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Do Changes in Transversus Abdominis and Lumbar Multifidus During Conservative Treatment Explain Changes in Clinical Outcomes Related to Nonspecific Low Back Pain? A Systematic Review

Published:November 04, 2013DOI:https://doi.org/10.1016/j.jpain.2013.10.008

      Abstract

      Previous research describes an inconsistent relation between temporal changes in transversus abdominis or lumbar multifidus and temporal changes in clinical outcomes. Unfortunately, a relevant systematic review is unavailable. As a result, this systematic review was designed to summarize evidence regarding the association between temporal changes in muscle morphometry and activity in response to treatment, and temporal changes in clinical outcomes. Candidate publications were identified from 6 electronic databases. Fifteen articles were included after scrutinization by 2 reviewers using predetermined selection criteria. The methodological quality of these articles was appraised using a standard tool. These methods revealed strong evidence that temporal alterations in transversus abdominis thickness change during contraction (as measured by B-mode or M-mode ultrasound) or feedforward activation of transversus abdominis (assessed via electromyography, tissue Doppler imaging, or M-mode ultrasound) were unrelated to temporal changes in low back pain (LBP)/LBP-related disability. There was limited evidence that temporal changes in transversus abdominis lateral sliding or lumbar multifidus endurance were unrelated to temporal changes in LBP intensity. Conflicting evidence was found for the relation between temporal changes in lumbar multifidus morphometry and temporal changes in LBP/LBP-related disability. This review highlights that temporal changes in transversus abdominis features tend to be unrelated to the corresponding LBP/LBP-related disability improvements, whereas the relation between multifidus changes and clinical improvements remains uncertain.

      Perspective

      This systematic review highlighted that changes in morphometry or activation of transversus abdominis following conservative treatments tend not to be associated with the corresponding changes in clinical outcomes. The relation between posttreatment changes in characteristics of lumbar multifidus and clinical improvements remains uncertain.

      Key words

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      References

        • Akbari A.
        • Khorashadizadeh S.
        • Gholam A.
        The effect of motor control exercise versus general exercise on lumbar local stabilizing muscles thickness: Randomized controlled trial of patients with chronic low back pain.
        J Back Musculoskeletal Rehabil. 2008; 21: 105-112
        • Al-Obaidi S.M.
        • Beattie P.
        • Al-Zoabi B.
        • Al-Wekeel S.
        The relationship of anticipated pain and fear avoidance beliefs to outcome in patients with chronic low back pain who are not receiving workers' compensation.
        Spine. 2005; 30: 1051-1057
        • Allison G.T.
        • Morris S.L.
        • Lay B.
        Feedforward responses of transversus abdominis are directionally specific and act asymmetrically: Implications for core stability theories.
        J Orthop Sports Phys Ther. 2008; 38: 228-237
        • Altman D.G.
        Systematic reviews of evaluations of prognostic variables.
        BMJ. 2001; 323: 224-228
        • Ariëns G.A.M.
        • van Mechelen W.
        • Bongers P.M.
        • Bouter L.M.
        • van der Wal G.
        Psychosocial risk factors for neck pain: A systematic review.
        Am J Ind Med. 2001; 39: 180-193
        • Bajek S.
        • Bobinac D.
        • Bajek G.
        • Vranić T.S.
        • Lah B.
        • Dragojević D.M.
        Muscle fiber type distribution in multifidus muscle in cases of lumbar disc herniation.
        Acta Med Okayama. 2000; 54: 235-241
        • Balagué F.
        • Mannion A.F.
        • Pellisé F.
        • Cedraschi C.
        Non-specific low back pain.
        Lancet. 2012; 379: 482-491
        • Barker P.J.
        • Guggenheimer K.T.
        • Grkovic I.
        • Briggs C.A.
        • Jones D.C.
        • Thomas C.D.L.
        • Hodges P.W.
        Effects of tensioning the lumbar fasciae on segmental stiffness during flexion and extension: Young Investigator Award winner.
        Spine. 2006; 31: 397-405
        • Beattie P.F.
        • Nelson R.M.
        Evaluating research studies that address prognosis for patients receiving physical therapy care: A clinical update.
        Phys Ther. 2007; 87: 1527-1535
        • Brooks C.
        • Kennedy S.
        • Marshall P.W.M.
        Specific trunk and general exercise elicit similar changes in anticipatory postural adjustments in patients with chronic low back pain: A randomized controlled trial.
        Spine. 2012; 37: E1543-E1550
        • Brown S.
        • Gregory D.
        • Carr J.
        • Ward S.
        • Masuda K.
        • Lieber R.
        Adaptation to the multifidus muscle in response to experimentally induced intervertebral disc degeneration.
        Spine. 2011; 36: 1728-1736
        • Brown S.H.M.
        • McGill S.M.
        A comparison of ultrasound and electromyography measures of force and activation to examine the mechanics of abdominal wall contraction.
        Clin Biomech (Bristol, Avon). 2010; 25: 115-123
        • Coghlan S.
        • Crowe L.
