31; post = 1.58 0.28). Conclusion: A single exercise progression did not acutely improve muscle
thickness of the EO and IO. The magnitude of change in TrA muscle thickness after the traditional-bridging
progression was less than the minimal detectable change, thus not clinically significant.

Keywords: lumbar stabilization, sonography, therapeutic exercise

Low back pain (LBP) is thought to affect 70% to 80%
of the population, and 60% to 90% of these individuals
have recurrent symptoms.15 Although LBP is a common
health problem, the underlying pathology and optimal
intervention strategy remain unclear.6 Since LBP is not a
homogeneous entity, individuals with similar symptoms
and clinical signs may be more likely to benefit from an
exercise program that enhances neuromuscular control of
the spine.7 Individuals with chronic LBP have been shown
to benefit from rehabilitation programs that incorporate
Guthrie is with the Orthopaedics Dept, Emory Sports Medicine
Center, Atlanta, GA. Grindstaff is with the Dept of Physical
Therapy, Creighton University, Omaha, NE. Croy is with the
Doctoral Program in Physical Therapy, U.S. ArmyBaylor
University, Ft Sam Houston, TX. Ingersoll is with the Office of
the Dean, Central Michigan University, Mt Pleasant, MI. Saliba
is with the Dept of Human Services, University of Virginia,
Charlottesville, VA.
therapeutic exercises to enhance neuromuscular control
of the spine.811
Neuromuscular control of the lumbar spine is
achieved though coordinated activity of a number of
muscles surrounding the spine.12 Individuals with LBP
have been shown to demonstrate deficiencies in trans-
versus abdominis (TrA) activation.1315 A fundamental
exercise in a motor-control exercise program for LBP is the
abdominal drawing-in maneuver (ADIM).16,17 This exercise
is used to preferentially activate the TrA while maintain-
ing relaxation of the more superficial musculature (rectus
abdominis, external oblique).17 Individuals with LBP have
been shown to demonstrate difficulty in increasing the
thickness of the TrA, measured with ultrasound imaging,
during an ADIM.15,18 Once subjects are able to success-
fully perform this exercise they are advanced to exercises
that are dynamic and require coordinated activation of
all spine-stabilizing musculature.11,17,19 These types of
exercises have been shown to reduce symptoms associ-
ated with LBP and improve function.11,2023

151
 152Guthrie et al
The use of suspension training, in addition to a
multimodal physical therapy intervention program, has
been shown to be effective in reducing pain, improving
functional status, and improving health-related quality of
life for up to 2 years in postpartum women with pelvic
pain.22,23 Suspension-training devices incorporate labile
surfaces to increase exercise difficulty and provide a
greater challenge to the patient. Exercises performed on
labile surfaces, compared with stable surfaces, result in
increased muscle-contraction speed and muscle-activity
levels.2426 A bridging exercise utilizing the suspension-
exercise device has been shown to result in greater
TrA muscle-thickness changes during exercise than a
traditional bridging exercise.27 It is currently unknown
if the facilitation of the TrA during a bridging exercise
performed on a suspension-training device carries over
to other tasks such as an ADIM after exercise interven-
tion. Therefore, the purpose of this study was to compare
changes in lateral abdominal-muscle thickness before
and after a single intervention consisting of either a
traditional-bridging progression or a suspension-exercise-
bridging progression. We hypothesized that after subjects
performed the suspension-exercise-bridge progression
there would be an acute increase in their TrA muscle
thickness while performing an ADIM, and these changes
would not be present after performing the traditional-
bridge progression.
Methods
Participants
Fifty-one adults (18 men, 33 women) with a current
episode of LBP participated in this study (Table 1 and
Figure 1). Participants were recruited from the university
community and from an athletic therapy clinic. Inclusion
criteria were based on physical examination and history
findings consistent with the stabilization classification,
which is a component of a treatment-based classification
system for individuals with LBP (Figure 2).7 Since the
clinical predictor rule used to identify individuals with
LBP who would be likely to benefit from stabilization
exercises has not been validated, other evidence-based
Table 1 Participant Demographics, Mean SD
Age (y)
Height (cm)
Mass (kg)
Body-mass index (kg/m2)
Oswestry score (%)
Fear-Avoidance Beliefs questionnaire score (physical activity)
Fear-Avoidance Beliefs questionnaire score (work)
Duration of symptoms (mo)
clinical examination (best-fit) criteria28,29 were used to
broaden the selection of individuals who may benefit
from stabilization exercise. Eligible participants met
at least 3 of 4 stabilization-classification criteria that
included age less than 40, straight-leg raise greater than
91, positive prone instability test, and instability catch
or aberrant movements in flexion/extension motions.7
If participants did not meet at least 3 of these 4 criteria,
they were further evaluated to see if they met at least 6
of the following best-fit criteria: spring-test hypermobil-
ity, increased episode frequency, more than 3 previous
episodes, positive posterior pelvic pain-provocation test,
difficulty performing active straight-leg raise, modified
Trendelenburg, or pain with palpation of the long dorsal
sacroiliac ligament or pubic symphysis. Exclusion
criteria were neurological symptoms distal to the hip,
spinal surgery, pregnancy, or known cancer or tumor.
