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Determining the Activation of Gluteus Medius and the Validity of the Single Leg Stance Test in Chronic, Nonspecific Low Back Pain

      Abstract

      Objectives

      To determine the activation of the gluteus medius in persons with chronic, nonspecific low back pain compared with that in control subjects, and to determine the association of the clinical rating of the single leg stance (SLS) with chronic low back pain (CLBP) and gluteus medius weakness.

      Design

      Cohort-control comparison.

      Setting

      Academic research laboratory.

      Participants

      Convenience sample of people (n=21) with CLBP (>12wk) recruited by local physiotherapists, and age- and sex-matched controls (n=22). Subjects who received specific pain diagnoses were excluded.

      Interventions

      Not applicable.

      Main Outcome Measures

      Back pain using the visual analog scale (mm); back-related disability using the Oswestry Back Disability Index (%); strength of gluteus medius measured using a hand dynamometer (N/kg); SLS test; gluteus medius onset and activation using electromyography during unipedal stance on a forceplate.

      Results

      Individuals in the CLBP group exhibited significant weakness in the gluteus medius compared with controls (right, P=.04; left, P=.002). They also had more pain (CLBP: mean, 20.50mm; 95% confidence interval [CI], 13.11–27.9mm; control subjects: mean, 1.77mm; 95% CI, −.21 to 3.75mm) and back-related disability (CLBP: mean, 18.52%; 95% CI, 14.46%–22.59%; control subjects: mean, .68%; 95% CI, −.41% to 1.77%), and reported being less physically active. Weakness was accompanied by increased gluteus medius activation during unipedal stance (R=.50, P=.001) but by no difference in muscle onset times. Although greater gluteus medius weakness was associated with greater pain and disability, there was no difference in muscle strength between those scoring positive and negative on the SLS test (right: F=.002, P=.96; left: F=.1.75, P=.19).

      Conclusions

      Individuals with CLBP had weaker gluteus medius muscles than control subjects without back pain. Even though there was no significant difference in onset time of the gluteus medius when moving to unipedal stance between the groups, the CLBP group had greater gluteus medius activation. A key finding was that a positive SLS test did not distinguish the CLBP group from the control group, nor was it a sign of gluteus medius weakness.

      Keywords

      List of abbreviations:

      CLBP (chronic low back pain), EMG (electromyography), iEMG (integrated electromyography), MVC (maximum voluntary contraction), RMS (root mean square), SLS (single leg stance), VAS (visual analog scale)
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      References