        • McCarthypersson U.
        • Minogue C.
        • Caulfield B.
        Neuromuscular electrical stimulation training results in enhanced activation of spinal stabilizing muscles during spinal loading and improvements in pain ratings.
        Conf Proc IEEE Eng Med Biol Soc. 2011; 2011: 7622-7625
        • Cornelius L.R.
        • van der Klink J.J.L.
        • Groothoff J.W.
        • Brouwer S.
        Prognostic factors of long term disability due to mental disorders: A systematic review.
        J Occup Rehabil. 2011; 21: 259-274
        • Coste J.L.
        • Lefran ois G.R.
        • Guillemin F.
        • Pouchot J.
        • French Study Group for Quality of Life in Rheumatology
        Prognosis and quality of life in patients with acute low back pain: Insights from a comprehensive inception cohort study.
        Arthritis Rheum. 2004; 51: 168-176
        • Critchley D.
        • Coutts F.
        Abdominal muscle function in chronic low back pain patients measurement with real-time ultrasound scanning.
        Physiotherapy. 2002; 88: 322-332
        • D'hooge R.
        • Cagnie B.
        • Crombez G.
        • Vanderstraeten G.
        • Achten E.
        • Danneels L.
        Lumbar muscle dysfunction during remission of unilateral recurrent nonspecific low-back pain: Evaluation with muscle functional MRI.
        Clin J Pain. 2013; 29: 187-194
        • Danneels L.A.
        • Vanderstraeten G.G.
        • Cambier D.C.
        • Witvrouw E.E.
        • De Cuyper H.J.
        CT imaging of trunk muscles in chronic low back pain patients and healthy control subjects.
        Eur Spine J. 2000; 9: 266-272
        • Dickx N.
        • Cagnie B.
        • Parlevliet T.
        • Lavens A.
        • Danneels L.
        The effect of unilateral muscle pain on recruitment of the lumbar multifidus during automatic contraction. An experimental pain study.
        Man Ther. 2010; 15: 364-369
        • Dunn K.M.
        • Jordan K.
        • Croft P.R.
        Characterizing the course of low back pain: A latent class analysis.
        Am J Epidemiol. 2006; 163: 754-761
        • Easterbrook P.J.
        • Gopalan R.
        • Berlin J.A.
        • Matthews D.R.
        Publication bias in clinical research.
        Lancet. 1991; 337: 867-872
        • Ekman M.
        • Johnell O.
        • Lidgren L.
        The economic cost of low back pain in Sweden in 2001.
        Acta Orthop. 2005; 76: 275-284
        • França F.R.
        • Burke T.N.
        • Hanada E.S.
        • Marques A.P.
        Segmental stabilization and muscular strengthening in chronic low back pain—A comparative study.
        Clinics. 2010; 65: 1013-1017
        • Ferreira P.H.
        • Ferreira M.L.
        • Hodges P.W.
        Changes in recruitment of the abdominal muscles in people with low back pain: Ultrasound measurement of muscle activity.
        Spine. 2004; 29: 2560-2566
        • Ferreira P.H.
        • Ferreira M.L.
        • Maher C.G.
        • Refshauge K.
        • Herbert R.D.
        • Hodges P.W.
        Changes in recruitment of transversus abdominis correlate with disability in people with chronic low back pain.
        Br J Sports Med. 2010; 44: 1166-1172
        • Fortin M.
        • Macedo L.G.
        Multifidus and paraspinal muscle group cross-sectional areas of patients with low back pain and control patients: A systematic review with a focus on blinding.
        Phys Ther. 2013; 93: 873-888
        • França F.R.
        • Burke T.N.
        • Caffaro R.R.
        • Ramos L.A.
        • Marques A.P.
        Effects of muscular stretching and segmental stabilization on functional disability and pain in patients with chronic low back pain: A randomized controlled trial.
        J Manipulative Physiol Ther. 2012; 35: 279-285
        • Freeman M.D.
        • Woodham M.A.
        • Woodham A.W.
        The role of the lumbar multifidus in chronic low back pain: A review.
        PM&R. 2010; 2: 124-146
        • Friedrich M.
        • Hahne J.
        • Wepner F.
        A controlled examination of medical and psychosocial factors associated with low back pain in combination with widespread musculoskeletal pain.
        Phys Ther. 2009; 89: 786-803
        • Fritz J.M.
        • George S.Z.
        • Delitto A.
        The role of fear-avoidance beliefs in acute low back pain: Relationships with current and future disability and work status.
        Pain. 2001; 94: 7-15
        • Fritz J.M.
        • Koppenhaver S.L.
        • Kawchuk G.N.
        • Teyhen D.S.
        • Hebert J.J.
        • Childs J.D.
        Preliminary investigation of the mechanisms underlying the effects of manipulation: Exploration of a multi-variate model including spinal stiffness, multifidus recruitment, and clinical findings.
        Spine. 2011; 36: 1772-1781
        • Glass G.V.
        • Hopkins K.D.
        Statistical Methods in Education and Psychology.
