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The Role of the Transverse Abdominis in

Low Back Pain

April 27, 2009 21 Comments

Todays guest post is written byHarrison Vaughan, PT, DPT. Harrison is a physical therapy

practicing in South Hill, VA atIn Touch Therapy. His professional interests include clinical

diagnostic tests and treatment consisting of orthopedic manual therapy, predominantly spinal

manipulation. Harrison previously contributed an excellent article on theQUADAS toolto assess the quality of research on studies examining the

efficacy of clinical examination tests.
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Transversus Abdominis: Are we on the right bandwagon?

Many physical therapistsbase their low back pain treatments around strengthening the transversus abdominis (also know

as the transverse abdominis, or TrA) muscle for stability. Strengthening of the TrA is oftenincorporated in treatments with a wide variety of patients with a wide variety of pathology.

However, what really is the dysfunction that we are trying to manage and is this really effective?

What does Transverse Abdominis do?

The function of the TrA is to stabilize the pelvis and low backpriorto movement of the body. Itacts within a feedforward bilateral muscle activation rationale from spinal perturbations with

everyday activities. Rehabilitation is typically aimed at restoring motor control of this key

stabilizing muscle. Literature points to effective means of treating low back pain with trunk

stabilization and strengthening of deep abdominal musculature to improve motor control1

.Diane Lee gives a great description of how to activate the TrA through abdominal drawing-in

maneuver (ADIM)2. However, how long does it take for someone to learn this and do you think

they will really do this correctly and efficiently if they are pain? It has been shown that teachinga patient to perform the ADIM maneuver can be time consuming and difficult.3

How effective is activating the Transversus Abdominis?

It has been shown that the TrA is activated after the deltoid (~50ms) with arm movement taskstudies with LBP patients.4 A recent study showed that during a volitional recruitment task for

the TrA , induced pain was shown to attenuate the activity of the TrA.5 It has also been

discovered that pain will alter a muscles role as an agonist or antagonist to control movement forprotection through the pain adaptation model.6 This has also been demonstrated with many prior

studies of reduced TrA muscle thickness with chronic LBP. In turn, the delay of TrA timing and

optimal muscle activation is altered, potentially making exercises that activate it ineffective when

pain is present.

If we abolish the pain, would motor control and activation of TrA resolve itself? There has notbeen any conclusive data to show that the spine is controlled less when the activation of TrA is

changed and altered timing of the TrA leads to poor core stability. The feed-forward activation of


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TrA can be interpreted differently from a small study that showed 3 of 8 pain-free individuals did

not have the feedforward responses in 70% of trials with bilateral arm tasks.7 Even

prophylactically, the isolated muscle pattern in pain-free subjects is controversial.8 This goes toshow further that low back pain is complex, multimodal and overall challenging to treat.

Is a lack of strength or stability really the reason for the low back pain?Do we claim to stabilize every patient? A recent study stated that some patients are notunstable at all and showed that LBP patients actually have increased stability rather than

decreased stability.9 Even if we feel a patient is unstable, how do we diagnose it as unstable?

Special tests to clarify this are inconclusive. P/A force over specific segments of lumbar spinehave been found to be useful to identify the segmental impairment. However, will activating the

TrA fix this? PPIVMs for extension & flexion have poor sensitivity values. A common test

practiced is the prone instability test also giving poor diagnostic values.10 You might as well flipa coin to determine instability by the values.

Some thoughts

As musculoskeletal specialists, we have significant knowledge

and a pertinent role in management of low back pain. We need toconcentrate on teachingthe patients how to control their

symptoms independently. To me, this means giving the patient

tools to provide self-pain relief through therapeutic means.Activating transverse abdominis stating it will give stability when

everyday aches and pains arise just doesnt seem feasible. The

use of foam rolls, towel rolls or any other affordable methods can

be very effective in not only giving relief, but obtaining jointmotion and allowing an exercise program to be more

advantageous. If a treatment doesnt give someone relief or

change, he or she will not be adherent to it, consecutively,returning to health care providers and starting the sequence again.