The study was approved by the institutional review
board of the University of Virginia, and written informed
consent was obtained from all participants before
testing.
Procedures
After we obtained informed consent all participants
completed a health-history form, modified Oswestry Low
Back Pain Disability Questionnaire, and Fear-Avoidance
Beliefs questionnaire and underwent a standardized
physical examination to determine their eligibility for the
study. Next, they underwent a brief training session and
were instructed on how to perform an ADIM. Participants
were verbally instructed to gently pull their navel to the
spine at the end of a normal exhalation and to hold this
contraction for 10 seconds while continuing normal
respiration.17 During the training session, the researcher
monitored participant progress using ultrasound imaging
but did not allow the participant to visualize the ultra-
sound screen. Practice trials were performed until the
researcher determined the participant could perform 3
isolated TrA contractions (thickening and lateral move-
ment of the muscle during ultrasound imaging) without
an appreciable increase in external oblique (EO) and
internal oblique (IO) muscle thickness.30
Total Traditional bridge Suspension-exercise bridge
23.1 6.0 23.8 7.0 22.5 5.1
173.6 10.5 171.5 10.6 175.7 10.2
74.7 14.5 72.7 12.9 76.7 15.8
24.6 2.8 24.6 2.4 24.6 3.2
25.8 10.0 26.6 10.8 24.8 9.4
14.9 5.9 15.2 6.4 14.7 5.5
5.5 7.3 7.0 6.8 4.0 7.6
39.0 41.0 44.9 55.2 33.3 19.2
 The Effect of Traditional Bridging 153

Figure 1 CONSORT (Consolidated Standards of Reporting Trials) flowchart.

Figure 2 Inclusion criteria. Abbreviations: SLR, straight-leg raise; ROM, range of motion; ASLR, active straight-leg raise;
SI, sacroiliac.

Ultrasound imaging was used to quantify muscle
thickness of the EO, IO, and TrA during an ADIM before
and after exercise intervention. Two images were obtained
during each ADIM, 1 during rest and 1 during ADIM con-
traction. All images were obtained after exhalation, and
the sequence was repeated 3 times for 6 images (3 resting,
3 contracted). Ultrasound images were obtained using a
LOGIQ Book XP (GE Healthcare Products, Milwaukee,
WI) with an 8-MHz linear transducer while the participant
was in the supine hook-lying position. The transducer was
placed on the lateral abdominal wall, in the transverse
plane, along the midaxillary line midway between the
iliac crest and the inferior angle of the rib cage, corre-
sponding to the side where the participant experienced
LBP. If pain was bilateral or central, the transducer was
placed on the right lateral abdominal wall. The transducer
154Guthrie et al
was oriented transversely perpendicular to the abdominal
musculature, with a slight tilt toward the pubis to align
with the fibers of the TrA to optimize the image. Trans-
ducer position was adjusted so the lateral insertion of the
TrA, on the thoracolumbar fascia, was approximately 2
cm from the edge of the image.30 Images were stored with
no indication of group assignment and were measured by
a blinded researcher. Before enrolling participants, both
researchers underwent a supervised training program for
ultrasound imaging by an experienced physical therapist.
The training program included transducer placement,
image acquisition, and image-measurement techniques.