        3rd ed. Allyn & Bacon, Needham Heights, MA1996
        • Gubler D.
        • Mannion A.F.
        • Schenk P.
        • Gorelick M.
        • Helbling D.
        • Gerber H.
        • Toma V.
        • Sprott H.
        Ultrasound tissue Doppler imaging reveals no delay in abdominal muscle feed-forward activity during rapid arm movements in patients with chronic low back pain.
        Spine. 2010; 35: 1506-1513
        • Haldeman S.
        • Kopansky-Giles D.
        • Hurwitz E.L.
        • Hoy D.
        • Mark Erwin W.
        • Dagenais S.
        • Kawchuk G.
        • Stromqvist B.
        • Walsh N.
        Advancements in the management of spine disorders.
        Best Pract Res Clin Rheumatol. 2012; 26: 263-280
        • Hamberg-van Reenen H.H.
        • Ariëns G.A.M.
        • Blatter B.M.
        • van Mechelen W.
        • Bongers P.M.
        A systematic review of the relation between physical capacity and future low back and neck/shoulder pain.
        Pain. 2007; 130: 93-107
        • Hayden J.A.
        • Côté P.
        • Bombardier C.
        Evaluation of the quality of prognosis studies in systematic reviews.
        Ann Intern Med. 2006; 144: 427-437
        • Hayden J.A.
        • Dunn K.M.
        • van der Windt D.A.
        • Shaw W.S.
        What is the prognosis of back pain?.
        Best Pract Res Clin Rheumatol. 2010; 24: 167-179
        • Henschke N.
        • Wouda L.
        • Maher C.G.
        • Hush J.M.
        • van Tulder M.W.
        Determinants of patient satisfaction 1 year after presenting to primary care with acute low back pain.
        Clin J Pain. 2013; 29: 512-517
        • Hides J.
        • Richardson C.
        • Jull G.
        Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain.
        Spine. 1996; 21: 2763-2769
        • Hides J.
        • Wilson S.
        • Stanton W.
        • McMahon S.
        • Keto H.
        • McMahon K.
        • Bryant M.
        • Richardson C.
        An MRI investigation into the function of the transversus abdominis muscle during “drawing-In” of the abdominal wall.
        Spine. 2006; 31: E175-E178
        • Hides J.A.
        • Jull G.A.
        • Richardson C.A.
        Long-term effects of specific stabilizing exercises for first-episode low back pain.
        Spine. 2001; 26: E243-E248
        • Hides J.A.
        • Stanton W.
        • McMahon S.
        • Sims K.
        • Richardson C.
        Effect of stabilization training on multifidus muscle cross-sectional area among young elite cricketers with low back pain.
        J Orthop Sports Phys Ther. 2008; 38: 101-108
        • Hides J.A.
        • Stokes M.J.
        • Saide M.
        • Jull G.A.
        • Cooper D.H.
        Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain.
        Spine. 1994; 19: 165-172
        • Hodges P.W.
        Pain and motor control: From the laboratory to rehabilitation.
        J Electromyogr Kinesiol. 2011; 21: 220-228
        • Hodges P.W.
        • Moseley G.L.
        • Gabrielsson A.
        • Gandevia S.C.
        Experimental muscle pain changes feedforward postural responses of the trunk muscles.
        Exp Brain Res. 2003; 151: 262-271
        • Hodges P.W.
        • Richardson C.A.
        Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds.
        Arch Phys Med Rehabil. 1999; 80: 1005-1012
        • 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
        • 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. 1996; 21: 2640-2650
        • Hodges P.W.
        • Tucker K.
        Moving differently in pain: A new theory to explain the adaptation to pain.
        Pain. 2011; 152: S90-S98
        • Hu Y.
        • Wong Y.L.
        • Lu W.W.
        • Kawchuk G.N.
        Creation of an asymmetrical gradient of back muscle activity and spinal stiffness during asymmetrical hip extension.
        Clin Biomech (Bristol, Avon). 2009; 24: 799-806
        • Hyun J.K.
        • Lee J.Y.
        • Lee S.J.
        • Jeon J.Y.
        Asymmetric atrophy of multifidus muscle in patients with unilateral lumbosacral radiculopathy.
        Spine. 2007; 32: E598-E602
        • Ihlebæk C.
        • Hansson T.H.
        • Lærum E.
        • Brage S.
        • Eriksen H.R.
        • Holm S.H.
        • Svendsrød R.
        • Indahl A.
        Prevalence of low back pain and sickness absence: A “borderline” study in Norway and Sweden.
        Scand J Public Health. 2006; 34: 555-558
        • Jellema P.
        • van der Windt D.A.W.M.
        • van der Horst H.E.
        • Stalman W.A.B.
        • Bouter L.M.
        Prediction of an unfavourable course of low back pain in general practice: Comparison of four instruments.
        Br J Gen Pract. 2007; 57: 15-22
        • Jemmett R.S.
        • Macdonald D.A.
        • Agur A.M.R.
        Anatomical relationships between selected segmental muscles of the lumbar spine in the context of multi-planar segmental motion: A preliminary investigation.
