[ research report ]

Julie A. Hides, PhD1 • Tanja Miokovic, BPhty (Hons)2 • Daniel L. Belavý, PhD3
Warren R. Stanton, PhD4 • Carolyn A. Richardson, PhD5

Ultrasound Imaging Assessment of Abdominal Muscle

Function During Drawing-in of the Abdominal Wall:
An Intrarater Reliability Study

A
ssessment of function of the deep abdominal musculature abdominis (TrA) muscle contraction,20
in the laboratory has largely used methodologies such as internal oblique (IO) muscle contraction,
and length of the TrA muscle obtained
functional movement tasks and fine-wire electromyography
using RUSI correlated well with mea-
(EMG).13,10,11,15,27 While fine-wire EMG is primarily restricted sures obtained by fine-wire EMG for iso-
to laboratory research, rehabilitative ultrasound imaging (RUSI) offers metric contractions of these muscles.12,20
a noninvasive and simpler method of assessing deep lumbopelvic For increases in thickness of the TrA and
muscle function. Recent work has shown that measures of transversus IO muscles and changes in length of the
TrA muscle (measured as lateral dis-
t Study Design: Test-retest intrarater reli- separate ultrasound images (averaged for days and placement of the fascial insertion of the
ability study. sides of abdomen), and (c) across 2 days (aver- TrA muscle) there were consistent, clear
t Objective: To examine reliability of aged for images and sides). changes in sonographic parameters, with
abdominal musculature measurements across a t Results: Reliability of assessing muscle incremental changes for contractions of
broad range of conditions for a physical therapist thickness was very high across 3 measurements of less than 20% of maximal voluntary con-
newly trained in assessment using rehabilitative the same image (intrarater correlation coefficients
traction (MVC).
ultrasound imaging (RUSI). [ICC3,1] were all greater than 0.97), fair to high
t Background: RUSI has previously been across 3 images (ICC3,4 = 0.62-0.82), and fair to Clinical muscle testing of the TrA
used to assess abdominal muscle function during high across 2 days (ICC3,6 = 0.63-0.85). Reliability muscle has been based on its anatomical
a drawing-in maneuver of the anterior abdominal of measuring the slide of the anterior abdominal structure and horizontal fiber arrange-
wall, and measurements conducted by an experi- fascia was very high across measurements from ment. Two muscle tests include observa-
enced assessor have been validated by compari- the same image (ICC3,1 = 0.98) but very low across
tion of the abdominal wall during either
son with magnetic resonance imaging. Few studies images (ICC3,4 = 0.44) and across 2 days (ICC3,6
= 0.36). a voluntary drawing-in of the abdominal
have examined the reliability of less experienced
operators, and only in isolated measurement t Conclusions: High reliability of a novice wall26 or by using automatic responses
conditions. rater was demonstrated for some measurement of the muscle to expiration.18 A relation-
t Methods and Measures: Nineteen conditions. Measures of reliability for recapturing ship between the clinical muscle test and
subjects (11 female, 8 male) without a history of the image and repetition across days ranged from laboratory EMG measures of TrA muscle
low back pain performed the abdominal drawing-in low to high. Inconsistencies in the pattern of results
function has been demonstrated.14 In ad-
maneuver in a supine hook-lying position. RUSI suggest that for a novice assessor using RUSI,
training should be performed and reliability as- dition, the action of the bilateral muscle
was used bilaterally to assess the thickness of the
internal oblique (IO) and transversus abdominis sessed for each abdominal muscle and measure- bellies of the TrA muscle has been viewed
(TrA) muscles at rest and on contraction, as well as ment condition intended to be used for research during the drawing-in maneuver using
changes in the length of the TrA muscle (indicated and clinical practice. J Orthop Sports Phys Ther RUSI and magnetic resonance imaging
by slide of the anterior abdominal fascia). The 2007;37(8):480-486. doi:10.2519/jospt.2007.2416
(MRI).8,9 In a recent study conducted on
reliability of a novice rater who received 8 hours t Key Words: internal oblique muscle, real-
elite asymptomatic cricketers,9 the mus-
