Archives of Physical Medicine and Rehabilitation
Volume 90, Issue 5 , Pages 761-767, May 2009

Ultrasound Characteristics of the Deep Abdominal Muscles During the Active Straight Leg Raise Test

Presented to the American Physical Therapy Association, February 6–9, 2008, Nashville, TN; and to the Texas Physical Therapy Association, October 18–21, 2007, Galveston, TX.

  • Deydre S. Teyhen, PT, PhD

      Affiliations

    • US Army-Baylor University Doctoral Program in Physical Therapy, Ft. Sam Houston, TX
    • Corresponding Author InformationReprint requests to Deydre S. Teyhen, PT, PhD, Dept of Physical Therapy, US Army Medical Department Center and School, 3150 Stanley Rd, Room 1303, ATTN: MCCS-HMT, Fort Sam Houston, TX 78234
    • ,
  • Jared N. Williamson, PT, DPT

      Affiliations

    • US Army-Baylor University Doctoral Program in Physical Therapy, Ft. Sam Houston, TX
    • ,
  • Nathan H. Carlson, PT, DPT

      Affiliations

    • US Army-Baylor University Doctoral Program in Physical Therapy, Ft. Sam Houston, TX
    • ,
  • Sean T. Suttles, PT, DPT

      Affiliations

    • US Army-Baylor University Doctoral Program in Physical Therapy, Ft. Sam Houston, TX
    • ,
  • Shaun J. O'Laughlin, PT, DPT

      Affiliations

    • US Army-Baylor University Doctoral Program in Physical Therapy, Ft. Sam Houston, TX
    • ,
  • Jackie L. Whittaker, BScPT

      Affiliations

    • School of Health Professions and Rehabilitation Sciences, University of Southampton, Highfield Campus, Southampton, UK
    • ,
  • Stephen L. Goffar, PT, PhD

      Affiliations

    • US Army-Baylor University Doctoral Program in Physical Therapy, Ft. Sam Houston, TX
    • ,
  • John D. Childs, PT, PhD

      Affiliations

    • US Army-Baylor University Doctoral Program in Physical Therapy, Ft. Sam Houston, TX

Article Outline

Abstract 

Teyhen DS, Williamson JN, Carlson NH, Suttles ST, O'Laughlin SJ, Whittaker JL, Goffar SL, Childs JD. Ultrasound characteristics of the deep abdominal muscles during the active straight leg raise test.

Objective

To determine whether changes in the transversus abdominis (TrA) and internal oblique (IO) muscles, as seen on ultrasound imaging, during the active straight leg raise (ASLR) test differ between subjects with and without unilateral lumbopelvic pain.

Design

Cross-sectional, case-control study.

Setting

Clinical laboratory.

Participants

Subjects (n=15) with unilateral symptoms in the lumbopelvic region and age-matched and sex-matched control subjects (n=15).

Interventions

Bilateral measurements of the deep abdominal muscles (TrA and IO) were obtained simultaneously using ultrasound imaging to compare the percent change in muscle thickness from rest with (1) immediately on raising, (2) after a 10-second hold, and (3) within 5 seconds after returning the lower extremity to the plinth.

Main Outcome Measure

Percent change in muscle thickness of both muscles from rest to the other 3 time intervals during the ASLR test.

Results

The 3-way group × side measured × time and 2-way side measured × time interactions were not significant for either the TrA (P≥.34) or the IO (P≥.14) muscles. The 2-way interaction group × time was significant for both the TrA (P=.003) and the IO (P=.02) muscles. On lifting the lower extremity, the control group demonstrated a 23.7% and 11.2% increase in TrA and IO muscle thickness, respectively, while those with lumbopelvic pain demonstrated a 6.4% and 5.7% increase in TrA and IO muscle thickness, respectively.

Conclusions

Although subjects with unilateral lumbopelvic pain demonstrated a smaller increase in muscle thickness, during the ASLR test there appears to be a symmetrical response in both of the deep abdominal muscles regardless of which lower extremity is lifted during the ASLR test or the unilateral nature of the symptoms. This study attests to the potential construct validity of using the ASLR test to assess different motor control strategies of the TrA and IO muscles in subjects with unilateral lumbopelvic pain.