        Man Ther. 2004; 9: 203-210
        • Jöud A.
        • Petersson I.F.
        • Englund M.
        Low back pain—Epidemiology of consultations.
        Arthritis Care Res. 2012; 64: 1084-1088
        • Kalichman L.
        • Hodges P.
        • Li L.
        • Guermazi A.
        • Hunter D.J.
        Changes in paraspinal muscles and their association with low back pain and spinal degeneration: CT study.
        Eur Spine J. 2010; 19: 1136-1144
        • Kankaanpaa M.
        • Taimela S.
        • Airaksinen O.
        • Hanninen O.
        The efficacy of active rehabilitation in chronic low back pain. Effect on pain intensity, self-experienced disability, and lumbar fatigability.
        Spine. 1999; 24: 1034-1042
        • Kiesel K.B.
        • Uhl T.
        • Underwood F.B.
        • Nitz A.J.
        Rehabilitative ultrasound measurement of select trunk muscle activation during induced pain.
        Man Ther. 2008; 13: 132-138
        • Kiesel K.B.
        • Underwood F.B.
        • Mattacola C.G.
        • Matacolla C.
        • Nitz A.J.
        • Malone T.R.
        A comparison of select trunk muscle thickness change between subjects with low back pain classified in the treatment-based classification system and asymptomatic controls.
        J Orthop Sports Phys Ther. 2007; 37: 596-607
        • Konitzer L.N.
        • Gill N.W.
        • Koppenhaver S.L.
        Investigation of abdominal muscle thickness changes after spinal manipulation in patients who meet a clinical prediction rule for lumbar stabilization.
        J Orthop Sports Phys Ther. 2011; 41: 666-674
        • Koppenhaver S.
        • Hebert J.
        • Fritz J.
        • Parent E.
        • Teyhen D.
        • Magel J.
        Reliability of rehabilitative ultrasound imaging of the transversus abdominis and lumbar multifidus muscles.
        Arch Phys Med Rehabil. 2009; 90: 87-94
        • Koppenhaver S.
        • Hebert J.
        • Parent E.
        • Fritz J.
        Rehabilitative ultrasound imaging is a valid measure of trunk muscle size and activation during most isometric sub-maximal contractions: A systematic review.
        Aust J Physiother. 2009; 55: 153-169
        • Koppenhaver S.L.
        • Fritz J.M.
        • Hebert J.J.
        • Kawchuk G.N.
        • Childs J.D.
        • Parent E.C.
        • Gill N.W.
        • Teyhen D.S.
        Association between changes in abdominal and lumbar multifidus muscle thickness and clinical improvement after spinal manipulation.
        J Orthop Sports Phys Ther. 2011; 41: 389-399
        • Korff Von M.
        • Deyo R.A.
        • Cherkin D.
        • Barlow W.
        Back pain in primary care: Outcomes at 1 year.
        Spine. 1993; 18: 855-862
        • Korff Von M.
        • Miglioretti D.L.
        A prognostic approach to defining chronic pain.
        Pain. 2005; 117: 304-313
        • Kumar S.
        • Sharma V.P.
        • Shukla R.
        • Dev R.
        Comparative efficacy of two multimodal treatments on male and female sub-groups with low back pain (part II).
        J Back Musculoskelet Rehabil. 2010; 23: 1-9
        • Laird R.A.
        • Kent P.
        • Keating J.L.
        Modifying patterns of movement in people with low back pain—Does it help? A systematic review.
        BMC Musculoskelet Disord. 2012; 13: 169
        • Lee W.
        • Lee Y.
        • Gong W.
        The effect of lumbar strengthening exercise on pain and the cross-sectional area change of lumbar muscles.
        J Phys Ther Sci. 2011; 23: 209-212
        • Luoto S.
        • Heliovaara M.
        • Hurri H.
        • Alaranta H.
        Static back endurance and the risk of low-back pain.
        Clin Biomech (Bristol, Avon). 1995; 10: 323-324
        • MacDonald D.
        • Moseley G.L.
        • Hodges P.W.
        Why do some patients keep hurting their back? Evidence of ongoing back muscle dysfunction during remission from recurrent back pain.
        Pain. 2009; 142: 183-188
        • Manchikanti K.N.
        • Pampati V.
        • Falco F.J.E.
        • Hirsch J.A.
        Growth of spinal interventional pain management techniques: Analysis of utilization trends and medicare expenditures 2000 to 2008.
        Spine. 2013; 38: 157-168
        • Mannion A.
        • Käser L.
        • Weber E.
        • Rhyner A.
        • Dvorak J.
        • Muntener M.
        Influence of age and duration of symptoms on fibre type distribution and size of the back muscles in chronic low back pain patients.
        Eur Spine J. 2009; 9: 273-281
        • Mannion A.F.
        • Caporaso F.
        • Pulkovski N.
        • Sprott H.
        Spine stabilisation exercises in the treatment of chronic low back pain: A good clinical outcome is not associated with improved abdominal muscle function.
        Eur Spine J. 2012; 21: 1301-1310
        • Mannion A.F.