of training was examined (a) across 3 measure- time ultrasound imaging, sonography, transversus
ments of the same ultrasound image, (b) across 3 abdominis muscle cle bellies of the TrA muscle were seen to
thicken as well as shorten in length dur-

 Senior Lecturer, Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia; Clinical Director, UQ/Mater
1

Back Stability Clinic, Mater Health Services, South Brisbane, Australia. 2 Physiotherapist, Mater Hospital, South Brisbane, Queensland, Australia. 3 Study Coordinator, Second
Berlin Bedrest Study, Berlin, Germany. 4 Psychologist and Biostatistician, UQ/ Mater Back Stability Clinic, Mater Health Services, South Brisbane, Australia. 5 Reader, Division
of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia. This study was approved by the Medical Research Ethics
Committee at The University of Queensland, Australia. Address correspondence to J.A. Hides, Division of Physiotherapy, School of Health and Rehabilitation Sciences, The
University of Queensland, Brisbane Queensland 4072, Australia. E-mail: j.hides@shrs.uq.edu.au

480 | august 2007 | volume 37 | number 8 | journal of orthopaedic & sports physical therapy
ing this maneuver, to give the appearance
of a deep muscle “corset,” as indicated by
anatomical studies.1,2 Measurements of
the lateral displacement of the anterior
fascial insertion of the TrA muscle and of
the thickness of the TrA and IO muscles
at rest and on contraction were conduct-
ed using both RUSI and MRI. Measure-
ments obtained using RUSI correlated
well with measurements obtained using
MRI (intraclass correlation coefficients
[ICCs] ranging from 0.78 to 0.95). Dif-
ferences in patterns of activation of the
abdominal muscles during the drawing-
in maneuver have been documented in
subjects with low back pain (LBP) using
MRI.25 Subjects with LBP were shown to
be less able than asymptomatic subjects
to draw-in the abdominal wall and also
displayed significantly less lateral slide of
the anterior abdominal fascia.
Randomized clinical trials that have
focused on re-educating TrA muscle
function through its drawing-in action
have been successful in decreasing lum-
bopelvic pain and disability.6,22,29 Goldby
et al6 successfully used RUSI to provide
feedback of abdominal muscle activation
to subjects with chronic LBP. In further
support of its use, a recent randomized
controlled trial showed that using RUSI
to provide feedback of TrA muscle activa-
tion was superior to clinical instruction
alone in healthy subjects.7
While RUSI is being used increas-
ingly to examine the abdominal muscles
in clinical practice,7 there are only a few
studies that have examined reliability of
measurement of these muscles. To date,
researchers have found RUSI to be reli-
able for measuring thickness of the ab-
dominal muscles at rest30 and changes in
thickness of the abdominal muscles when
they contract.3,5,17,21 Although interrater
reliability of 2 measurers (experienced
therapist and a novice) has been shown,28
studies have not, as yet, reported novice
therapists’ intrarater reliability across a
range of measurement conditions. The
purpose of this study, which used RUSI
to assess the TrA and IO muscles on both
sides at rest and on contraction, was to
journal of orthopaedic & sports physical therapy | volume 37 | number 8 | august 2007 |
examine measurements made by a physi-
cal therapist who had little experience in
RUSI but underwent a short, supervised
training program.
MATERIALS AND METHODS
Subjects
N
ineteen normal healthy sub-
jects (11 female, 8 male) participat-
ed in the study. The mean (6SD)
age, height, and body mass of the subjects
was 20.3 6 5.0 years, 172.0 6 9.8 cm, and
64.5 6 11.4 kg, respectively. Exclusion
criteria were a history of LBP, previous
lumbar surgery, known neuromuscular
or joint disease, significant spinal ab-
normality (eg, scoliosis), participation in
competitive sports more than 3 times a
week, pregnancy, and familiarity with the
testing procedure. An asymptomatic pop-
ulation was selected, as it was assumed
that their performance of the abdominal
drawing-in maneuver would be relatively
consistent on the 2 testing days. The study
was approved by the Medical Research
Ethics Committee at The University of
Queensland, Australia. Informed consent
was obtained from each subject and the
rights of human subjects were protected.