Measures of within-session intratester reliability, standard
error of measure (SEM), and the minimal detectable
change using a 95% confidence interval for resting and
contracted muscle-thickness values were obtained on
10 separate participants. After training, both research-
ers demonstrated excellent intratester reliability for
all muscle-thickness measures (at rest and contracted;
Table 2). Reliability was consistent with previous reports
of this measurement technique.3133
The preintervention and postintervention images
were measured after data collection by a researcher who
was blinded to the exercise condition. Thicknesses of the
EO, IO, and TrA were measured using Image J software
(version 1.41o, Wayne Rasband, National Institutes
of Health, USA). EO, IO, and TrA thicknesses were
measured using the distance between the superior edge
of the deep hyperechoic fascial line to the inferior edge
of the superior fascial line.32 The thickness ratio of each
muscle (EO, IO, and TrA) was calculated by dividing
the contracted thickness during an ADIM by the resting
thickness (contracted thickness/resting thickness).33
Intervention
After baseline measurement of lateral abdominal-muscle
thickness, participants were randomly assigned to either
the traditional-bridging group or the suspension-exercise-
bridging group using a computer-generated randomiza-
Table 2 Intratester Reliability (ICC3,3) and 95% Confidence Intervals (95% CI), Standard Error
of Measurement (SEM), and Minimal Detectable Change (MDC) Using Estimates for Ultrasound-
Imaging Measurements of Lateral Abdominal Muscles (cm) at Rest and During an Abdominal
Drawing-In Maneuver
Examiner 1
ICC (95% CI)
External oblique resting .95 (.79.99)
External oblique contracted .93 (.70.98)
Internal oblique resting .98 (.931.00)
Internal oblique contracted .94 (.77.99)
Transversus abdominis resting .99 (.971.00)
Transversus abdominis contracted .99 (.971.00)
tion schedule and preprinted cards enclosed in sealed
envelopes. Four sets of 5 repetitions were performed,
and each exercise progression consisted of 4 levels of
difficulty. Each repetition was held for 5 seconds, and a
1-minute rest was allowed between sets. All participants
started at the first level. Both progressions were nearly
identical in terms of limb position, movement, and hold
time, but the suspension-exercise-bridge group had
their legs suspended in every level. Criteria for exercise
progression required the exercise to be performed in a
pain-free manner with correct technique. If the participant
could not perform the exercise correctly or pain resulted,
assistance was provided via elastic cords or the progres-
sion level of the exercise was decreased. Immediately
after intervention, images were obtained during 3 ADIMs
using the same methods previously described.
Traditional Bridge. The traditional bridge exercise
consisted of 4 possible levels (Figure 3). The researcher
monitored success at each level before advancing the par-
ticipant to the next stage of the exercise. The researcher
observed the alignment and/or any compensatory move-
ments and asked participants about whether the activity
increased their pain. Each exercise began with the partici-
pant in the supine hook-lying position on the treatment
table with the knees bent to 90, feet flat on the table,
and arms crossed over the chest. Participants were then
instructed to push through their heels to lift their hips
into the air while maintaining straight alignment of the
knees, hips, and shoulders. No specific instructions were
given regarding activation of abdominal musculature (ie,
performing the bridging exercise in conjunction with an
ADIM). In the first level, the participants held this posi-
tion for 5 seconds and then were instructed to lower back
to the starting position. The second level consisted of the
participants extending their right knee for 3 seconds fol-
lowed by their left knee for 3 seconds and then lowering
back to the starting position. In the third level, participants
had an air-filled balance disc placed between their scapu-
lae to perform the exercise on an unstable surface, and in
the fourth level they were instructed to extend their knees,
Examiner 2
SEM MDC ICC SEM MDC
.05 .14 .93 (.71.98) .04 .12
.08 .21 .88 (.52.97) .07 .20
.04 .12 .94 (.75.99) .07 .21
.12 .32 .97 (.88.99) .09 .24
.01 .04 .98 (.90.99) .02 .06
.02 .05 .99 (.971.00) .02 .05

(A)
(C)
Figure 3 Traditional-bridge-exercise progression. (A) Two-leg. (B) Single-leg. (C) Two-leg with unstable surface under back.
(D) Single-leg with contralateral hip abduction.
as well as abduct the hip 45. Participants performed 5
repetitions on each level of the exercise.
The participants were progressed to each level based
on the clinicians subjective clinical opinion. If partici-
pants could perform the exercise correctly, with no pain,
and without difficulty, they were progressed to the next
level. If they could not perform the exercise correctly, it
was painful, or it was difficult, the level of exercise was
decreased or modified to enable 4 sets of 5 repetitions.
Suspension-Exercise Bridge. he suspension-exercise
device used in this study was a Redcord Workstation
Professional (Redcord AS, Staubo, Norway). This
device consists of a rope, sling, and pulleys that are
used to suspend the legs during the bridging exercise.