Key Words: Low back pain, Rehabilitation

List of Abbreviations: ASLR, active straight leg raise, CI, confidence interval, ICC, intraclass correlation coefficient, IO, internal oblique, MDC, minimal detectable change, TrA, transversus abdominis, USI, ultrasound imaging

 

ALTERED NEUROMUSCULAR control and muscular function are thought to contribute to the development of chronic lumbopelvic pain, one of the most common reasons people seek medical attention in the United States.1 One common presentation of lumbopelvic pain is unilateral pain over the sacroiliac joint region. Patients with lumbopelvic pain have been shown to have altered muscle recruitment patterns of the TrA and IO muscles.2, 3, 4

The ASLR test has been used to assess the functional ability to transfer loads through the pelvis,5, 6, 7, 8 and has been used to discriminate between patients with lumbopelvic pain and healthy subjects.5, 6 The ASLR test is performed with the patient lying supine. The test is judged to be positive when the patient flexes the hip by lifting the lower extremity with the knee fully extended off the table 5cm and experiences unilateral pain, discomfort, or a feeling of heaviness relative to when the opposite leg is lifted.4, 7 The ASLR test has been validated against radiographic mobility of the pelvic joints7 and has been correlated with other disease severity scales in patients with lumbopelvic pain.6 O'Sullivan et al4 demonstrated that subjects with a positive ASLR test used different load transfer strategies (ie, increased pelvic floor descent and changes in intra-abdominal pressure) during the test than those in whom the test was negative. However, they did not assess the role of the deep abdominal muscles (TrA and IO) during the ASLR test. Knowledge of muscle performance (ie, a change in muscle thickness) of deep abdominal muscles during the ASLR test and comparing differences between those with and without unilateral lumbopelvic dysfunction may provide valuable insights into underlying motor control deficits in this patient population.

Despite the purported usefulness of the ASLR test, only minimal evidence has been reported regarding the muscular response of the pelvic floor muscles during this test.4 Recent advancements in the field of rehabilitative USI9 have allowed assessments of the deep abdominal muscles' behavior during specific tasks.10, 11, 12 USI is a noninvasive tool that has proven a reliable and valid measurement of muscle activity and thickness based on comparisons with electromyography and magnetic resonance imaging, respectively,13, 14, 15, 16, 17, 18, 19, 20 including differentiating changes in thickness of the TrA and IO muscles. However, limited information exists regarding the muscular behavior of the deep abdominal muscles in subjects with a positive ASLR test. The primary purpose of this study was to determine whether changes in muscle thickness of the TrA and IO muscles during performance of the ASLR test differ between subjects with and without unilateral lumbopelvic pain. The secondary purpose was to determine whether differences in percent change in muscle thickness exist based on whether the lower extremity lifted was ipsilateral or contralateral to the side of symptoms. Understanding the answer to these questions will help provide additional evidence of construct validity for the ASLR test in patients with lumbopelvic pain. A better understanding of the performance of the deep abdominal muscles during limb movement may ultimately prove beneficial in terms of prescribing specific therapeutic exercises to help decrease the severity and recurrence of lumbopelvic pain.

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Methods 

Subjects 

We recruited a sample of 30 adults between 18 to 50 years of age, 15 subjects with lumbopelvic pain and 15 healthy age-matched (±2y) and sex-matched control subjects who did not meet any of the exclusion criteria (appendix 1). The determination of lumbopelvic pain was based on at least 1 positive sacroiliac provocation test (see appendix 1)21, 22, 23, 24 and a positive ASLR test.4, 7 These tests were selected based on their use in previous research to identify a subgroup of patients with unilateral lumbopelvic pain and to facilitate our ability to compare our findings with previous research on the ASLR test.4, 21, 22, 23, 24 All subjects were Department of Defense health care beneficiaries, including active duty military, family members, and retirees. Subjects provided written informed consent and signed Health Insurance Portability and Accountability Act privacy forms approved by the Brooke Army and Wilford Hall Medical Centers' Institutional Review Board prior to participation.

Procedures 

This study used a cross-sectional, case-control design in which all data were collected in a single session. We screened potential subjects with lumbopelvic pain with a physical examination including the ASLR and sacroiliac joint provocation tests. Eligible consenting subjects completed an additional physical examination, history, and demographic questionnaire. Additionally, we provided subjects with educational information about the abdominal musculature and a standardized overview of the testing procedures.