        • Panjabi M.M.
        The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement.
        J Spinal Disord. 1992; 5: 383-389
        • Hodges P.W.
        • Richardson C.A.
        Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis.
        Spine (Phila Pa 1976). 1996; 21: 2640-2650
        • Hodges P.W.
        • Richardson C.A.
        Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limb.
        J Spinal Disord. 1998; 11: 46-56
        • Nadler S.F.
        • Malanga G.A.
        • Bartoli L.
        • Feinberg J.H.
        • Prybicien M.
        • Deprince M.
        Hip muscle imbalance and low back pain in athletes: influence of core strengthening.
        Med Sci Sports Exerc. 2002; 34: 9-16
        • Hungerford B.
        • Gilleard W.
        • Hodges P.
        Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain.
        Spine (Phila Pa 1976). 2003; 28: 1593-1600
        • Nelson-Wong E.
        • Gregory D.E.
        • Winter D.A.
        • Callaghan J.P.
        Gluteus medius muscle activation patterns as a predictor of low back pain during standing.
        Clin Biomech (Bristol, Avon). 2008; 23: 545-553
        • Tsao H.
        • Galea M.P.
        • Hodges P.W.
        Reorganization of the motor cortex is associated with postural control deficits in recurrent low back pain.
        Brain. 2008; 131: 2161-2171
        • Ferguson S.A.
        • Marras W.S.
        • Burr D.L.
        • Davis K.G.
        • Gupta P.
        Differences in motor recruitment and resulting kinematics between low back pain patients and asymptomatic participants during lifting exertions.
        Clin Biomech (Bristol, Avon). 2004; 19: 992-999
        • Lamoth C.J.
        • Meijer O.G.
        • Daffertshofer A.
        • Wuisman P.I.
        • Beek P.J.
        Effects of chronic low back pain on trunk coordination and back muscle activity during walking: changes in motor control.
        Eur Spine J. 2006; 15: 23-40
        • Vogt L.
        • Pfeifer K.
        • Banzer W.
        Neuromuscular control of walking with chronic low-back pain.
        Man Ther. 2003; 8: 21-28
        • Nouwen A.
        • Van Akkerveeken P.F.
        • Versloot J.M.
        Patterns of muscular activity during movement in patients with chronic low-back pain.
        Spine (Phila Pa 1976). 1987; 12: 777-782
        • Lariviere C.
        • Gagnon D.
        • Loisel P.
        The comparison of trunk muscles EMG activation between subjects with and without chronic low back pain during flexion-extension and lateral bending tasks.
        J Electromyogr Kinesiol. 2000; 10: 79-91
        • Ng J.K.
        • Richardson C.A.
        • Parnianpour M.
        • Kippers V.
        EMG activity of trunk muscles and torque output during isometric axial rotation exertion: a comparison between back pain patients and matched controls.
        J Orthop Res. 2002; 20: 112-121
        • van Dieen J.H.
        • Cholewicki J.
        • Radebold A.
        Trunk muscle recruitment patterns in patients with low back pain enhance the stability of the lumbar spine.
        Spine (Phila Pa 1976). 2003; 28: 834-841
        • Bruno P.A.
        • Bagust J.
        An investigation into motor pattern differences used during prone hip extension between subjects with and without low back pain.
        Clin Chiropractic. 2007; 10: 68-80
        • Leinonen V.
        • Kankaanpaa M.
        • Airaksinen O.
        • Hanninen O.
        Back and hip extensor activities during trunk flexion/extension: effects of low back pain and rehabilitation.
        Arch Phys Med Rehabil. 2000; 81: 32-37
        • Pirouzi S.
        • Hides J.
        • Richardson C.
        • Darnell R.
        • Toppenberg R.
        Low back pain patients demonstrate increased hip extensor muscle activity during standardized submaximal rotation efforts.
        Spine (Phila Pa 1976). 2006; 31: E999-1005
        • Himmelreich H.
        • Vogt L.
        • Banzer W.
        Gluteal muscle recruitment during level, incline and stair ambulation in healthy subjects and chronic low back pain patients.
        J Back Musculoskelet Rehabil. 2008; 21: 193-199
        • Gottschalk F.
        • Kourosh S.
        • Leveau B.
        The functional anatomy of tensor fasciae latae and gluteus medius and minimus.
        J Anat. 1989; 166: 179-189
        • Richardson C.
        • Jull G.
        • Hodges P.
        • Hides J.
        Therapeutic exercises for spinal segmental stabilization in low back pain: scientific basis and clinical approach.
        Churchill Livingstone, Edinburgh1999
        • Gibbons S.
        • Comerford M.
        Strength versus stability: part 1: concepts and terms.
        Orthop Division Rev. 2001; 4: 21-27
        • Kibler W.B.
        • Press J.
        • Sciascia A.
        The role of core stability in athletic function.