        • Pulkovski N.
        • Schenk P.
        • Hodges P.W.
        • Gerber H.
        • Loupas T.
        • Gorelick M.
        • Sprott H.
        A new method for the noninvasive determination of abdominal muscle feedforward activity based on tissue velocity information from tissue Doppler imaging.
        J Appl Phys. 2008; 104: 1192-1201
        • Marshall P.
        • Murphy B.
        Delayed abdominal muscle onsets and self-report measures of pain and disability in chronic low back pain.
        J Electromyogr Kinesiol. 2010; 20: 833-839
        • Marshall P.W.
        • Murphy B.A.
        Muscle activation changes after exercise rehabilitation for chronic low back pain.
        Arch Phys Med Rehabil. 2008; 89: 1305-1313
        • Marshall P.W.M.
        • Murphy B.A.
        Evaluation of functional and neuromuscular changes after exercise rehabilitation for low back pain using a Swiss ball: A pilot study.
        J Manipulative Physiol Ther. 2006; 29: 550-560
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.
        Int J Surg. 2009; 151: 264-270
        • Mohseni-Bandpei M.A.
        • Critchley J.
        • Staunton T.
        • Richardson B.
        A prospective randomised controlled trial of spinal manipulation and ultrasound in the treatment of chronic low back pain.
        Physiotherapy. 2006; 92: 34-42
        • Morris S.L.
        • Lay B.
        • Allison G.T.
        Corset hypothesis rebutted—Transversus abdominis does not co-contract in unison prior to rapid arm movements.
        Clin Biomech (Bristol, Avon). 2012; 27: 240-254
        • Parkkola R.
        • Rytökoski U.
        • Kormano M.
        Magnetic resonance imaging of the discs and trunk muscles in patients with chronic low back pain and healthy control subjects.
        Spine. 1993; 18: 830-836
        • Pengel L.H.M.
        Acute low back pain: Systematic review of its prognosis.
        BMJ. 2003; 327: 323
        • Portney L.
        • Watkins M.
        Foundations of Clinical Research: Applications to Practice.
        3rd ed. Prentice Hall, Upper Saddle River, NJ2009
        • Richardson C.
        • Hodges P.
        • Hides J.
        Therapeutic Exercise for Lumbopelvic Stabilization: A Motor Control Approach for the Treatment and Prevention of Low Back Pain.
        2nd ed. Churchill Livingstone, Philadelphia, PA2004
        • 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, Philadelphia, PA1998
        • Shea B.J.
        • Grimshaw J.M.
        • Wells G.A.
        • Boers M.
        • Andersson N.
        • Hamel C.
        • Porter A.C.
        • Tugwell P.
        • Moher D.
        • Bouter L.M.
        Development of AMSTAR: A measurement tool to assess the methodological quality of systematic reviews.
        BMC Med Res Methodol. 2007; 7: 10
        • Shea B.J.
        • Hamel C.
        • Wells G.A.
        • Bouter L.M.
        • Kristjansson E.
        • Grimshaw J.
        • Henry D.A.
        • Boers M.
        AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews.
        J Clin Epidemiol. 2009; 62: 1013-1020
        • Smeets R.J.E.M.
        • Wade D.
        • Hidding A.
        • Van Leeuwen P.J.C.M.
        • Vlaeyen J.W.S.
        • Knottnerus J.A.
        The association of physical deconditioning and chronic low back pain: A hypothesis-oriented systematic review.
        Disabil Rehabil. 2006; 28: 673-693
        • Steiger F.
        • Wirth B.
        • de Bruin E.D.
        • Mannion A.F.
        Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review.
        Eur Spine J. 2012; 21: 575-598
        • Stroup D.F.
        • Berlin J.A.
        • Morton S.C.
        • Olkin I.
        • Williamson G.D.
        • Rennie D.
        • Moher D.
        • Becker B.J.
        • Sipe T.A.
        • Thacker S.B.
        Meta-analysis of observational studies in epidemiology: A proposal for reporting.
        J Am Med Assoc. 2000; 283: 2008-2012
        • Sun X.
        • Briel M.
        • Busse J.W.
        • You J.J.
        • Akl E.A.
        • Mejza F.
        • Bala M.M.
        • Mertz D.
        • Diaz-Granados N.
        • Vandvik P.O.
        • Malaga G.
        • Srinathan S.K.
        • Dahm P.
        • Johnston B.C.
        • Alonso-Coello P.
        • Hassouneh B.
        • Walter S.D.
        • Heels-Ansdell D.
        • Bhatnagar N.
        • Altman D.G.
        • Guyatt G.H.
        Credibility of claims of subgroup effects in randomised controlled trials: Systematic review.
        BMJ. 2012; 344: e1553
        • Sung P.S.
        Multifidi muscles median frequency before and after spinal stabilization exercises.
        Arch Phys Med Rehabil. 2003; 84: 1313-1318
        • Teyhen D.S.
        • Williamson J.N.
        • Carlson N.H.
        • Suttles S.T.
        • O'Laughlin S.J.