Since low back pain re-occurs in 70% of cases depending on

source, we may not be challenging this problem appropriately. I think having the transversus

abdominus as an active component in the treatment is somewhat useful but not conclusive. Painrelieving exercises and education need to be the forefront of each program so muscle activation

can be optimal.

What are your opinions? Do you get good results from concentrating on TrA as your main

intervention? If so, how effective do you find it and what is your approach? Is there any

technique or method that you would recommend others to try?

References

1. Teyhen DS, Miltenberger CE, Deiters HM, et al.. The use of ultrasound imagingof the abdominal drawing-in maneuver in subjects with low back pain. J Orthop

Sports Phys Ther. 2005 Jun;35(6):346-55.

2. Accessed 3 March 2009.

http://dianelee.ca/services/TRANSVERSUSABDOMINIS.pdf
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3. OSullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific

stabilizing exercise in the treatment of chronic low back pain with radiologic

diagnosis of spondylolysis or spondylolisthesis. Spine.1997;22:2959-2967.

4. Cresswell AG, Thorstensson A. Changes in intraabdominal pressure, trunkmuscle activation and force during isokinetic lifting and lower. Eur J Appl Physio

Occup Physiol. 1994; 68: 315-21.5. Kiesel et al. Rehabiliation ultrasound measurement of select muscle activation

during induced pain. Manual Therapy. 2008. 13. 132-138

6. Lund et al. 1991. The pain adaptation model: a discussion of the relationshipbetween chronic musculoskeletal pain and motor activity. Can J Physiol.

Pharmac. 69: 683-694.

7. Hodges P, Cresswell A, Thorstennson A. Preparatory trunk motion accompanies

rapid upper limb movement. Exp Brain Res 1999;124:69-79.

8. Allison GT. The push throw continuum and core stability are Physiotherapists

teaching the correct motor patterns? in APA National Conference SportsPhysiotherapy Australia. Cairns, Queensland, Australia: 2007.

9. Hodges P, Van den Hoorn W, Dawson A, et al. Changes in the mechanicalproperties of the trunk in low back pain may be associated wtih recurrence. J

Biomech. In press.

10.Cook C, Hegedus E. Orthopedic Physical Examination Tests: An Evidence-BasedApproach. Prentice Hall. 2007.

Flynn, T. (2005). The Use of Ultrasound Imaging of the Abdominal Drawing-in Maneuver in

Subjects With Low Back Pain Journal of Orthopaedic and Sports Physical Therapy DOI:

10.2519/jospt.2005.1780Photos fromWikipedia

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The Missing Link in Protecting Against Back Pain

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Injury Prevention,Rehabilitation,Spine

Core

Free Evidence Based Practice Course

Plays of the Week 5/1/0921 Responses to The Role of the Transverse Abdominis in Low Back Pain

1.

Jan ReplyApril 27, 2009 at 9:10 am

Dear Harrison,

Thank you for your article. I think that the importance of the m.TA is hugely overrated.

Literature that covers inguinal hernia operations show no correlations with low back pain,

while the m.TA is dysfunctional for a longer period. Another very interesting study was inthe Netherlands where I am based among 800 pregnant women with low back pain. They

wanted to see how low back pain develops postpartum. We all know that the muscles take

4 tot 8 weeks to recover before they become functional again. Almost 600 women quit

the trial 1 week postpartum. Reason? Low back pain was gone, while the m.TA was notrestored in function yet.

There is NO study that proofs that segment stabilising exercises actually perform better

than any other way of moving (primary outcome should be pain and dysfunction). A daily

walk will do the trick. If instability of the spine exists than stability would be a harmonyof co-contraction where speed, power, duration and order of dozens involved muscles

that will change per millisecond and differ with any change in posture. The idea that a

training of a single muscle, the m.TA will compensate for all of that is just ridiculous.

I never train the m.TA and my results are on par with my colleagues, but I have theresults faster.

Grtz, Jan

2.

Sharon ReplyApril 27, 2009 at 9:36 am

I would have to absolutely agree with Jan that attention to TA muscle activation is very

overrated. LBP is very complex due to the nature and amount of pain producingstructures. LBP and its origin, if not directly dealt with will inhibit TA function and

patient compliance anyway. Introducing exercise too soon is perhaps why our profession

misses the target and people go elsewhere for pain relief. Identify the source of thedysfunction and use a combination of all manual modalities to correct the identified issue.