Instrumentation and Training
The anterolateral abdominal muscles
were imaged in brightness mode (b-
mode) on both sides, using a Synergy
ultrasound apparatus (GE-Diasonics,
San Jose, CA). A physical therapist un-
derwent training and performed all of
the subsequent measurements. Training
in RUSI of the anterolateral abdominal
muscles included 2 hours of 1-on-1 prac-
tice supervised by the senior researcher
in this project. In addition, the physical
therapist had received 3 hours of lec-
tures and 3 hours of practical instruction
on RUSI as part of the physical therapy
course curriculum.
Subject Familiarization With the Testing
Procedure  Subjects were positioned in
a supine hook-lying position, with their
hips in 45° of flexion (Figure 1). A pres-
sure biofeedback unit (Chattanooga, Hix-
son, TN), a device that detects changes in
pressure, was placed under the subject’s
lumbar spine and inflated to 40 mmHg.
Subjects were then provided with stan-
dard instructions on how to activate their
TrA muscle using the drawing-in maneu-
ver9: “Take a relaxed breath in and out,
hold the breath out, and then draw in
your lower abdomen without moving
your spine.” During this maneuver, the
pressure biofeedback unit was monitored
for any pressure increase indicative of spi-
nal movement. If spinal movement was
detected (suggestive of activation of the
rectus abdominis or oblique abdominal
muscles to induce posterior pelvic tilt),
the subjects were asked to repeat the ac-
tivation without moving the spine, to try
to activate the TrA muscle.
Testing Protocol  For RUSI assessment,
subjects were placed in the same position
as the familiarization procedure. During
testing, subjects performed 6 drawing-in
maneuvers, separated by a 2-minute rest
between each. During these maneuvers,
RUSI of the anterolateral abdominal wall
was performed (3 times each on the left
and right sides) in a randomized order.
A transverse image of the anterolateral
abdominal wall was obtained along a
line midway between the inferior angle
of the rib cage and the iliac crest for left
and right sides.4,9 The ultrasound trans-
ducer was aligned perpendicular to the
anterolateral abdominal muscles. To
FIGURE 1. The subject was positioned in a supine
hook-lying position, with the hips in 45° of flexion.
The ultrasound transducer was aligned perpendicu-
lar to the anterolateral abdominal wall, along a line
midway between the inferior angle of the rib cage and
the iliac crest. Measurements were made for the left
and right sides.
481
 [ research report
standardize the position of the trans-
ducer, the anterior fascial insertion of
the TrA muscle was positioned approxi-
mately 2 cm from the medial edge of the
ultrasound image when the subject was
relaxed.4 The subject was not able to see
the ultrasound monitor, so did not receive
feedback of performance of the contrac-
tion. Ultrasound images were obtained at
rest, with the subjects instructed to “hold
the breath out” and during contraction,
while holding the drawing-in maneuver.
Images were stored for offline analysis
(Figure 2).
Intrarater reliability of RUSI measure-
ments for a novice assessor was examined
(a) across 3 repeated measurements of
the same image in a rest and contracted
condition (using the right-sided image
from the first 10 subjects), (b) across 3
recaptured images taken for each side of
the abdomen, at rest and contracted, and
(c) across 2 days, 4 to 7 days apart.
Image Analysis  Still ultrasound images
of the muscles were extracted offline.
Image visualization and measurements
were conducted using a software package
(ImageJ, Version 1.36b).15 On each image,
thickness of the TrA and IO muscles was
measured at rest and on contraction. The
thickness of the external oblique muscle
was not assessed in this study, as a previ-
ous study showed that thickness changes
measured using RUSI did not correlate
with activation of this muscle assessed
using fine-wire EMG.12 Measurements
on ultrasound images were performed as
follows (Figure 2):
• Thickness of the TrA and IO muscles
at rest and on contraction (left and
right). Thickness of the TrA and IO
muscles were measured as the dis-
tance between the superior and infe-
rior hyperechoic muscle fascias, at the
middle of the image. Measurements
were conducted perpendicular to the
muscle fascias. Separate images were
measured for the rest and contracted
conditions.