There were 4 possible levels of the suspension-bridging
exercise (Figure 4). The participants in the suspension-
exercise-bridge group began by laying supine on the
treatment table with their hips and knees bent to 90.
The participants knees were placed in a sling that was
suspended from the ceiling. During the exercise, no
The Effect of Traditional Bridging 155
(B)
(D)
specific instructions were given regarding activation
of abdominal musculature (ie, performing the bridging
exercise in conjunction with an ADIM). The first level
consisted of participants lifting their hips while maintain-
ing straight alignment of the knees, hips, and shoulders.
The participants held this position for 5 seconds and then
were instructed to lower back to the starting position. In
the second level, each participants left knee remained
in the sling and the right knee was not in the sling. The
participant was instructed to hold the right leg at the
same level as the left and to lift the hips into the air while
maintaining straight alignment of the knees, hips, and
shoulders. Participants held this position for 5 seconds
and then lowered back to the starting position. In the third
level, they had both knees placed in the sling and a disc
was placed between their scapulae to provide an unstable
surface on which to perform the bridge. In the fourth level,
the participants ankles were placed in 2 separate slings
and they were instructed to perform the bridge and then
abduct their legs 1 at a time before lowering back to the
starting position. The participants performed 5 repetitions
156Guthrie et al
(A)
(C)
Figure 4 Suspension-exercise-bridge progression. Sling was placed on the posterior aspect of the knee. (A) Two-leg. (B) Single-
leg. (C) Two-leg with unstable surface under back. (D) Single-leg with contralateral hip abduction.
on each level of the exercise. The same subjective criteria
were used to progress them through each level of exercise
in the suspension-exercise-bridging intervention as was
used in the traditional-bridge intervention.
Data Analysis
A randomized control trial with 1 between factor, exer-
cise group (traditional, suspension), and 1 within factor,
time (preintervention and postintervention) was used to
examine the effects of exercise on the contraction ratios
(muscle-contracted thickness/muscle-relaxed thickness)
of the EO, IO, and TrA.
Participant demographics between groups were
compared using independent t tests. Separate repeated-
measures ANOVAs were performed to compare con-
traction ratios of the EO, IO, and TrA before and after
exercise (traditional, suspension). The level of statistical
significance was set a priori at P < .05. Statistical analy-
ses were performed with SPSS Version 16.0 (SPSS Inc,
Chicago, IL).
(B)
(D)
Sample-size calculations indicated that the number
of participants required to detect a 0.3 difference in TrA
contraction ratio between groups was 24 subjects per
group. This was based on standard deviations (0.36) from
a previous study,33 an a priori significance level of P =
.05, and a power of .80.
Results
The traditional-bridge-exercise group and the suspension-
exercise-bridge group did not differ in terms of demo-
graphic stabilization-classification criteria or preinterven-
tion TrA thickness ratios (Table 1). It was not possible to
obtain clear images for 2 participants; therefore, data for
those participants were not included in the analysis. All
participants were able to progress through the first 2 levels
of their respective exercise progressions. One individual
was not able to progress to Level 3 when performing the
traditional bridge, but all were able to complete Level 3
for the suspension-exercise-bridge progression. Seven
individuals were not able to complete the traditional-
 The Effect of Traditional Bridging 157

bridging exercise, while 4 individuals were not able to
complete the suspension-exercise-bridge progression.
No individual in either group reported pain during the
exercise intervention at any level, and all individuals who
progressed to subsequent levels performed each exercise
with correct technique.
Descriptive data regarding resting and contracted
muscle thickness, as well as muscle-contraction ratios, are
presented in Table 3. There was not a significant group-
by-time interaction for the EO (F1,47 = 0.44, P = .51) or
IO (F1,47 = 0.30, P = .59) muscle-thickness contraction
ratios. When groups were pooled there were no significant
differences between preintervention and postintervention
contraction ratios for the EO (F1,47 = 0.41, P = .53) or IO
(F1,47 = 0.40, P = .53).
There was a significant difference (F1,47 = 4.05, P
= .05) in TrA thickness ratios by group. The traditional-
bridge progression (pre = 1.55 0.22, post = 1.65 0.21)
resulted in greater TrA activation (P = .03) after exercise
than the suspension-exercise-bridge progression (P = .51;
pre = 1.61 0.31, post = 1.58 0.28; Table 3).