Muscle re-education can be a part of the whole treatment program, but should be

introduced in middle to later stages of rehab in my opinion. Sharon
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3.

Christie Downing, PT, DPT, cert MDT ReplyApril 27, 2009 at 5:21 pm

Very good post, Harrison.

The myth that the TrA can be isolated and the whole core stability mantra are thebiggest whores (sorry to get so vulgar)in the PT world, in my opinion. Its trickle down

effect into the world of strength, conditioning and personal training have made me spend

countless hours reprogramming patients who think that the solution to their sciatica is get

their core strong.

I use the word whore to imply how this whole concept has gotten around and itsblanket application to all patients with low back pain has killed our critical thinking skills

as clinicians.

I believe it was last months PT journal that discussed at length the fallability of the core

stability paradigm. To reiterate, definitions remain poorly defined, theoreticalcomponents are often unvalidated (or down right unproven as Jan implies). Controversy

remains as to whether bracing abdominal drawing in maneuver or motor control

are superior to one another (and no one has ever been able to definitively define anddemonstrate the differences to me in the first place).

However, we do know this:

cross sectional muscle area is limited in those with low back pain, timing is altered in

feedforward mechanisms in those with low back pain.

Yet, we have done a poor job:

1. Establishing a cause effect relationship2. Whether the dysfunctional timing causes pain or whether pain causes altered timing

3. Whether correciton of the musclar function leads to improved outcomes.Do I ever use core stability? Yesdo I use it in all my patients?heck noId say

barely a quarter. My first line of defense is always to classify a patient with back pain.Reducible derangements are treated with direction specific exercises, central sensitization

with pain education, graded exposure to activity and perhaps some nervous system

mobilization.

For those without directional preference, I tend to follow treatment based classifications.If they fall into the stabilization category, I do tend to do this. However, even Fritzs

research on TBC with matched treatments really rendered an outcome of about 50%

rather mediocre in my opinion. Whats worse is that there is so far, no predictive abilities

of those who fall into this classification. At least with the McKenzie method for those

with derangements that centralize with direction specific movement, we can be fairlyconfident that the vast majority will be significantly better in two weeksor on the flip

side that those who do not centralize are anticipated to have poor outcomes.

In any case, the blakent application of core stability and muscle reducation programs forall patients has really made us no more than personal trainers. What has happened to

critical thinking?
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4.

Trevor Winnegge DPT,MS,OCS,CSCS ReplyApril 27, 2009 at 5:49 pm

My feelings on transverse abdominus training are that I include it in a program forlumbar hypermobility treatment, but I do not make it the showcase muscle to train. It is

well documented the role of TrA in conjunction with diaphragm to help increase

intraabdominal pressure during movement tasks (Hodges, Journal of Physiology, 1997 is

a good article). It is also documented the effect of increased abdominal pressure on thelumbar spine. That fact alone, I feel it is necessary to include it into a comprehensive

lumbar hypermobility treatment regimen. I feel with its attachments in so many different

places-diaphragm/costal cartilage, thoracolumbar fascia, anterior 2/3 of the inner lip ofthe iliac crest and the inguinal ligament-why not train it with your program? I think

leaving it out all together from your training regimen is detrimental, but I also think

making it your first focus wont really help either. Just another tool for the PT LBPtoolbox. I also think a lot of PTs misdiagnose LBP and may be overutilizing TrA

training, instead of addressing the primary impairments first!

5.

Trevor Winnegge DPT,MS,OCS,CSCS ReplyApril 27, 2009 at 5:58 pm

Christie-what do you do after you take someone with a reducible directional derangement and rid

them of their pain? Do you add any ther ex at that time?I completely agree with you in

that not everyone needs stab! I ask you this though-would it be detrimental to any patient,when they are pain free to increase strength of their core stabilizing structures? that may

seem like I am a proponent of blanket stab, but I assure you I am not. I do like to treat a

disc dereangement with manual techniques and positional based ther ex first. At the end

stage of their rehab, however, I do employ the more functional stab exercises. What doyou do at that stage of rehab? how do you feel about the back schools or spinal

programs where patients receive no manual PT and simply lift boxes, and do stab

execises for a few hours a day???? that may be a debate for a whole other day!!!!!!! Greatconversation with this post Harrison!!!!