        • Whittaker J.L.
        • Goffar S.L.
        • Childs J.D.
        Ultrasound characteristics of the deep abdominal muscles during the active straight leg raise test.
        Arch Phys Med Rehabil. 2009; 90: 761-767
        • Tosteson T.D.
        • Buzas J.S.
        • Demidenko E.
        • Karagas M.
        Power and sample size calculations for generalized regression models with covariate measurement error.
        Stat Med. 2003; 22: 1069-1082
        • Tsao H.
        • Druitt T.R.
        • Schollum T.M.
        • Hodges P.W.
        Motor training of the lumbar paraspinal muscles induces immediate changes in motor coordination in patients with recurrent low back pain.
        J Pain. 2010; 11: 1120-1128
        • Tsao H.
        • Galea M.P.
        • Hodges P.W.
        Driving plasticity in the motor cortex in recurrent low back pain.
        Eur J Pain. 2010; 14: 832-939
        • Tsao H.
        • Hodges P.W.
        Immediate changes in feedforward postural adjustments following voluntary motor training.
        Exp Brain Res. 2007; 181: 537-546
        • Tsao H.
        • Hodges P.W.
        Persistence of improvements in postural strategies following motor control training in people with recurrent low back pain.
        J Electromyogr Kinesiol. 2008; 18: 559-567
        • Turner E.L.
        • Perel P.
        • Clayton T.
        • Edwards P.
        • Hernández A.V.
        • Roberts I.
        • Shakur H.
        • Steyerberg E.W.
        • CRASH trial collaborators
        Covariate adjustment increased power in randomized controlled trials: An example in traumatic brain injury.
        J Clin Epidemiol. 2012; 65: 474-481
        • Unsgaard-Tøndel M.
        • Nilsen T.I.L.
        • Magnussen J.
        • Vasseljen O.
        Is activation of transversus abdominis and obliquus internus abdominis associated with long-term changes in chronic low back pain? A prospective study with 1-year follow-up.
        BMJ Sports Med. 2012; 46: 729-734
        • van Tulder M.W.
        • Assendelft W.J.J.
        • Koes B.W.
        • Bouter L.M.
        • Group TEBOTCCBR
        Method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group for Spinal Disorders.
        Spine. 1997; 22: 2323-2330
        • Vasseljen O.
        • Fladmark A.M.
        Abdominal muscle contraction thickness and function after specific and general exercises: A randomized controlled trial in chronic low back pain patients.
        Man Ther. 2010; 15: 482-489
        • Vasseljen O.
        • Unsgaard-Tøndel M.
        • Westad C.
        • Mork P.J.
        Effect of core stability exercises on feed-forward activation of deep abdominal muscles in chronic low back pain: A randomized controlled trial.
        Spine. 2012; 37: 1101-1108
        • Vos T.
        • Flaxman A.D.
        • Naghavi M.
        • Lozano R.
        • Michaud C.
        • Ezzati M.
        • Shibuya K.
        • Salomon J.A.
        • Abadalla S.
        • Aboyans V.
        • Abraham J.
        • Ackeman I.
        • Aggarwal R.
        • Ahn S.Y.
        • Ali M.K.
        • Alvarado M.
        • Anderson H.R.
        • Anderson L.M.
        • Andrews K.G.
        • Atkinson C.
        • Baddour L.M.
        • Bahalim A.N.
        • Barker-Collo S.
        • Barrero L.H.
        • Bartels D.H.
        • Basanez M.G.
        • Baxter A.
        • Bell M.L.
        • Benjamin E.J.
        • Bennett D.
        • Bernabe E.
        • Bhalla K.
        • Bhandari B.
        • Bikbov B.
        • Abdulhak A.B.
        • B G.
        • Black J.A.
        • Blencowe H.
        • Blore J.D.
        • B F.
        • Bolliger I.
        • Bonaventure A.
        • Boufous S.
        • Bourne R.
        • Bossussinesq M.
        • Braithwaite T.
        • Brayne C.
        • Bridgett L.
        • Brooker S.
        • Brooks P.
        • Brugha T.S.
        • Bryan-Hancock C.
        • Bucello C.
        • Buchbinder R.
        • Buckle G.
        • Budke C.M.
        • Burch M.
        • Burney P.
        • Burstein R.
        • Calabria B.
        • Campbell B.
        • Canter C.E.
        • Carabin H.
        • Carapetis J.
        • Camona L.
        • Cella C.
        • Charlson F.
        • Chen H.
        • Cheung A.T.
        • Chou D.
        • Chugh S.S.
        • Coffeng L.E.
        • Colan S.D.
        • Colquhoun S.
        • Colson K.E.
        • Candon J.
        • Connor M.D.
        • Cooper L.T.
        • Corriere M.
        • Cortinovis M.
        • Couville de Vaccaro K.
        • Couser W.
        • Cowie B.C.
        • Criqui M.H.
        • Cross M.
        • Dabhadkar K.C.
        • Dahiya M.
        • Dahodwala N.
        • Damsere-Derry J.
        • Danaei G.