Discussion
This study demonstrates that a single bridging-exercise
intervention, traditional or suspension, does not have an
immediate effect on EO or IO muscle-thickness ratios
during an ADIM. The traditional-bridge-exercise progres-
sion did significantly improve the ability to perform an
ADIM in individuals with LBP who met stabilization-
classification criteria, but findings should be interpreted
with caution. Although the traditional-bridge-exercise
progression resulted in a 6% increase in the TrA contrac-
tion ratio, the changes in muscle thickness were less than
the minimal detectable change (>.05 cm)34 and thus not
thought to be clinically significant.
Although a single intervention would not be expected
to alter muscle morphology, it is plausible to acutely
facilitate muscle function after a single intervention.
A lumbopelvic-joint manipulation has been shown to
acutely increase muscle thickness of the TrA in individu-
als with LBP.34,35 The acute increase in muscle function
is thought to be due to increased neural excitability
resulting in muscle facilitation. Although those studies
examined the effects of spinal manipulation, the results
demonstrate that facilitation of the TrA is possible after
a single intervention. Neither bridging progression had
an immediate clinical effect on EO, IO, or TrA muscle-
thickness ratios during an ADIM. These results do not
support the hypothesis of the study, which proposed that
the suspension-exercise-bridge progression would result
in greater TrA activation than the traditional-bridge pro-
gression. Facilitation of TrA activation may be beneficial
for individuals with LBP since they have been shown
to demonstrate deficiencies in TrA activation measured
using ultrasound imaging.14,15
The exercise progressions used in this study were
nearly identical in terms of limb positions and move-
ments, with the exception of the legs being suspended in

Table 3 Lateral Abdominal-Muscle Thickness, Mean SD

Group Preintervention Postintervention
External oblique relaxed (cm) Traditional 0.62 0.23 0.62 0.25
Suspension 0.73 0.26 0.72 0.30
External oblique contracted (cm) Traditional 0.66 0.26 0.63 0.24
Suspension 0.76 0.23 0.74 0.31
External oblique contraction ratio Traditional 1.05 0.17 1.06 0.22
Suspension 1.08 0.21 1.05 0.19
Internal oblique relaxed (cm) Traditional 1.01 0.27 0.98 0.26
Suspension 1.08 0.32 1.04 0.33
Internal oblique contracted (cm) Traditional 1.14 0.29 1.12 0.28
Suspension 1.22 0.42 1.20 0.41
Internal oblique contraction ratio Traditional 1.14 0.16 1.15 0.12
Suspension 1.13 0.15 1.15 0.14
Transversus abdominis relaxed (cm) Traditional 0.40 0.07 0.39 0.07
Suspension 0.40 0.12 0.39 0.10
Transversus abdominis contracted (cm) Traditional 0.61 0.11 0.63 0.12
Suspension 0.63 0.14 0.62 0.17
Transversus abdominis contraction ratio Traditional* 1.55 0.22 1.65 0.21
Suspension 1.61 0.31 1.58 0.28
*Significant difference (P = .03) preintervention to postintervention.
158Guthrie et al
the suspension-exercise-bridging group. The suspension-
exercise progression has been shown to result in higher
TrA activation during exercise than the traditional-bridg-
ing exercise.27 Although higher TrA activation occurs
during the suspension-exercise bridge,27 changes in the
ability to perform an ADIM after exercise intervention
were not immediate in this study. Facilitation of muscle
activation before performing therapeutic exercise has
been shown to improve clinical outcomes relative to
traditional rehabilitation programs.36 If TrA deficits are
due to reflexive muscle inhibition, traditional strengthen-
ing interventions may not fully address the neurological
dysfunction.3640 Although neurological adaptations and
motor-pattern efficiency and timing are thought to occur
in less than 6 weeks, it is possible that changes in muscle
thickness may take longer than 6 weeks with consistent
intervention sessions.21 Rehabilitation programs that
incorporate therapeutic exercises to enhance neuro-
muscular control of the spine are typically performed a
number of times per week for multiple weeks (>3).811,21
Future research should examine the cumulative effects of
exercises on lateral abdominal-muscle thickness, motor-
pattern efficiency, timing, and patient-oriented outcomes
such as pain relief, function, and quality of life.
The participants in this study were recruited from the
university community and from an athletic therapy clinic.
They responded to a flier that stated eligibility criteria.