6.

Christie Downing, PT, DPT cert MDT ReplyApril 27, 2009 at 7:22 pm

I do not do any further trianing with people who have a completely resolvable

derangementmeaning they can tolerate end range flexion (or whatever was thecausitive movement), repetitively, without reoccurance of symptoms or obstruction to
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movement and that they can return to their desired activity pain free. I make the

restoration of function as specific to their goals as possible. Usually that means showing

them how to do it with good body mechanics (which in my opinion is enough to turn onthe core in most patients). Id rather put someone on the treadmill if they are a runner or

cycle for 10 miles if that is one of their primary activities as opposed to making them

balance on a ball. In all, I find that those with reducible derangements who understandwhat to do to prevent reoccurance and what to do should it happen anyway, rarely or

never need to return to me. Giving this group of people stabilization exercises is,

IMHO, medically uncessary and unproven treatment. Yet, for patients who subscribe tothis mantra and actually list it as a goal for them to get their core strong, I certainly

educate them about the lack of validity of the core stabilization theory (well, rather I just

ease their concerns about it) and rather than COMPLETELY crush their belief system (a

big no-no), Ill throw in a few exercises for them to do if it helps them feel moreempowered.

however, in those who seem to plateau (still have some lingering symptoms) with

direciton specific exercises and manual therapy, there is a point that one must get on

with it. This is often a point I induce core stabilizationnot so much that I think it willget them better, but more or less to encourange activity, reduce fear and test the

stability of the reduction.

I really have no use for back schools, Im constantly educating my patients and make it as

individualized as possible. We had a formal back school at one point and discontinued it.Everyones said they were learning everything from their PT.

As far as work hardening program (ie, lifting boxes)theres often a group of patients

who need thisfor training and restoring funciton for their job. But more often than not,

I think its to reduce the fear of return to work. Im not necessarily convinced these

funcitonal training programs are continuing to make any further mechanicalimprovements. The real issue here, IMHO is reducing fear avoidance behaviors through

graded exposure to activity. But then again, I dont do work hardening, so anyone whodoes probably has a better foothold in this part of the arguement than I. In all, I think itsan important part of recovery when I cannot replicate someones work setting in my

clinic.

7.

Anonymous ReplyApril 27, 2009 at 9:13 pm

I liken the TrA in low back pain to the VMO with patello-femoral pain: initially do some

work it to get it firing, but once you fix the biomechanics of the movement it should berecruited on its own. The TrA doesnt work in isolation in our ADLs, so why would we

do extensive rehab on it in that way?

Chris
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8.

Trevor Winnegge DPT,MS,OCS,CSCS ReplyApril 28, 2009 at 9:04 am

Christie,Interesting points-as always! Interesting to hear your perspective from the mckenzie point

of view. What would you do for a higher level athlete who wants to return to sports with

twisting-like tennis, hockey or baseball? I am also very curious to see what Mr Mike

Reinold has to say on this matter, with his professional athletes. Mike-when rehabbing apro baseball player, do you incorporate stab exercises? Just do manual?

I think for most people, as soon as they are painfree, they wont do their home exercises

for core stab anyways!!!!! so it may all be a moot point anyways!!!!!

9.

Christie ReplyApril 28, 2009 at 6:30 pm

I think you always have to look at athletes a little differentlyfirst, because the placebo

effect is so high in this population, but second that their bodies are asked to function at

end ranges and to be able to respond quicker. That being said, some sort of functional

training is required that goes above and beyond the average person or even therecreational athlete. I would think, howeverand this is pure specutlation on my part,

that it really becomes proprioceptive traning more than anything elseand doesnt really

stabilize the spine per see, just allows it to respond more quickly at appropriately.