• Slide of the anterior abdominal fascia
(left and right). For measurements of
slide of the anterior abdominal fascia,
482 | august 2007 | volume 37 | number 8 | journal of orthopaedic & sports physical therapy
]
A B
FIGURE 2. (A) Ultrasound image of the muscles of the right anterolateral abdominal wall at rest, showing 3 muscle
layers of the anterolateral abdominal wall and the measurements conducted. The most superficial layer is the
external oblique (EO) muscle, the middle layer is the internal oblique (IO) muscle, and the deepest layer is the
transversus abdominis (TrA) muscle. The fascial tip of the TrA muscle is represented by a circle and the distance
from the medial edge of the TrA muscle to the medial edge of the ultrasound image was measured. Thickness
measurements of the TrA and IO muscles were performed perpendicular to the muscle fascias approximately in
the middle of the ultrasound image. (B) Ultrasound image of the muscles of the right anterolateral abdominal wall
on the drawing-in maneuver, showing 3 muscle layers of the anterolateral abdominal wall and the measurements
conducted. The most superficial layer is the external oblique (EO) muscle, the middle layer is the internal oblique
(IO) muscle, and the deepest layer is the TrA muscle. Measurements of the thickness of the TrA and IO muscles and
slide of the anterior abdominal fascia are shown. For slide of the anterior abdominal fascia, the starting position (from
the relaxed image, represented by a circle) was superimposed on the contracted image, and the distance from this
point to the medial edge of the contracted transversus abdominis muscle (seen as a second circle) was measured.
Note the lateral pull of the TrA.
the distance from the medial edge of anterior abdominal fascia. ICCs in the
the TrA muscle to the medial edge of range of 0.0 to 0.5 were considered very
the ultrasound image was measured at low, those ranging from greater than 0.5
rest (as per Hodges et al12). This start- to 0.7 were considered low, those greater
ing position was then superimposed than 0.7 to 0.9 were considered high,
on the contracted image, and the dis- and those greater than 0.9 were consid-
tance from this point to the medial ered very high.
edge of the contracted TrA muscle was Repeated Measurements of the Same
measured. Image  For each outcome variable,
Muscle thicknesses and slide of the analysis of reliability across 3 repeated
TrA fascia were measured in millimeters. measurements of the same image was
All still images were deidentified. conducted on the first 10 subjects, using
Statistical Analysis  Intrarater reliability the first image taken on the right side.
was examined by (1) analysis of variance The ANOVA contained this repeated
(ANOVA) to examine systematic change measure, as well as the covariates of age,
in scores across repeated measurements, gender, height, and body mass. For each
using linear mixed-effects models23 in outcome variable, ICC3,1 was calculated.
the R, Version 2.1.1, statistical package Repeated Images of the Same Object  For
(The R Foundation, Wien, Austria); (2) each outcome variable, analysis across
calculation of the ICCs based on compo- the 3 repeated images was based on an
nents of variance19 to examine change in ANOVA design with fixed effects for im-
the rank order of scores; and (3) calcu- age, side of abdomen, and 2-way interac-
lation of the standard error of measure- tions between these factors. Age, gender,
ment (SEM) to examine the precision height, and body mass were included as
of measurement (SEM = pooled SD × covariates in the ANOVA. For each out-
[1 – ICC]1/2). These analyses were per- come variable, ICC3,4 was calculated us-
formed for each of the outcome vari- ing the average of the first image taken
ables: IO muscle thickness (at rest and for both sides on both days (4 images),
contracted), TrA muscle thickness (at compared to the second and third set of
rest and contracted), and slide of the images taken.
 Repeated Procedure Across Days  The
Thickness Measures of the Internal Oblique effect across the 2 days was examined by
TABLE 1 and Transversus Abdominis Muscles, and including the fixed effect of day (testing
Slide of the Anterior Abdominal Fascia* day) in the ANOVAs described above.
For each outcome variable, ICC3,6 was
Rest Contracted
calculated using the average value of the
Measure Left Right Left Right 6 images taken on day 1, compared to the
IO thickness (mm) 7.2 (1.5) 6.8 (1.4) 8.4 (2.0) 7.7 (1.4) average value of the 6 images on day 2.