The flier specifically targeted individuals with LBP 18 to
50 years of age who had increasing symptom frequency,
more than 3 previous episodes of LBP, no symptoms
distal to the knee, and no history of spine surgery. Most
of the participants met the inclusion criteria since the
recruitment methods provided prescreening of partici-
pants who were likely to already meet at least 3 criteria
for a best-fit classification. Although the individuals in
this study were currently experiencing an episode of LBP,
they were not actively seeking medical care. Individuals
who meet stabilization-classification criteria are thought to
demonstrate the greatest deficit in the TrAs ability to thicken
during an ADIM.15 The average TrA thickness ratio for study
participants before exercise intervention was 1.58, which
was consistent with a previous study examining individu-
als with LBP who met stabilization-classification criteria.15
Although a deficit in TrA activation may exist, the role of
the TrA in neuromuscular control of the lumbar spine
has been questioned.4144 Spine biomechanical research
indicates that no single muscle is solely responsible for
neuromuscular control of the lumbar spine, which occurs
due to coordinated activity of a number of muscle sur-
rounding the spine.12 Although previous studies have
demonstrated improvements in pain and function, this
may have been due to the inability to completely target
specifically one of the muscles surrounding the lumbar
spine. In addition, the inability to adequately perform an
ADIM (static controlled task) may not accurately reflect
neuromuscular control of the spine during dynamic
tasks. Future research should attempt to better identify
individuals with LBP who would benefit from exercises
to improve neuromuscular control of the spine.
Conclusions
Neither traditional- nor suspension-exercise-bridge
progression has an immediate clinical effect on EO, IO,
or TrA activation immediately after a single exercise
intervention. Previous studies have shown bridging
exercise utilizing the suspension-exercise device result-
ing in greater TrA muscle-thickness changes during
exercise than a traditional-bridging exercise, indicating a
facilitation of muscle activation.27 The bridging exercise,
regardless of surface stability, can still be considered an
important component of a rehabilitation program for
individuals with LBP, but its mechanism of effective-
ness does not appear to be related to immediate changes
in TrA activation. It is possible that changes would be
evident after a comprehensive and progressive therapeutic
exercise intervention program.
Acknowledgments
The opinions or assertions contained herein are the private
views of the authors and are not to be construed as official or
as reflecting the views of the Department of the Army or the
Department of Defense.
References
1. Deyo RA, Mirza SK, Martin BI. Back pain prevalence
and visit rates: estimates from US national surveys 2002.
Spine. 2006;31:27242727. PubMed doi:10.1097/01.
brs.0000244618.06877.cd
2. Hart LG, Deyo RA, Cherkin DC. Physician office visits for
low back pain. frequency, clinical evaluation, and treatment
patterns from a US national survey. Spine. 1995;20:1119.
PubMed doi:10.1097/00007632-199501000-00003
3. Nachemson A. Lumbar spine instability: a critical update
and symposium summary. Spine. 1985;10:290291.
PubMed doi:10.1097/00007632-198504000-00019
4. Turner JA. Educational and behavioral interventions for
back pain in primary care. Spine. 1996;21:28512857;
discussion 28582859. PubMed doi:10.1097/00007632-
199612150-00010
5. Horal J. The clinical appearance of low back disorders in
the city of Gothenburg, Sweden. comparisons of incapaci-
tated probands with matched controls. Acta Orthop Scand
Suppl. 1969;118:1109.
6. Koes BW, van Tulder MW, Ostelo R, Burton AK, Waddell
G. Clinical guidelines for the management of low back
pain in primary care: an international comparison. Spine.
2001;26:25042513. PubMed doi:10.1097/00007632-
200111150-00022
7. Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary
development of a clinical prediction rule for determin-
ing which patients with low back pain will respond
to a stabilization exercise program. Arch Phys Med
Rehabil. 2005;86:17531762. PubMed doi:10.1016/j.
apmr.2005.03.033
8. Ferreira PH, Ferreira ML, Maher CG, Herbert RD,
Refshauge K. Specific stabilisation exercise for spinal
and pelvic pain: a systematic review. Aust J Physio-
ther. 2006;52:7988. PubMed doi:10.1016/S0004-
9514(06)70043-5

9. Philadelphia Panel. Philadelphia Panel evidence-based
clinical practice guidelines on selected rehabilitation
interventions for low back pain. Phys Ther. 2001;81:1641
1674. PubMed
10. van Tulder MW, Koes BW, Bouter LM. Conservative
treatment of acute and chronic nonspecific low back pain.
a systematic review of randomized controlled trials of the
most common interventions. Spine. 1997;22:21282156.