10.

dunc2134 ReplyApril 30, 2009 at 10:21 am

I too would like to see Mikes response to this interesting discussion. Not only for

athletes with low back dysfunctions but for shoulder and knee patients as well. How

does this translate to what we have been preaching with core stability exercisesthroughout return to play rehab for shoulder patients, knees, etc.?

11.

Dr. Davon Jacobson, MD ReplyApril 30, 2009 at 10:54 am

This is really a well laid out website. I like how you have presented the information in

full detail. Keep up the great work and please stop by my site sometime. The url ishttp://healthy-nutrition-facts.blogspot.com
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12.

Christie ReplyApril 30, 2009 at 4:35 pm

OK, maybe this is a little silly, but certainly pertinent to our discussion:

http://vidilife.com/video_play_220621_The_Office_Fitness_Orb.htm

13.

Trevor Winnegge ReplyApril 30, 2009 at 7:23 pm

gotta love the office!!!!!!!!

14.

amy castillo ReplyMay 1, 2009 at 7:39 pm

I hope we have not thrown out neuormusular training/strengthening completely!!!

Sure the TrA thing, clinically I dont have a real time US unit at my disposalcant say I

have figured it out in isolation.

But to say that the practice of working on core stability and neuromusclular control isunecessary is going too far.

Julie Hides has done a nice job of making a good case for multifidus in her Spine

articles(94, 96). And the 2001 article does support prevention of recurrance through suchtraining. Just in 2008 in Manip Ther she was able to show unilat CSA deficits in thechronic population as well.

OSullivans neuromuscular control approach (ref #3 above) shows where we need to go

with some of these subpopulations. Beyond lying on the back and dead bugs.

As far as the athletic populationrehabing the full kinetic chain including the lumbar

spine/pelvic girdle on ALL my athletes has served me well. This is especially true inthose who have been unsuccessful with prior rounds of PT that look local only. Or those

who blew out their ACL 2 year ago and now have shoulder tendonitis.

I will plank till the end!

15.

Jan ReplyMay 2, 2009 at 3:12 am

Amy,

Although the work of Hides and OSullivan is fascinating, there has been no evidencethat low back pain will gain from it. I saw Hides during a convention last month and
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asked her for proof of curing backpain, she had none. Segment Stabilizing Exercises only

provide results if the control group is passive therapy. Al the wonderful research should

stay in the laboratories, not in our clinics.

Dont believe we should throw out everything concerning the TrA, but we should notgive it anymore attention than we do other structures.

16.

Trevor Winnegge ReplyMay 2, 2009 at 6:08 am

I think Jan makes the best point here..Dont believe we should throw out everything

concerning the TrA, but we should not give it anymore attention than we do otherstructures. TrA should simply be another tool in our toolbox. I liken the recent TrA craze

to the VMO of the knee. Is VMO training important for a knee patient-sure it is. Would

we get a patient better if we only focused on the VMO, and neglected other hip and knee

musculature? of course not! take TrA strengthening for what it is-another muscle you canadd into your core training programs. Like Jan said, lets not make it the end all and be all

of eliminating back pain!

17.

Mike Reinold ReplyMay 2, 2009 at 6:32 am

I have been watching and enjoying this discussion, every time I wanted to jump in I had

to run!

This is why I love these discussions and this forum for us to all interact collaboration.After reading through all of these comments, I think we are ALL right! I never advocateone absolute method to treat, it appears that combining everything that has been

discussed here may be the best option.

No, focusing on the TrA as primary treatment will not yield results. This is because the

problem is multifaceted. The TrA and core training etc is just a part of the puzzle.Agree with the comments above that say, why not include TrA? I would still train the

core (whatever that may mean). Why not? Wouldnt any type of physical activity and

increase in strength help our patients?

In regard to athletes, training the core is important. That being said, it comes down to the

definition of core. Crunches are not an athletic core training movement. Athletes need

two things from the core:1. Rotary power sports depend on the athletes ability to separate their hips from their

shoulders (i.e. trunk rotation). Look at the model of a hitter or golfer, they need to

stabilize their legs, rotate their shoulders against their hips, and then explode back andthrough. Need to enhance rotary strength in my mind.