Active Straight Leg Raise Test 

The ASLR test was performed with the subject lying supine with lower extremities straight on a standard plinth, hands resting on the chest, and elbows on the plinth. The feet were positioned 20cm apart prior to the subject being asked to raise the lower extremity 5cm off the plinth without bending the knee.4 During the initial instructions, the investigator lifted the subject's lower extremity to the correct position (5cm) and stated, “This is the position we are going to use for the ASLR test.” To coordinate the timing of the ASLR test and the USI assessment, subjects were told which lower extremity to lift, then given the preparatory command, “prepare to lift,” and the command of execution, “lift.” After holding the lower extremity in the raised position for 10 seconds, subjects were given the commands “prepare to lower,” and “lower,” to return the lower extremity to the resting position.

All subjects performed the ASLR test with both lower extremities. An average of 3 repetitions of the ASLR test per lower extremity was used to assess changes in muscle thickness of the deep abdominal muscles during the ASLR test. Test order was counter-balanced to protect against the potential for an order effect to occur. To minimize the influence of fatigue, a 30-second rest period was provided between each condition.

Ultrasound Imaging 

Changes in muscle thickness during the ASLR test were assessed with USI. Bilateral ultrasound measurements were obtained simultaneously by 2 pairs of researchers using 2 portable ultrasound unitsa with 5-MHz, 60-mm curvilinear arrays (fig 1). USI was obtained as outlined by previous researchers.10, 25, 26 The transducers were placed on the anterolateral aspect of the abdominal wall just superior to the iliac crest, perpendicular to the body's axillary line,10, 25, 26 and oriented to capture the anterior insertion of the TrA. During quantitative assessment, the interface of the thoracolumbar fascia and TrA was visualized in the upper right margin of the onscreen display.

Resting thickness values were obtained at the end of a normal expiration as determined based on visual observation of the ultrasound image.10, 25, 26 To assess change in muscle thickness, resting thickness values were compared with 3 different points during the ASLR test: (1) immediately on lifting the straight lower extremity, (2) after the 10-second hold period, and (3) within 5 seconds after returning the lower extremity to the final (resting) phase of the ASLR test. Measurements of muscle thickness were performed using Image-Pro Plus Software version 4.5.b Electronic onscreen calipers were aligned at the superficial border of each muscle's hyperechoic fascial line (fig 2). A vertical straight line through the center of the ultrasound image was used to ensure standardized placement of the measurement line in relation to the center of the TrA muscle belly. Percent change in thickness between the initial resting state and the other 3 points in time (immediately on lifting the lower extremity, after the 10-second hold period, and within 5 seconds after returning the lower extremity to the resting position) was calculated to assess the changes in TrA and IO muscle thickness during the ASLR test.

  • View full-size image.
  • Fig 2. 

    Ultrasound image of the deep abdominal muscles depicting (top to bottom) skin, superficial fascia, hyperechoic fascial borders (white), external oblique, internal oblique, transversus abdominis muscles (dark gray, between white borders), and abdominal contents.

To minimize bias, 3 pairs of investigators collected data; one investigator in each team was designated as the recorder, and the other investigator was designated as the imager. The imager was responsible for positioning the transducer for optimal visualization of the musculature while the recorder verified proper exercise performance and annotated measurements. Each member of the team was required to agree on the placement of the transducer prior to the start of each ASLR test. The teams consisted of physical therapy students who were provided training sessions in the measurement procedures by 2 investigators (D.S.T. and J.L.W.) experienced with the use of USI in the assessment of anterolateral abdominal musculature. To collect the bilateral ultrasound images, 2 pairs of researchers were used with each subject.