TrA thickness (mm) 3.4 (0.8) 3.6 (0.8) 4.8 (1.4) 4.8 (1.3)
TrA slide (mm) ... ... 9.1 (3.3) 7.1 (2.6) RESULTS
Abbreviations: IO, internal oblique muscle; TrA, transversus abdominis muscle.

T
* Values represent mean (standard deviation) for each dependent measure based on state (rest,
he means and standard devia-
contracted), and side (left and right). For each subject, the average of 6 images (3 images obtained on
each of 2 days) was used; n = 19. tions of muscle thickness and lat-
eral slide of the anterior abdominal
fascia, while performing a drawing-in
Intrarater Reliability Across Repeated maneuver, are shown in Table 1.
TABLE 2
Measurement of the Same Image* Repeated Measurements of the Same
Image  Intrarater reliability was very high
ICC3,1 SEM (mm)
for this procedure. The ANOVA results
Measures Rest Contracted Rest Contracted showed no systematic difference in scores
IO thickness 0.99 (0.97-1.00) 0.98 (0.95-1.00) 0.028 0.033 for remeasurement of the same image
TrA thickness 0.98(0.95-1.00) 0.97 (0.98-1.00) 0.018 0.020 (for all: F20,9,2.38, P..12). The single-
TrA slide ... 0.98 (0.94-0.99) ... 0.035 measure ICC values of the novice assessor
Abbreviations: ICC, intraclass correlation (95% confidence interval); IO, internal oblique muscle; for IO and TrA muscle thickness and lat-
SEM, standard error of measurement; TrA, transversus abdominis muscle.
* n = 10.
eral slide of the anterior abdominal fascia
were all greater than 0.97 (Table 2). SEM
values less than 0.03 mm help to confirm
the accuracy of the rater’s measurements
TABLE 3 Intrarater Reliability Across 3 Images*
of the same image.
Repeated Images  No systematic dif-
ICC3,4 SEM (mm) ference in scores was found across im-
Measures Rest Contracted Rest Contracted ages in mean IO muscle thickness or
IO thickness 0.82 (0.55-0.95) 0.66 (0.23-0.92) 0.157 0.385 TrA muscle thickness measurements at
TrA thickness 0.62 (0.32-0.85) 0.80 (0.56-0.93) 0.247 0.224 both rest and contracted conditions, or
TrA slide ... 0.36 (0.06-0.85) ... 2.288 in slide of the anterior abdominal fas-
Abbreviations: ICC, intraclass correlation coefficient (95% confidence interval); IO, internal oblique cia (for all: F1,36,1.10, P..30). The ICC
muscle; SEM, standard error of measurement; TrA, transversus abdominis muscle. values of muscle measurements by the
* The data for each of the 3 images are based on the average of 4 measures (1 image from each side of
the abdomen captured on 2 days); n = 19.
novice assessor ranged from low to high
and were not consistent for the rest and
contracted conditions (Table 3). The ICC
value for the novice’s measurements of
TABLE 4 Intrarater Reliability Across 2 Days
slide of the anterior abdominal fascia
was very low. The precision of the mea-
ICC3,6 SEM (mm) surements for recaptured images was
Measures Rest Contracted Rest Contracted lower (indicated by relatively higher
IO thickness 0.69 (0.30-0.92) 0.63 (0.21-0.94) 0.295 0.432 SEMs) compared with repeated mea-
TrA thickness 0.85 (0.42-0.98) 0.84 (0.52-0.96) 0.089 0.176 surement of the same image. In the case
TrA slide ... 0.44 (0.06-0.93) ... 1.811 of slide of the anterior abdominal fas-
Abbreviations: ICC, intraclass correlation coefficient (95% confidence interval); IO, internal oblique cia, the lack of precision and wide 95%
muscle; SEM, standard error of measurement; TrA, transversus abdominis muscle. confidence interval (CI) confirm the
* The data for each day are based on the average of 6 measures (3 images taken on each side of the
abdomen); n = 19.
poor reliability of the assessor for this
procedure.