PubMed doi:10.1097/00007632-199709150-00012
11. Costa LOP, Maher CG, Latimer J, et al. Motor Control
exercise for chronic low back pain: a randomized placebo-
controlled trial. Phys Ther. 2009;89:12751286. PubMed
doi:10.2522/ptj.20090218
12. Kavcic N, Grenier S, McGill SM. Determining the
stabilizing role of individual torso muscles during reha-
bilitation exercises. Spine. 2004;29:12541265. PubMed
doi:10.1097/00007632-200406010-00016
13. Hodges PW, Richardson CA. Delayed postural contraction
of transversus abdominis in low back pain associated with
movement of the lower limb. J Spinal Disord. 1998;11:46
56. PubMed doi:10.1097/00002517-199802000-00008
14. Ferreira PH, Ferreira ML, Hodges PW. Changes in
recruitment of the abdominal muscles in people with low
back pain: ultrasound measurement of muscle activity.
Spine. 2004;29:25602566. PubMed doi:10.1097/01.
brs.0000144410.89182.f9
15. Kiesel KB, Underwood FB, Mattacola CG, Nitz AJ,
Malone TR. A comparison of select trunk muscle thick-
ness change between subjects with low back pain clas-
sified in the treatment-based classification system and
asymptomatic controls. J Orthop Sports Phys Ther.
2007;37:596607. PubMed
16. Lacte M, Thomas D, Thomas J. Clinical Evaluation of
Muscle Function. London, UK: Churchill Livingstone;
1987.
17. Hodges PW, Richardson CA. Altered trunk muscle
recruitment in people with low back pain with upper limb
movement at different speeds. Arch Phys Med Rehabil.
1999;80:10051012. PubMed doi:10.1016/S0003-
9993(99)90052-7
18. Teyhen DS, Bluemle LN, Dolbeer JA, et al. Changes in
lateral abdominal muscle thickness during the abdominal
drawing-in maneuver in those with lumbopelvic pain. J
Orthop Sports Phys Ther. 2009;39:791798. PubMed
19. OSullivan PB, Phyty GD, Twomey LT, Allison GT. Evalu-
ation of specific stabilizing exercise in the treatment of
chronic low back pain with radiologic diagnosis of spon-
dylolysis or spondylolisthesis. Spine. 1997;22:29592967.
PubMed doi:10.1097/00007632-199712150-00020
20. Hides JA, Jull GA, Richardson CA. Long-term effects
of specific stabilizing exercises for first-episode low
back pain. Spine. 2001;26:E243E248. PubMed
doi:10.1097/00007632-200106010-00004
21. Hides JA, Stanton WR, Wilson SJ, Freke M, McMahon S,
Sims K. Retraining motor control of abdominal muscles
among elite cricketers with low back pain. Scand J Med Sci
Sports. 2010;20:834842. PubMed doi:10.1111/j.1600-
0838.2009.01019.x
22. Stuge B, Laerum E, Kirkesola G, Vollestad N. The efficacy
of a treatment program focusing on specific stabilizing
exercises for pelvic girdle pain after pregnancy: a random-
ized controlled trial. Spine. 2004;29:351359. PubMed
doi:10.1097/01.BRS.0000090827.16926.1D
23. Stuge B, Veierod MB, Laerum E, Vollestad N. The efficacy
of a treatment program focusing on specific stabilizing
The Effect of Traditional Bridging 159
exercises for pelvic girdle pain after pregnancy: a two-
year follow-up of a randomized clinical trial. Spine.
2004;29:E197E203. PubMed doi:10.1097/00007632-
200405150-00021
24. McGill SM. Low back exercises: evidence for improving
exercise regimens. Phys Ther. 1998;78:754765. PubMed
25. Vera-Garcia FJ, Grenier SG, McGill SM. Abdominal
muscle response during curl-ups on both stable and labile
surfaces. Phys Ther. 2000;80:564569. PubMed
26. Riemann BL, Myers JB. SM. L. Comparison of the ankle,
knee, hip, and trunk corrective action shown during single-
leg stance on firm, foam, and multiaxial surfaces. Arch
Phys Med Rehabil. 2003;84:9095. PubMed doi:10.1053/
apmr.2003.50004
27. Saliba SA, Croy TW, Grooms DR, Guthrie R, Weltman
A, Grindstaff TL. Differences in transverse abdominis
activation during a stable and unstable bridging exercise
in individuals with low back pain. N Am J Sports Phys
Ther. 2010;5:6373. PubMed
28. Delitto A, Erhard RE, Bowling RW. A treatment-based
classification approach to low back syndrome: identifying
and staging patients for conservative treatment. Phys Ther.