A pilot study consisting of 10 healthy subjects was used to establish interrater reliability of the teams' ability to measure the muscle thickness at rest and while performing the ASLR test. Averages of 3 measurements of muscle thickness were assessed at rest and while the subject held the raised position during the ASLR test. Both investigators in each team were blinded from the measurement values during ASLR test performances. Interrater reliability was calculated using the ICC2,3 model, and the response stability was calculated using the SE of the measurement and minimal detectable change (table 1). These values were consistent with previous reports using the same measurement technique to assess the abdominal drawing-in maneuver.10, 26 Previous researchers have found the interimage and interrater reliability to have ICCs greater than .93 using the same measurement technique to assess the abdominal drawing-in maneuver.10, 26

Table 1. Interrater Reliability Ultrasound Imaging Values
(n=10)ICC95% CISEMMDC95
TrA
Rest0.940.86–0.980.25mm0.69mm
Contracted0.960.88–0.990.27mm0.75mm
Percent change0.880.69–0.977.1%19.6%
IO
Rest0.990.96–1.00.38mm1.05mm
Contracted0.970.93–0.990.67mm1.86mm
Percent change0.890.72–0.976.8%19.0%

Abbreviations: MDC95, minimal detectable change based on the 95% CI; SEM, standard error of the measurement.

Data Analysis 

The dependent measures were percent change of muscle thickness of the TrA and IO muscles. The muscular thickness of TrA (equation 1) and the IO muscles (equation 2) while contracted were normalized based on the resting thickness values. These percentages were calculated to assess relative change of muscle thickness of these 2 deep abdominal muscles.

(1)
(2)

Descriptive statistics, including measures of central tendency and dispersion for continuous variables, were calculated to summarize the data. Baseline variables between groups were compared with paired t tests for continuous data. We examined the primary aim with a 3-way repeated-measures analysis of variance. Independent variables were group with 2 levels (those with and without unilateral lumbopelvic pain), side with 2 levels (ipsilateral or contralateral to lower extremity raised), and time with 3 levels (from rest to immediately on lifting the straight lower extremity, to the end of the hold period, and to returning the lower extremity to the resting posture). For patients in the unilateral lumbopelvic group, the ipsilateral side was the symptomatic side, and the contralateral side was the asymptomatic side for the ASLR test. Post hoc analyses were performed using paired t tests. Paired t tests were used based on the subjects in both groups being matched for age and sex. Each comparison was subject to an alpha level equal to .05 based on the exploratory purpose of the study. All statistical analyses were conducted using SPSS 12.0.c

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Results 

Subjects 

Thirty subjects enrolled in this study, 15 subjects with unilateral lumbopelvic pain (mean ± SD, 38.3±8.6y; 26.7±4.1kg/m2) and 15 age-matched (±2y) and sex-matched control subjects (mean ± SD, 36.7±8.8y; 27.2±3.7kg/m2). Each group contained 7 female subjects (46.7%). All subjects with unilateral lumbopelvic pain had a positive ASLR test and had 2.9±0.7 sacroiliac joint provocation tests. Those with unilateral lumbopelvic pain had an Oswestry Disability Index score of (22.7±11.9%) and a fear-avoidance belief questionnaire (work subscale) score of (14.1±9.3). Of the subjects with unilateral lumbopelvic pain, 6 had greater than 10 prior episodes, 2 had between 5 and 10 episodes, 3 had 3 to 5 prior episodes, and 4 had less than 3 prior episodes of lumbopelvic pain. Only 2 subjects with lumbopelvic pain and 1 subject from the control group reported not participating in regular physical activity.

Resting thickness of the TrA and IO muscles was equivalent between the groups. Average thickness of the TrA muscle at rest was 4.4±0.1mm and 3.8±0.7mm for those without and with lumbopelvic pain, respectively (P=.07). Average thicknesses of the IO muscle at rest were 8.7±3.0mm and 7.9±2.4mm for those without and with lumbopelvic pain, respectively (P=.45).

Changes in Muscle Thickness During the Phases of the Active Straight Leg Raise Test Based on Group and Side Measured 

The 3-way group × side measured × time interaction was not significant for either the TrA (P=.34) or the IO (P=.20) muscles. Additionally, the 2-way side measured × time interaction was not significant for either the TrA (P=.37) or the IO (P=.14) muscles. The bilateral ultrasound measurements obtained during the ASLR test demonstrated a symmetrical response (table 2, fig 3) in changes in muscle thickness of the TrA muscle from rest to when the lower extremity was lifted (P=.91), during the hold phase (P=.46), and on lowering the lower extremity (P=.65). A bilateral response of the IO muscles from rest to when the lower extremity was lifted (P=.06), during the hold phase (P=.13), and on lowering the lower extremity (P=.38) was also noted. However, a post hoc analysis showed that the power was low for both muscles (TrA=.20; IO=.35) for the 2-way interaction.