journal of orthopaedic & sports physical therapy | volume 37 | number 8 | august 2007 | 483
 [ research report
Repeated Days  No systematic difference thermore, repeated measurements were
in scores existed across test days in mean conducted from the same stored images,
IO muscle thickness measurements or as well as across 3 images and across 2
TrA muscle thickness at both rest and days. It would be expected that measur-
contracted conditions (for all: F1,36,2.22, ing muscles repeatedly from stored im-
P..15). Slide of the anterior abdomi- ages would be associated with the least
nal fascia did not differ across test days potential for measurement error. This
(F1,36 = 1.45, P = .24). The ICC values of is because measuring the thickness of
the novice assessor’s IO muscle thickness the abdominal muscles, which are well
measurement across day were low, where- defined on the ultrasound image, is a
as ICC values for TrA muscle measure- relatively straightforward task. However,
ment were high (Table 4). The ICC value accurately reimaging the subject to obtain
for the novice’s measurement of slide of comparable images may require a higher
the anterior abdominal fascia was very level of skill. Factors such as relocation
low (Table 4). The SEMs showed the great- of the original imaging site, reproduction
est variability across day, compared to re- of the same transducer pressure and ori-
peated measurement of same image and entation, as well as maintenance of these
recaptured image within the same day. factors during muscle contraction could
adversely affect reliability.
DISCUSSION In terms of repeated measurement of
the same stored image, the results of a
]
reliability of measures of the TrA and IO
muscles at rest and on contraction. Mea-
surements were not always more reliable
at rest, with higher reliability estimates
reported for the contracted condition in
one third of the sample.21
The amount of training undertaken
may also be an important factor when
considering reliability of the rater. In
their investigation, Ferreira et al5 report-
ed an intrarater ICC of 0.85 for an asses-
sor trained for 3 months in measurement
of TrA muscle thickness. This was com-
pared with an assessor with no previous
training whose measurements were not
reliable (ICC = 0.26).
Across-day reliability may be of interest
to physical therapy practitioners who per-
form repeated assessments of abdominal
muscle function over time and who might
compare measurements from different

R
esults from this study relating
to the morphology of the muscles
of the anterolateral abdominal wall
can be compared with values from other
studies.3,9,24,28,30 Rankin et al24 reported
values (at rest) for muscle thickness for
55 men and 68 women of various ages
who were moderately active. The thick-
nesses of both the TrA and IO muscles at
rest were thicker than values reported in
this current study. Hides et al9 reported
muscle thicknesses for young asymptom-
atic male elite cricketers and, not unex-
pectedly, elite male athletes had thicker
muscles at rest than the subjects of the
current investigation and the moderately
active subjects of Rankin et al.24 One pos-
sible explanation for this is muscle hyper-
trophy in the athletes due to strenuous
training and competition. Also, there were
females included in the current investiga-
tion and only male subjects in the study
of Hides et al.9 A gender effect has been
previously reported, and male subjects
were shown to have significantly thicker
muscles than female subjects.3,24,28
The current investigation examined
many aspects of reliability of measure-
ment. Two muscles were measured on
both sides of the abdomen in both re-
laxed and contracted conditions. Fur-
study by Teyhen et al30 and the current
study support this premise, with both
studies reporting high ICC values and
very low SEMs. In the study by Teyhen
et al,30 a novice assessor achieved high
intrarater reliability for measurement of
2 ultrasound images of the TrA muscle
(and a combined measure of the antero-
lateral abdominal muscles).
In terms of measurement of recaptured
images and repetition across days, the
novice physical therapist showed variable
reliability for attainment of images and
subsequent measurement of the thick-
nesses of the TrA and IO muscles both at
rest and on contraction. It may have been
expected that ICC values would be higher
for measurements of the muscles at rest,
as performance of muscle contraction
may be inherently variable in nature. Re-
sults from the current study showed this
to be the case for the IO muscle at rest;
but in the case of the TrA muscle, higher
ICC values were found for the contracted
condition. Measurement precision based
on the size of the SEMs showed a similar
pattern of variation across these condi-
tions. Other studies have also provided
evidence of similar inconsistencies. Mis-
uri et al21 reported coefficients of variation
ranging from 0% to 15.7% for intrarater
treatment sessions. Bunce et al3 mea-
sured the thickness of the TrA muscle for
3 different conditions using m-mode and
reported across-day intrarater reliability
(ICC1,1 = 0.88-0.94; SEM, 0.35-0.66 mm).