1995;75:470485. PubMed
29. Fritz JM, Cleland JA, Childs JD. Subgrouping patients with
low back pain: evolution of a classification approach to
physical therapy. J Orthop Sports Phys Ther. 2007;37:290
302. PubMed
30. Henry SM, Westervelt KC. The use of real-time ultrasound
feedback in teaching abdominal hollowing exercises to
healthy subjects. J Orthop Sports Phys Ther. 2005;35:338
345. PubMed
31. Hides JA, Miokovic T, Belav DL, Stanton WR, Rich-
ardson CA. Ultrasound imaging assessment of abdominal
muscle function during drawing-in of the abdominal wall:
an intrarater reliability study. J Orthop Sports Phys Ther.
2007;37:480486. PubMed
32. Teyhen DS, Miltenberger CE, Deiters HM, et al. The use of
ultrasound imaging of the abdominal drawing-in maneuver
in subjects with low back pain. J Orthop Sports Phys Ther.
2005;35:346355. PubMed
33. Teyhen DS, Rieger JL, Westrick RB, Miller AC, Molloy
JM, Childs JD. Changes in deep abdominal muscle
thickness during common trunk-strengthening exercises
using ultrasound imaging. J Orthop Sports Phys Ther.
2008;38:596605. PubMed
34. Raney NH, Teyhen DS, Childs JD. Observed changes in
lateral abdominal muscle thickness after spinal manipula-
tion: a case series using rehabilitative ultrasound imaging.
J Orthop Sports Phys Ther. 2007;37:472479. PubMed
35. Gill NW, Teyhen DS, Lee IE. Improved contraction
of the transversus abdominis immediately following
spinal manipulation: a case study using real-time ultra-
sound imaging. Man Ther. 2007;12:280285. PubMed
doi:10.1016/j.math.2006.06.014
36. Pietrosimone BG, Saliba S, Hart JM, Hertel J, Kerrigan
DC, Ingersoll CD. Effects of transcutaneous electrical
nerve stimulation and therapeutic exercise on quadriceps
activation in people with tibiofemoral osteoarthritis. J
Orthop Sports Phys Ther. 2011;41:412. PubMed
37. Chmielewski TL, Stackhouse S, Axe MJ, Snyder-Mackler
L. A prospective analysis of incidence and severity of quad-
riceps inhibition in a consecutive sample of 100 patients
with complete acute anterior cruciate ligament rupture. J
Orthop Res. 2004;22:925930. PubMed doi:10.1016/j.
orthres.2004.01.007
160Guthrie et al
38. Mizner RL, Stevens JE, Snyder-Mackler L. Voluntary
activation and decreased force production of the quadriceps
femoris muscle after total knee arthroplasty. Phys Ther.
2003;83:359365. PubMed
39. Hurley MV, Jones DW, Wilson DR, Newham DJ. Reha-
bilitation of quadriceps inhibited due to isolated rupture
of the anterior cruciate ligament. J Orthop Rheumatol.
1992;5:145154.
40. Klein AB, Snyder-Mackler L, Roy SH, DeLuca CJ.
Comparison of spinal mobility and isometric trunk exten-
sor forces with electromyographic spectral analysis in
identifying low back pain. Phys Ther. 1991;71:445454.
PubMed
41. Allison GT, Morris SL. Transversus abdominis
and core stability: has the pendulum swung? Br J
Sports Med. 2008;42:930931. PubMed doi:10.1136/
bjsm.2008.048637
42. Grenier SG, McGill SM. Quantification of lumbar stability
by using 2 different abdominal activation strategies. Arch
Phys Med Rehabil. 2007;88:5462. PubMed doi:10.1016/j.
apmr.2006.10.014
43. Koumantakis GA, Watson PJ, Oldham JA. Trunk muscle
stabilization training plus general exercise versus general
exercise only: randomized controlled trial of patients with
recurrent low back pain. Phys Ther. 2005;85:209225.
PubMed
44. Brown SH, Howarth SJ, McGill SM. Spine stabil-
ity and the role of many muscles. Arch Phys Med
Rehabil. 2005;86:18901899. PubMed doi:10.1016/j.
apmr.2005.07.281