Table 2. Percent Change in Muscle Thickness During the Active Straight Leg Raise Test Based on Measurement of the Asymptomatic or Symptomatic Side⁎
N=30 Side Measured†
IpsilateralContralateralMean Difference
Muscle MeasuredStage of ASLRMean ± SD95% CIMean ± SD95% CIMean ± SD95% CI
TrA (%)To lift15.3±2.99.4to21.214.8±2.98.9to20.70.5±4.1–7.9to8.8
To hold11.9±3.05.9to17.815.0±3.09.1to20.9–3.1±4.2–11.5to5.3
To return2.7±1.30.1to5.41.9±1.3–0.7to4.50.8±1.8–2.9to4.5
IO (%)To lift5.5±2.11.2to9.811.4±2.17.1to15.6–5.9±3.0–11.9to0.2
To hold6.8±2.71.4to12.212.6±2.77.2to18.0–5.8±3.8–13.4to1.8
To return0.7±1.1–1.4to2.92.1±1.1–0.1to4.2–1.3±1.5–4.4to1.7

⁎The 3-way group × side measured × time interaction was not significant for either the TrA (P=.34) or the IO (P=.20) muscles. Additionally, the 2-way side measured × time interaction was not significant for either the TrA (P=.37) or the IO (P=.14) muscles. Therefore, the data presented represent all 30 subjects.

†For patients in the unilateral lumbopelvic group, the ipsilateral side was the symptomatic side and the contralateral side was the asymptomatic side for the ASLR test.

  • View full-size image.
  • Fig 3. 

    Percent changes in muscle thickness of the TrA and IO muscles were not statistically significant based on whether the ultrasound measurements were obtained on the ipsilateral or contralateral side (symptomatic or asymptomatic side for the lumbopelvic group), or based on group membership.

Changes in Muscle Thickness in Subjects With and Without Lumbopelvic Pain 

The 2-way interaction group × time was significant for both the TrA (P=.003) and the IO (P=.02) muscles (table 3, fig 4). Comparison of measurements between groups demonstrated a decreased percent change in muscle thickness during the ASLR test in subjects with unilateral lumbopelvic pain compared with the age-matched and sex-matched control subjects. The mean percent change in TrA muscle thickness during the lifted phases of the ASLR test ranged from 20% to 24% in those without lumbopelvic pain and was only 6% to 7% in those with unilateral lumbopelvic pain, and this response was statistically significant (P≤.003). The mean difference between the groups from rest to leg lift was 17.3% (95% CI, 9.0%–25.6%), and the mean difference between the groups from rest to the end of the 10-second hold time was 12.9% (95% CI, 4.5%–21.3%). The mean percent change in IO muscle thickness during the lifted phases of the ASLR test ranged from 11% to 13% in those without unilateral lumbopelvic pain and was only 5% to 6% in those with unilateral lumbopelvic pain (P≥.07). The mean difference between the groups from rest to leg lift was 5.5% (95% CI, –0.5% to 11.5%), and the mean difference between the groups from rest to the 10-second hold time was 6.6% (95% CI, –1.0% to 14.2%).

Table 3. Percent Change in Muscle Thickness During the Active Straight Leg Raise Test for Those With and Without Unilateral Lumbopelvic Pain
Group Assigned
Control (n=15)Lumbopelvic (n=15)Mean Difference
Muscle MeasuredStage of ASLRMean ± SD95% CIMean ± SD95% CIMean ± SD95% CI
TrA (%)To lift⁎23.7±2.917.8to29.66.4±2.90.5to12.317.3±4.19.0to25.6
To hold†19.9±3.013.9to25.87.0±3.01.0to12.912.9±4.24.5to21.3
To return†5.2±1.32.5to7.8–0.5±1.3–3.1to2.15.7±1.81.9to9.4
IO (%)To lift11.2±2.16.9to15.55.7±2.11.4to9.95.5±3.0–0.5to11.5
To hold13.0±2.77.6to18.46.4±2.71.0to11.86.6±3.8–1.0to14.2
To return1.0±1.1–1.1to3.21.8±1.1–0.4to3.90.7±1.5–2.3to3.8

⁎Pairwise comparison between group assignments (P<.001).