        Sports Med. 2006; 36: 189-198
        • Borghuis J.
        • Hof A.L.
        • Lemmink K.A.
        The importance of sensory-motor control in providing core stability: implications for measurement and training.
        Sports Med. 2008; 38: 893-916
        • Semciw A.I.
        • Pizzari T.
        • Murley G.S.
        • Green R.A.
        Gluteus medius: an intramuscular EMG investigation of anterior, middle and posterior segments during gait.
        J Electromyogr Kinesiol. 2013; 23: 858-864
        • Cresswell A.G.
        • Oddsson L.
        • Thorstensson A.
        The influence of sudden perturbations on trunk muscle activity and intra-abdominal pressure while standing.
        Exp Brain Res. 1994; 98: 336-341
        • Hodges P.W.
        • Richardson C.A.
        Contraction of the abdominal muscles associated with movement of the lower limb.
        Phys Ther. 1997; 77 (discussion 142-4): 132-142
        • Hodges P.
        • Cresswell A.
        • Thorstensson A.
        Preparatory trunk motion accompanies rapid upper limb movement.
        Exp Brain Res. 1999; 124: 69-79
        • Moseley G.L.
        • Hodges P.W.
        • Gandevia S.C.
        Deep and superficial fibers of the lumbar multifidus muscle are differentially active during voluntary arm movements.
        Spine (Phila Pa 1976). 2002; 27: E29-36
        • Guimaraes C.Q.
        • Sakamoto A.C.
        • Laurentino G.E.
        • Teixeira-Salmela L.F.
        Electromyographic activity during active prone hip extension did not discriminate individuals with and without low back pain.
        Rev Bras Fisioter. 2010; 14: 351-357
        • Comerford M.J.
        • Mottram S.L.
        Functional stability re-training: principles and strategies for managing mechanical dysfunction.
        Man Ther. 2001; 6: 3-14
        • Rogers M.W.
        • Pai Y.-C.
        Dynamic transitions in stance support accompanying leg flexion movements in man.
        Exp Brain Res. 1990; 81: 398-402
        • Kendall K.D.
        • Schmidt C.
        • Ferber R.
        The relationship between hip-abductor strength and the magnitude of pelvic drop in patients with low back pain.
        J Sport Rehabil. 2010; 19: 422-435
        • Arab A.M.
        • Nourbakhsh M.R.
        The relationship between hip abductor muscle strength and iliotibial band tightness in individuals with low back pain.
        Chiropr Osteopat. 2010; 18: 1
        • Nadler S.F.
        • Malanga G.A.
        • Fienberg J.H.
        • Prybicien M.
        • Stitik T.P.
        • DePrince M.
        Relationship between hip muscle imbalance and occurrence of low back pain in collegiate athletes: a prospective study.
        Am J Phys Med Rehabil. 2001; 28: 572-577
        • Marshall P.W.
        • Patel H.
        • Callaghan J.P.
        Gluteus medius strength, endurance, and co-activation in the development of low back pain during prolonged standing.
        Hum Mov Sci. 2011; 30: 63-73
        • Nelson-Wong E.
        • Callaghan J.P.
        Is muscle co-activation a predisposing factor for low back pain development during standing? A multifactorial approach for early identification of at-risk individuals.
        J Electromyogr Kinesiol. 2010; 20: 256-263
        • Hardcastle P.
        • Nade S.
        The significance of the Trendelenburg test.
        J Bone Joint Surg Br. 1985; 67: 741-746
        • Lee D.
        Treatment of pelvic instability.
        in: Vleeming A. Mooney V. Dorman T. Snijders C. Stoeckart R. Movement and stability and low back pain: the essential role of the pelvis. Churchill Livingstone, New York1997: 445-460
        • Sahrmann S.
        Diagnosis and treatment of movement impairment syndromes.
        Mosby, St. Louis2002
        • Roussel N.A.
        • Nijs J.
        • Truijen S.
        • Smeuninx L.
        • Stassijns G.
        Low back pain: clinimetric properties of the Trendelenburg test, active straight leg raise test, and breathing pattern during active straight leg raising.
        J Manipulative Physiol Ther. 2007; 30: 270-278
        • Tidstrand J.
        • Horneij E.
        Inter-rater reliability of three standardized functional tests in patients with low back pain.
        BMC Musculoskelet Disord. 2009; 10: 58
        • DiMattia M.A.
        • Livengood A.L.
        • Uhl T.L.
        • Mattacola C.G.
        • Malone T.R.
        What are the validity of the single-leg-squat test and its relationship to hip-abduction strength?.
        J Sport Rehabil. 2005; 14: 108-123
        • Kendall K.D.
        • Patel C.
        • Wiley J.P.
        • Pohl M.B.
        • Emery C.A.
        • Ferber R.
        Steps toward the validation of the Trendelenburg test: the effect of experimentally reduced hip abductor muscle function on frontal plane mechanics.
        Clin J Sport Med. 2013; 23: 45-51
        • Millisdotter M.