2. The core serves as a transfer of energy. This has to do with the above as well, but in

many athletes, energy is developed in the lower extremities and transferred into the upper

extremities. This has to transfer through the core, either through rotary power of through
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stabilization to not allow energy leaks. Meaning, maintaining a stable core without

relying on end range of motion of your lumbar spine or pelvis (i.e. locking in extension

because your core function is poor) for stability.

I think you can apply these concepts to all patients as a part of normal functioning, but toa much smaller degree.

What do you guys think about how I defined the need of the core in athletes? How wouldyou alter or add to my thoughts?

18.

Harrison Vaughan, PT, DPT ReplyMay 2, 2009 at 9:36 am

All,Thanks for the kind words and great discussion on this debatable topic! I agree with Mike

that everyone seems to be on the right page as a whole. It is very interesting to read

everyone's approach as nothing is set in stone related to treating this condition.There will always be an argument on the best route, including some individuals statingevery patient needs to strengthen pelvic musculature, perform proper breathing

techniques with the diaphragm, etc etc as it is all related and connected to the LB. Does

this mean I get a guy to pull his ***** up!? Hano!

We, as physical therapists, need to know the means of diminishing pain with a cause &effect approach as main path. As many of you all know, once the horrendous pain

diminishes, each pt has a totally different demeanor, personality and quality of

movement. Are these pts able to walk, vacuum, clean the house, pitch, run, etc due to

increases in strength over a 2 wk spandoubtful per exer phys guidelines.

This is what can really separate us from personal trainers, yoga instructors, etc. in that

they don't have the 7 yrs of education to do this properly. (On a side note, in the state ofVA but unsure of other states, it is LEGAL to advertise that you perform physical therapy

even if you are not a licensed physical therapistvery disturbing). Also, physicians reallydon't have the proper means of fixing LBP other than medication so we need to be on the

top of the chain as main caregivers.

It is unfortunate that as the economy recesses and healthcare reimbursement drops; I see

that pts self-discharge or time-frames for insurance ends once pt is out of pain prior toreally being able to "increase core stability" to the extent it needs to be for me to be

happy and sure that symptoms will not arise again. What will really happen in the

futureduration shortens, reimbursement drops to the point of not coming out on top??

I really enjoy the quotable articles in the posts above and I even include in my article. I

am an advocate for evidence based practice, but honestly, it is 10 yrs behind clinicalpractice (a prime example is recent study on PT better than Sx for OA of knee:

http://content.nejm.org/cgi/content/short/359/11/1097)Going into the knee surgically

does not just remove bad cartilage but takes away good stuff tooNo brainer. I feel wecan all learn from each other well, if not better, than EBP to not only make us better

clinicians, but more importantly, to give the best care for our patients.

On that note, continue the excellent discussion points as Mike has taken technology to

great heights to improve our field of physical therapy.
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19.

Putting Health Back into Fitness ReplyMay 3, 2009 at 4:41 pm

You guys that are responding are brilliant..im not a PT, but even with the clients i train asa personal trainer/fitness coach, i avoid reductionist approaches, pegging things on one

muscle, and looking to over-stabilize certain parts of the body. Im not the brightest bulb

on the shelf, but i have a feeling that when the body is aligned and the movement quality

is there, then pain will be less likely to pop up. No one client is the same and protocol-oriented approaches like TVA activation exercises seem to be a fear response used by

those who dont understand that the body works as a unit.

I am a certified postural alignment specialist through the Egoscue Method, and have had

great results with my clients getting them out of pain by giving simple exercises to helpre-align their joints and getting their bodies to be more functional. Have you guys done

any postural education or postural exercises with your clients?Charlie Reid B.S., CSCS, CPT, PAS II

20.

Jan ReplyMay 4, 2009 at 3:52 am

Hi everybody,

Glad to see that everybody is responding so constructively. I have to respond to Harrsionwith his take on EBP.

Sometimes EBP is 10 years behind clinical observations. There is one problem here. Ourown observations and reasoning are limited. If Id to accept my own observation as the

norm, the sun would revolve around the earth and I would be back in the medieval ages.We have clinical for thousands of years, but we are really curing people the last 100

years. This has everything to do with embracing the RCTs that will help us to avoid bias

and coincidence.