†Pairwise comparison between group assignments (P=.003).

Changes in Muscle Thickness During the Phases of the Active Straight Leg Raise Test 

There was a main effect of time for both the TrA and IO muscles (P<.001). In general, the muscle thickness values increased on lifting the leg, and these changes in muscle thickness were maintained throughout the 10-second hold phase for both the TrA (P=.56) and the IO (P=.29) muscles. On lowering the lower extremity to the plinth, the muscle thickness values decreased for both the TrA and the IO (P<.001) muscles. Although the percent change in muscle thickness for those with unilateral lumbopelvic pain was diminished, the pattern of change in muscle thickness was consistent regardless of group assignment or side measured (see Fig 3, Fig 4).

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Discussion 

Despite its purported use in the clinical examination of patients with lumbopelvic pain, scant evidence exists to describe the deep abdominal muscle response during the ASLR test.4, 5, 6, 7, 8 Although preliminary evidence has identified altered pelvic floor muscle performance during the ASLR test,4 it was unknown whether the performance of the deep abdominal muscles differed based on the presence or absence of lumbopelvic pain, or whether the lower extremity lifted was ipsilateral or contralateral to the symptomatic side. In this study, subjects with unilateral lumbopelvic pain demonstrated a different muscular response during the ASLR test. Those with unilateral lumbopelvic pain demonstrated a diminished change in muscle thickness of both the TrA and IO muscles compared with asymptomatic subjects. Based on an average resting thickness value of 4.4mm in those without lumbopelvic pain, the 23.7% increase represents an average increase of 1mm muscle thickness after the leg is lifted in the ASLR test. In comparison, those with lumbopelvic pain had an average resting thickness value of the TrA of 3.8mm; therefore, the 6.4% increase would represent only a .24-mm increase in TrA thickness. Although these findings were statistically significant and the absolute change in muscle thickness values exceeded the MDC value, the percent change does not exceed the MDC. Our reported MDC may be artificially conservative because of low sample size.

A comparison of the percent change values for both muscles also provides additional information regarding the muscle behavior of these muscles during the ASLR test. In those without lumbopelvic pain, the average increase in TrA thickness was about twice that of the IO muscle (23.7% and 11.2%, respectively) during the ASLR test, while those with unilateral lumbopelvic pain demonstrated minimal changes in muscle thickness in both the TrA and IO muscles (6.4% and 5.7%, respectively). The changes in those without lumbopelvic pain are consistent with prior findings that suggest a preferential response of the TrA muscle during similar motor control tasks.10, 11, 12 The smaller and different pattern of changes in muscle thickness in patients with unilateral lumbopelvic pain who have a positive ASLR test suggest that patients with unilateral lumbopelvic pain who have a positive ASLR test may benefit from motor control exercises that specifically target activation of the deep abdominal musculature. Our findings corroborate the findings of previous researchers4, 5, 6, 7, 27, 28 who have advocated the clinical utility of the ASLR test to identify patients with dysfunction in the lumbopelvic region. Future researchers should assess whether these changes represent changes in motor control strategies, muscle inhibition, or associated with increases in intra-abdominal pressure.

Both groups of subjects, those with and without unilateral lumbopelvic pain, demonstrated a symmetrical change in TrA or IO muscle thickness during the ASLR test, regardless of whether the ultrasound measurements were ipsilateral or contralateral to the side of symptoms, which is consistent with prior research suggesting that these deep abdominal muscles function similarly on both sides.11, 12 Clinically, this reinforces the concept that these TrA and IO muscles function as a coordinated unit during the execution of a unilateral limb movement.11, 12 The power for this 2-way interaction for group × side measured was relatively low for both muscles (TrA=.20; IO=.35). Although the differences in group means for the TrA muscle do not appear to be clinically meaningful, the potential for there to be a clinically meaningful difference in the IO muscle should be explored further in future research. Specifically, it would be interesting to explore the potential trend for a greater percent change in muscle thickness of the IO muscle on the side contralateral to the symptomatic side for the ASLR test.