When these results are compared with
those from the current investigation, the
results for our novice assessor were again
inconsistent, with better reliability across
days for measurement of the TrA muscle
both at rest and on contraction than for
the IO muscle. In contrast, in a study con-
ducted by Rankin et al,24 ICC values for
across-day reliability of measurements of
the thickness of the TrA, IO, and external
oblique muscles (at rest), conducted by an
expert, were consistently high and ranged
from 0.96 to 0.99.
The novice assessor in the current
investigation was also inconsistent in
relation to measurement of slide of the
anterior abdominal fascia. The novice
was reliable when measuring from stored
images but was not able to reliably assess
the slide of the anterior abdominal fascia
across 3 measurements and across days.
As measurement of slide of the anterior
abdominal fascia may reflect relative in-
dependence in activity of the TrA muscle
during the drawing-in maneuver, this
measurement may represent a clinically

484 | august 2007 | volume 37 | number 8 | journal of orthopaedic & sports physical therapy
relevant addition to the more commonly
performed measurement of muscle thick-
ness. Furthermore, this measurement re-
flects that the contraction of the muscle
is concentric in nature (ie, the length of
the muscle decreases). It is, however, a
more difficult measure to perform. This
is primarily because it may require more
precision and experience to perform the
imaging technique well. If the assessor
moves the transducer medially or later-
ally during the draw-in maneuver, there
is potential for measurement error. Me-
dial lateral movement of the transducer
will not affect thickness measurements to
the same degree, as the thickness of the
anterolateral abdominal muscles is rela-
tively constant and the direction of the
thickness measurements is in an antero-
posterior direction. These measurements
will not vary greatly if the transducer is
moved slightly laterally or medially.
However, movement of the transducer
in either a medial or lateral direction will
have a large impact on measurements
conducted in the medial lateral direction.
This movement of the transducer can be
quite difficult to control, as the contours
of the abdominal wall may change when
the muscles contract during the abdomi-
nal drawing-in maneuver. Placing the
transducer in a dense foam cube, as in
the procedure used by Ferreira et al,4 may
improve the reliability of the assessor at
performing this measurement. Future
studies are required to determine how
much training of assessors is required to
reliably perform measurement of slide of
the anterior abdominal fascia during the
drawing-in maneuver.
The limitations of this study include
a relatively small sample, use of only 1
novice rater, and only healthy subjects
being investigated. It may be more dif-
ficult to reliably measure subjects with
symptoms as their performance of the ab-
dominal drawing-in maneuver can be less
consistent on 2 testing days due to pos-
sible alterations in motor control related
to LBP. Future studies should establish
the measurement error in other subject
populations, as the measurement error
journal of orthopaedic & sports physical therapy | volume 37 | number 8 | august 2007 |
reported in this study may not necessar-
ily generalize to clinical situations. This
single-case feasibility study showed that
a novice rater was not consistent across a
broad range of measurement conditions,
and future studies should examine if this
pattern is generalizable to a larger group
of novice raters.
CONCLUSION
A
physical therapist, newly
trained in RUSI, showed variable
reliability when assessing muscles
of the anterolateral abdominal wall dur-
ing the abdominal drawing-in maneuver.
While the novice assessor showed high
reliability when measuring from stored
images, the pattern of reliability was not
consistent across other measurement fac-
tors, including the muscle measured and
the state (rest and contracted) of the mus-
cle for measurements conducted across
images and across days. Inconsistencies
in the pattern of results suggest that for
a novice assessor using RUSI, training
should be performed and reliability as-
sessed for each abdominal muscle and
measurement condition intended to be
used for research and clinical practice.
ACKNOWLEDGMENTS
T
he authors would like to thank
the subjects studied, Tom Johnsen
(Scientific Officer, Division of Phys-
iotherapy, The University of Queensland),
Ross Darnell for statistical advice, and
Mr Ian Wong for assistance with data
collection. t
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