        • Stromqvist B.
        • Jonsson B.
        Proximal neuromuscular impairment in lumbar disc herniation: a prospective controlled study.
        Spine (Phila Pa 1976). 2003; 28: 1281-1289
        • Fetto J.
        • Leali A.
        • Moroz A.
        Evolution of the Koch model of the biomechanics of the hip: clinical perspective.
        J Orthop Sci. 2002; 7: 724-730
        • Summers S.
        Evidence-based practice part 2: reliability and validity of selected acute pain instruments.
        J Perianesth Nurs. 2001; 16: 35-40
        • Fairbank J.C.
        • Pynsent P.B.
        The Oswestry Disability Index.
        Spine (Phila Pa 1976). 2000; 25: 2940-2952
        • Tremblay M.S.
        • Shephard R.J.
        • McKenzie T.L.
        • Gledhill N.
        Physical activity assessment options within the context of the Canadian Physical Activity, Fitness, and Lifestyle Appraisal.
        Can J Appl Physiol. 2001; 26: 388-407
        • Hodges P.W.
        • Bui B.H.
        A comparison of computer-based methods for the determination of onset of muscle contraction using electromyography.
        Electroencephalogr Clin Neurophysiol. 1996; 101: 511-519
        • Perry J.
        • Bekey G.
        EMG-force relationships in skeletal muscle.
        Crit Rev Biomed Eng. 1981; 7: 1-22
        • Kendall F.P.
        Muscles: testing and function, with posture and pain.
        4th ed. Williams & Wilkins, Baltimore1993
        • Ekstrom R.A.
        • Donatelli R.A.
        • Carp K.C.
        Electromyographic analysis of core trunk, hip, and thigh muscles during 9 rehabilitation exercises.
        J Orthop Sports Phys Ther. 2007; 37: 754-762
        • Burden A.M.
        • Trew M.
        • Baltzopoulos V.
        Normalisation of gait EMGs: a re-examination.
        J Electromyogr Kinesiol. 2003; 13: 519-532
        • Sims K.J.
        • Brauer S.G.
        A rapid upward step challenges medio-lateral postural stability.
        Gait Posture. 2000; 12: 217-224
        • Jaric S.
        Muscle strength testing: use of normalisation for body size.
        Sports Med. 2002; 32: 615-631
        • Fredericson M.
        • Cookingham C.L.
        • Chaudhari A.M.
        • Dowdell B.C.
        • Oestreicher N.
        • Sahrmann S.A.
        Hip abductor weakness in distance runners with iliotibial band syndrome.
        Clin J Sport Med. 2000; 10: 169-175
        • Livengood A.L.
        • DiMattia M.A.
        • Uhl T.L.
        “Dynamic Trendelenburg”: single-leg-squat test for gluteus medius strength.
        Athl Ther Today. 2004; 9: 24-25
        • Levin O.
        • Van Nevel A.
        • Malone C.
        • Van Deun S.
        • Duysens J.
        • Staes F.
        Sway activity and muscle recruitment order during transition from double to single-leg stance in subjects with chronic ankle instability.
        Gait Posture. 2012; 36: 546-551
        • Dwyer M.K.
        • Stafford K.
        • Mattacola C.G.
        • Uhl T.L.
        • Giordani M.
        Comparison of gluteus medius muscle activity during functional tasks in individuals with and without osteoarthritis of the hip joint.
        Clin Biomech (Bristol, Avon). 2013; 28: 757-761
        • Fetto J.F.
        • Austin K.S.
        A missing link in the evolution of THR: “discovery” of the lateral femur.
        Orthopedics. 1994; 17: 347-351
        • Grimaldi A.
        Assessing lateral stability of the hip and pelvis.
        Man Ther. 2011; 16: 26-32
        • Larivière C.
        • Bilodeau M.
        • Forget R.
        • Vadeboncoeur R.
        • Mecheri H.
        Poor back muscle endurance is related to pain catastrophizing in patients with chronic low back pain.
        Spine (Phila Pa 1976). 2010; 35: E1178-E1186
        • Hosseinifar M.
        • Akbari M.
        • Behtash H.
        • Amiri M.
        • Sarrafzadeh J.
        The effects of stabilization and McKenzie exercises on transverse abdominis and multifidus muscle thickness, pain, and disability: a randomized controlled trial in nonspecific chronic low back pain.
        J Phys Ther Sci. 2013; 25: 1541-1545
        • Kankaanpää M.
        • Taimela S.
        • Laaksonen D.
        • Hänninen O.
        • Airaksinen O.
        Back and hip extensor fatigability in chronic low back pain patients and controls.
        Arch Phys Med Rehabil. 1998; 79: 412-417
        • Seay J.F.
        • Sauer S.G.
        • Frykman P.N.
        • Roy T.C.
        A history of low back pain affects pelvis and trunk mechanics during a sustained lift/lower task.
        Ergonomics. 2013; 56: 944-953
        • Di Fabio R.P.
        • Mackey G.
        • Holte J.B.
        Disability and functional status in patients with low back pain receiving workers' compensation: a descriptive study with implications for the efficacy of physical therapy.
        Phys Ther. 1995; 75: 180-193