Results from this study may also assist future researchers in the assessment of the deep abdominal muscles using ultrasound imaging during the ASLR test. In the absence of a difference in muscular response bilaterally, it may make intuitive sense to select the symptomatic side for future assessment of muscular performance. Additionally, the percent changes in muscle thickness on lifting the lower extremity and after the lower extremity was held for 10 seconds were not statistically significant for either those with or without lumbopelvic pain. Therefore, measurements to represent the activated state of the deep abdominal muscles could be assessed at any time during the lifted phase of the ASLR test.

Study Limitations 

There are several limitations to this study that should be considered. Our sample size was relatively low. Additionally, our sample included only those subjects with unilateral lumbopelvic pain with symptoms over the sacroiliac region who had a positive ASLR test; therefore, our results may not be generalizable to a wide spectrum of patients with low back pain. Future researchers should assess the influence of a lumbar stabilization exercise regimen on the clinical and muscular response of the ASLR test in those with unilateral lumbopelvic pain.

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Conclusions 

Although subjects with unilateral lumbopelvic pain demonstrated a different muscular response than asymptomatic subjects, there appears to be a symmetrical response in the deep abdominal muscles regardless of which lower extremity is lifted during the ASLR test or the unilateral nature of the symptoms. Subjects with unilateral lumbopelvic pain did not display a preferential change in TrA muscle thickness compared with those without lumbopelvic pain during the ASLR test. This study provides an element of construct validity for using the ASLR test to assess muscular response of the TrA and IO muscles in subjects with unilateral lumbopelvic pain.

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Acknowledgments 

In memoriam, we acknowledge Captain Anna Kelly, USAF, who assisted in the development of the methods and data collection during this study. Additionally, we thank the following personnel for assistance in data collection: Nichole Bluemle, PT, DPT, Jeff Dolbeer, PT, DPT, and Sarah Baker, PT, DPT.

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Appendix 1: Inclusion and Exclusion Criteria 

Inclusion criteria for the lumbopelvic pain group1. Unilateral pain over the sacroiliac joint. Defined as not proximal to the iliac crests3, 4, 5, 29, 30 and not distal to the popliteal fossa.
2. A positive ASLR test.4, 7
3. Pain lasting over 3mo without signs of abating.4
4. A positive result on 1 of 6 sacroiliac joint provocation tests (Sn=1.00; Sp=0.44).4, 21, 22
A. Distraction.
B. Compression.
C. Posterior shear test (thigh-thrust test).
D. Gaenslen provocation test (right).
E. Gaenslen provocation test (left).
F. Sacral thrust test.
General exclusion criteria for both groups1. Known pregnancy, or pregnancy less than 6mo postpartum.4, 5
2. A history of fracture, neoplasm, or previous surgery of the lumbar spine, the pelvic girdle, the hip joint, or the femur.5
3. Signs of radiculopathy, as defined by 2 of the 4 neurologic signs: diminished sensation to touch in a dermatomal region, a positive neural tension test, motor weakness not secondary to pain, or diminished reflexes.5
4. Bilateral sacroiliac pain or a bilaterally positive ASLR test.
Exclusion criteria for the control group1. A history of low back, sacroiliac, pelvic, hip, or thigh pain in the last year resulting in lost work days, inability to perform recreational activities, or symptoms that required medical attention.31
2. A history of congenital lumbar or pelvic anomalies.29
3. An inability to perform or a positive ASLR test.4, 29

Abbreviations: Sn, Sensitivity; Sp, Specificity.

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  • a Ultrasound imaging device, Sonosite TITAN; Sonosite Inc, 21919 30th Dr SE, Bothell, WA 98021.
  • b Image Processing Solutions Inc, 761 Silver Spring Ave, Ste B, Silver Spring, MD 20910.
  • c SPSS Inc, 233 S. Wacker Dr., 11th Fl, Chicago, IL 60606.

 We certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on us or on any organization with which we are associated.

 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 Departments of the Army, Air Force, or Defense.

PII: S0003-9993(09)00120-8

doi:10.1016/j.apmr.2008.11.011

Archives of Physical Medicine and Rehabilitation
Volume 90, Issue 5 , Pages 761-767, May 2009

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