        • Davis A.
        • De Leo D.
        • Degenhardt L.
        • Dellavalle R.
        • Delossantos A.
        • Denenberg J.
        • Derrett S.
        • Jarlais Des D.C.
        • Dharmaratne S.D.
        • Dherani M.
        • Diaz-Tome C.
        • Dolk H.
        • Dorsey E.R.
        • Driscoll T.
        • Duber H.
        • Ebel B.
        • Edmond K.
        • Elbaz A.
        • Ali S.E.
        • Erskine H.
        • Erwin P.J.
        • Espindola P.
        • Ewoigbokhan S.E.
        • Farazadfar F.
        • Feigin V.
        • Felson D.T.
        • Ferrari A.
        • Ferri C.P.
        • Fevre E.M.
        • Finucane M.M.
        • Flaxman S.
        • Flood L.
        • Foreman K.
        • Forouzanfar M.H.
        • Fowkes G.R.
        • Franklin R.
        • Fransen M.
        • Freeman M.K.
        • Gabbe B.J.
        • Gabriel S.E.
        • Gakidou E.
        • Ganatra H.A.
        • Garcia B.
        • Gaspari F.
        • Gillum R.F.
        • Gmel G.
        • Gosselin R.
        • Grainger R.
        • Groeger J.
        • Guillemin F.
        • Gunnell D.
        • Gupta R.
        • Haagsma J.
        • Hagan H.
        • Halasa Y.A.
        • Hall W.
        • Haring D.
        • Haro J.M.
        • Harrison J.E.
        • Havmoeller R.
        • Hay R.J.
        • Higashi H.
        • Hill C.
        • Hoen B.
        • Hoffman H.
        • Hotez P.J.
        • Hoy D.
        • Huang J.J.
        • Ibeanusi S.E.
        • Jacobsen K.H.
        • James S.L.
        • Javis D.
        • Jarsrasaria R.
        • Jayaraman S.
        • Johns N.
        • Jonas J.B.
        • Karthikeyan G.
        • Kassebaum N.
        • Kawakami N.
        • Keren A.
        • Khoo J.P.
        • King C.H.
        • Knowlton L.M.
        • Kobusingye O.
        • Koranteng A.
        • Krishnamurthi R.
        • Lalloo R.
        • Laslett L.L.
        • Lathlean T.
        • Leasher J.L.
        • Lee Y.Y.
        • Leigh J.
        • Lim S.S.
        • Limb E.
        • Lin J.K.
        • Lipnick M.
        • Lipshultz S.E.
        • Liu W.
        • Loane M.
        • Lockett Ohno S.
        • Lyons R.
        • Ma J.
        • Mabweijano J.
        • Maclntyre M.F.
        • Malekzadeh R.
        • Mallinger L.
        • Manivannan S.
        • Marcenes W.
        • March L.
        • Margolis D.J.
        • Marks G.B.
        • Marks R.
        • Matsumori A.
        • Matzopoulos R.
        • Mayosi B.M.
        • McAnulty J.H.
        • McDermott M.M.
        • McGill N.
        • McGrath J.
        • Medina-Mora M.E.
        • Meltzer M.
        • Mensah G.A.
        • Merriman T.R.
        • Meyer A.C.
        • Miglioli V.
        • Miller M.
        • Miller T.R.
        • Mitchell P.B.
        • Mocumbi A.O.
        • Moffitt T.E.
        • Mokdad A.A.
        • Monsata L.
        • Montico M.
        • Moradi-Lakeh M.
        • Moran A.
        • Morawska L.
        • Mori R.
        • Murdoch M.E.
        • Mwaniki M.K.
        • Naidoo K.
        • Nair M.N.
        • Naldi L.
        • Narayan K.M.V.
        • Nelson P.K.
        • Nelson R.G.
        • Nevitt M.
        • Newton C.R.
        • Nolte S.
        • Norman P.
        • Norman R.
        • O'Donnell M.
        • O'Hanlon S.
        • Olives C.
        • Omer S.B.
        • Ortblad K.
        • Osborne R.
        • Ozgediz D.
        • Page A.
        • Pahari B.
        • Pandian J.D.
        • Rivero A.P.
        • Patten S.B.
        • Pearce N.
        • Padilla R.P.
        • Perez-Ruiz F.
        • Perico N.
        • Pesudovs K.
        • Phillips D.
        • Phillips M.R.
        • Pierce K.
        • Pion S.
        • Polanczyk G.V.
        • Polinder S.
        • Pope III, C.A.
        • Popova S.
        • Porrini E.
        • Pourmalek F.
        • Prince M.
        • Pullan R.L.
        • Ramaiah K.D.
        • Ranganathan D.
        • Razavi H.
        • Regan M.
        • Rehm J.T.
        • Rein D.B.
        • Remuzzi G.
        • Richardson K.
        • Rivara F.P.
        • Roberts T.
        • Robinson C.
        • Rodriguez De Leon F.
        • Ronfani L.
        • Room R.
        • Rosenfeld L.C.
        • Rushton L.