From a clinical point of view I would start with level A evidence. If that doesnt work, Iwould go to level B. If it all doesnt work, then you start experimenting on your clients

(thats what it is, even if it is educated clinical reasoning).

On low back pain, all evidence is still pointing to the discs. Although we tried to move

away from it with the pelvic stability model (Snijders, Vleeming, etc) and the rest of the

lumbarstability model (Panjabi, hodges, richardson, hides, etc.) or the combinedlumbarpelvic stability model, we end up back to the discs.

Although posture and wrong movement patterns will influence the asymmetric pressure

on the disc. The quality of the disc is mainly genetic in nature (Batti 2009). If you still

think that non-specific low backpain has nothing to do with the discs, you have somereading to catch up.

An its true that patient with (chronic) non-specific lowback pain have problems in their

feedforward mechanism. The problem is we dont know whether this is causal. It is likely
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that muscles contract later, just to minimize the pain. In that case, working the TrA is not

your first priority.

As I stated earlier, I never do anything specific with the TrA in my patients and my

success record is on par with any colleague I know. The funny thing is that every reviewwill predict this. The only thing is that I do it cheaper, with less effort (training the TrA is

timeconsuming, even frustrating).On the subject of athletes, I believe that optimal movement patterns will minimize the

energy leaks, Mike is referring to. Biomechanics in sports had proven its value. But ineven then, the core would be just a another link in a chain. A tennis player will transfer

the ground reaction force to a smash through the core. But the legs and the core together

will be responsible for only 50 percent (Groppel 1992) of the transfer. I still believe weput to much effort in a few muscles.

21.

Phil Page, PT, ATC ReplyMay 7, 2009 at 3:51 pm

Undoubtedly, chronic low back pain can be caused by a number of musculoskeletal

pathomechanics, just as we see in chronic shoulder pain, knee pain, etc. The late VladimirJanda MD identified his specific patterns of muscle imbalance as one possible

mechanism in CLBP. Janda first speculated that the TrA was prone to weakness and

motor control dysfunction in chronic low back pain, which was subsequently

substantiated by the Australian researchers. While Janda influenced researchers atQueensland University, he pointed out that in-fact, the TrA functions in a reflexive feed-

forward mechanism, and voluntary training (ie Abdominal Hollowing) is likely neither

functional nor effective. Unfortunately, the media inflated these miracle research

findings of the TrA, spreading its myth as the key to curing CLBP in numerous newsarticles, which many clinicians also accepted as gospel.

The TrA likely does contribute to core stability, but not in isolation. Through its insertion

in the thoracolumbar fascia, it definitely can influence lumbar stabilization. Recentlyhowever, Canadian researcher Stuart McGill PhD has refuted the claims of the TrA as a

primary core stabilizer, noting that biomechanically, no single muscle can dominate

core stability (Kavcic et al. 2004, Spine 29(11):1254-65). Later, McGills lab found thatthe abdominal hollowing maneuver contributed little if any to spinal stability (Grenier &

McGill 2007, APMR 88:54-62), finding instead that bracing of the entire abdominal

region improves lumbar stability. Therefore, the argument that TrA training is

stabilization training is completely false. In fact, researchers from western Australia

recently published a short and critical discussion on the topic of TrA as a core stabilizer(Allison & Morris, 2008, Br J Sports Med 42:930-31).

In summary, it appears that the TrA is not as much of the holy grail as we had

previously thought. It obviously is not an isolated core stabilizer, but likely involved aspart of the entire pelvic chain to help provide core stability, rotary force, and force

transmission with the other abdominal muscles, multifidus, diaphragm, and pelvic floor.

As with many motor control dysfunctions, we are very limited in our knowledge andtechnology to assess and treat chronic low back pain from a functional perspective. It is
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still important to assess TrA function as part of the phasic chain of muscles prone to

inhibition to identify the presence of Jandas muscle imbalance syndromes; however, as

Janda stated, training it voluntarily as with abdominal hollowing, is not functional. TheTrA should be integrated in movement as it functions in a feed-forward mechanism.

Phil Page, PT, ATC

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