        • Sacco R.L.
        • Saha S.
        • Sampson U.
        • Sanchez-Riera L.
        • Sanman E.
        • Schwebel D.C.
        • Scott J.G.
        • Segui-Gomez M.
        • Shahraz S.
        • Shepard D.S.
        • Shin H.
        • Shivakoti R.
        • Singh D.
        • Singh G.M.
        • Singh J.A.
        • Singleton J.
        • Sleet D.A.
        • Sliwa K.
        • Smith E.
        • Smith J.L.
        • Stapelberg N.J.C.
        • Steer A.
        • Steiner T.
        • Stalk W.A.
        • Stovner L.J.
        • Sudfeld C.
        • Syed S.
        • Tamburlini G.
        • Tavakkoli M.
        • Taylor H.R.
        • Taylor J.A.
        • Taylor W.J.
        • Thomas B.
        • Thomson W.M.
        • Thurston G.D.
        • Tleyjeh I.M.
        • Tonelli M.
        • Towbin J.A.
        • Truelsen T.
        • Tsilimbaris M.K.
        • Ubeda C.
        • Undurranga E.A.
        • van der Werf M.J.
        • van Os J.
        • Vavilala M.S.
        • Venketasubramanian N.
        • Wang M.
        • Wang W.
        • Watt K.
        • Weatherall D.J.
        • Weinstock M.A.
        • Weintraub R.
        • Weisskopf M.G.
        • Weissman M.M.
        • White R.A.
        • Whiteford H.
        • Wiersma S.T.
        • Wilkinson J.D.
        • Williams H.C.
        • Williams S.R.M.
        • Witt E.
        • Wolfe F.
        • Woolf A.D.
        • Wulf S.
        • Yeh P.H.
        • Zaidi A.K.M.
        • Zheng Z.J.
        • Zonies D.
        • Lopez A.D.
        • Murray C.J.L.
        Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010.
        Lancet. 2012; 380: 2163-2196
        • Waddell G.
        1987 Volvo award in clinical sciences: A new clinical model for the treatment of low-back pain.
        Spine. 1987; 12: 632-644
        • Walker B.F.
        The prevalence of low back pain: A systematic review of the literature from 1966 to 1988.
        J Spinal Disord. 2000; 13: 205-217
        • Wallwork T.L.
        • Stanton W.R.
        • Freke M.
        • Hides J.A.
        The effect of chronic low back pain on size and contraction of the lumbar multifidus muscle.
        Man Ther. 2009; 14: 496-500
        • Wessels T.
        • van Tulder M.
        • Sigl T.
        • Ewert T.
        • Limm H.
        • Stucki G.
        What predicts outcome in non-operative treatments of chronic low back pain? A systematic review.
        Eur Spine J. 2006; 15: 1633-1644
        • Whittaker J.L.
        • Stokes M.
        Ultrasound imaging and muscle function.
        J Orthop Sports Phys Ther. 2011; 41: 572-580
        • Whittaker J.L.
        • Teyhen D.S.
        • Elliott J.M.
        • Cook K.
        • Langevin H.M.
        • Dahl H.H.
        • Stokes M.
        Rehabilitative ultrasound imaging: Understanding the technology and its applications.
        J Orthop Sports Phys Ther. 2007; 37: 434-449
        • Willemink M.J.
        • van Es H.W.
        • Helmhout P.H.
        • Diederik A.L.
        • Kelder J.C.
        • van Heesewijk J.P.M.
        The effects of dynamic isolated lumbar extensor training on lumbar multifidus functional cross-sectional area and functional status of patients with chronic nonspecific low back pain.
        Spine. 2012; 37: E1651-E1658
        • Williams J.M.
        • Haq I.
        • Lee R.Y.
        An investigation into the onset, pattern, and effects of pain relief on lumbar extensor electromyography in people with acute and chronic low back pain.
        J Manipulative Physiol Ther. 2013; 36: 91-100
        • Wong A.Y.
        • Kawchuk G.
        • Parent E.C.
        • Prasad N.
        Repeatability of instrumented spinal stiffness measurements using a mechanical indentation device in individuals with and without low back pain.
        Man Ther. 2013; 18: 395-402
        • Wong A.Y.L.
        • Parent E.
        • Kawchuk G.
        Reliability of 2 ultrasonic imaging analysis methods in quantifying lumbar multifidus thickness.
        J Orthop Sports Phys Ther. 2013; 43: 251-262
        • Wong A.Y.L.
        • Parent E.C.
        • Funabashi M.
        • Stanton T.R.
        • Kawchuk G.N.
        Do various baseline characteristics of transversus abdominis and lumbar multifidus predict clinical outcomes in non-specific low back pain? A systematic review.
        Pain. 2013; ([Epub ahead of print])
        • Zielinski K.A.
        • Henry S.M.
        • Ouellette-Morton R.H.
        • DeSamo M.J.
        Lumbar multifidus muscle thickness does not predict patients with low back pain who improve with trunk stabilization exercises.
        Arch Phys Med Rehabil. 2013; 94: 1132-1138