ISSN: 2320-5407 Int. J. Adv. Res.

9(04), 664-670

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/12748

DOI URL: http://dx.doi.org/10.21474/IJAR01/12748

RESEARCH ARTICLE
INTERRATER AND INTRARATER RELIABILITY OF PRESSURE BIOFEEDBACK UNIT IN
MEASUREMENT OF TRANSVERSES ABDOMINIS MUSCLE ACTIVATION IN ASYMPTOMATIC
ADULTS

Disha Vallabhbhai Solanki1 and Dr. Neela Soni2

1. PhD Scholar in Gujarat University, I/C Lecturer, Government Spine Institute and Physiotherapy College,
Ahmedabad, India.
2. Ph. D. Guide in Gujarat University and Academic Director, SKUM College of Physiotherapy, Ahmedabad,
India.
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Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Background –The Transverse abdominis with its direct attachments to
Received: 10 February 2021 lumber vertebrae through thoracolumber fascia contributes as a local
Final Accepted: 16 March 2021 stabilizer of spine which have meaningful role for spinal stability.
Published: April 2021 Transverse abdominis(TrA) activation is vital component in
rehabilition of patients with Low back pain. The Pressure Biofeedback
Key words:-
Transversus Abdominis, Abdominal Unit (PBU) is a device designed to teach and measure Transverses
Drawing-in Test, Pressure Biofeedback abdominis activation by Abdominal draw-in maneuver which is often
unit (PBU), Reliability used by clinicians.
Methods – 60 healthy male and female subjects were selected for
study. The abdominal draw-in test was performed with the subject in a
prone lying position, and the Pressure Biofeedback Unit (Chattanooga
Stabilizer ) was utilized to evaluate the ability of the subject to perform
this abdominal isolation test. For intrarater reliability, the examiner
carried out the test twice at the interval of 2 days. For interrater
reliability, 2 examiners did the test one after the other on the same day.
Results – Intraclass Correlation Coefficient (ICC) were calculated to
determine interrater and intrarater reliability.ICC value for inter-rater
reliability is 0.87 with 95% confidence interval (0.78-0.92). ICC value
for intra-rater reliability is 0.86 with 95% confidence interval (0.79 –
0.93).
Conclusion - Pressure Biofeedback Unit shows good to excellent inter-
rater and intra-rater reliability.

Copy Right, IJAR, 2021,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
The Transverse abdominis arises from the thoracolumbar fascia at the lateral raphe, the internal aspects of the lower
six costal cartilages, where it inserts with the diaphragm, the lateral third of the inguinal ligament and anterior two
thirds of the inner lip of the iliac crest 1. Its “belt-like” fiber orientation limits its ability to generate motion but
emphasize its relationship to increasing intra-abdominal pressure 2, which is considered to have major effects on
lumbopelvic stability 1. The activation of the Transverse abdominis delayed in activation in low back pain patients. 3
and has similarly been identified to precede extremity movement in healthy individuals 4

Corresponding Author:- Disha Vallabhbhai Solanki

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Address:- PhD Scholar in Gujarat University, I/C Lecturer, Government Spine Institute and Physiotherapy
College, Ahmedabad, India.
ISSN: 2320-5407 Int. J. Adv. Res. 9(04), 664-670

Transverse abdominis activation can be measured by various tools. It has been divided into laboratory test and
clinical test. Laboratory test includes ultrasound imaging measures from a pressure sensor, Needle EMG and surface
electromyography.7 Most of the studies that have measured the activity of the deep abdominal wall muscles used
fine-wire electromyography. However, this type of assessment is invasive, painful, uncomfortable, and costlier and
may present the risk of infection.8 Clinical tests involves the recruitment by palpation method 5 and by PBU.6 But
palpation method is subjective in nature so it requires skill of physiotherapist. Whereas with PBU, objective
assessment can be done and evaluated.

Test should be conducted in prone lying with PBU (Stabilizer, Chattanooga, California, USA). 9 It is a reliable and
valid clinical device for assessing deep abdominal muscle function, and has been used to develop a method for the
careful monitoring of lumbar stabilization. 10,11 very few studies were available assessing reliability of pressure
biofeedback unit in asymptomatic adults. Lima et al(2011) done systematic review on measurement properties of
pressure biofeedback unit in the evaluation of TrA also suggested that TrA activity assessment yet to be answered
and further studies are needed.12 The purpose of the present study was to evaluate intra‐tester and intertester
reliability of the PBU.

Methods:-
In this study Sixty asymptomatic individuals those who are willingness to participate in this study both male and
female between 19 - 40 years of age were randomly selected. Those whose Body mass index ≤ 24 is included in this
study. Exclusion criteria’s were Low back pain - subjects who has missed work due to back pain in preceding two
years; Lumbar spine surgery ; Pregnancy ; Severe kyphosis or scoliosis; Spinal stenosis; Neurological disease;
Cancer; Trauma to the lumbar spine; Nerve root entrapment

Rater description:-
Both examiners were trained Physiotherapist having sound knowledge of utility of PUB and skilled in assessing
Abdominal drawing in maneuver.

Procedure:-
Subjects were called for the study through mouth to mouth publicity. Each subject was given subject information
sheet and written consent were taken in vernacular language. Demographic data like height and weight of the subject
was taken. Assessment of core strength (Transversus Abdominis) was done with Pressure Biofeedback Unit (PBU)
(StabilizerTM, Chattanooga, California, USA). Familiarization was done with description of the task and
demonstration of test performance. Adequate practice trials were given till the subject mastered the technique. The
actual task i.e. Abdominal draw-in test was performed with the subject in a prone lying position on the hard surface
with arms by the side and the PBU was placed under the abdomen with the navel in the centre and the distal edge of
the pad in line with the right and left anterior superior iliac spines. The PBU was then inflated to 70 mmHg and was
allowed to stabilize, allowing for detection of fluctuations in pressure due to normal breathing, which was
approximately 2 mmHg for each inhalation and exhalation. Subjects were instructed to perform abdominal drawing
in. The instructions were given to breathe in and out and then, without breathing in, to slowly draw in the abdomen
so that it lifts up off the pad, keeping the spinal position steady. Deep inspiration was avoided. During this test, the
investigator closely monitored the pressure gauge of the PBU and the subject to detect whether any compensatory
mechanisms were employed, this included movements of the pelvis and spine, breathe holding, rib elevation and
bulging of abdomen15,16,17. Then pressure reduction which was held at least up to 10 seconds was noted. Stop watch
was used to note down the time. The same procedure was repeated for three times and average of the three
repetitions was used for analysis. Rest time between the measurements was 1 min.

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Fig.1:- Examiner scoring the Inter-Rater Reliability.

Fig. 2:- Examiner scoring the Intra-Rater Reliability.

For inter-rater reliability, both examiners did the test one after the other on the same day. For intra-rater reliability,
the Examiner A carried out the test twice at the interval of 2 days. Following a period of instruction in the abdominal
drawing-in test each subject was assessed in a randomized order during first visit by both the examiners. Both
examiners and subjects were blind to the result of previous attempts.

On the first test day, Examiner A measured the first set. Subsequently, the participant had a 5-minute break and was
able to get up from the plinth and walk around the test room before Examiner B measured the second set. To reduce
order effect, the observer sequence was randomized in advance. On the second test day (i.e. after 2 days), test sets

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were undertaken by Examiner A. On both test days, the participants were explicitly asked not to practice the
Abdominal drawing in maneuver beyond the tests.15

Results:-
In this study total number of subjects were 60 among them 18 were male and 42 were female.

Table 1:- Demographic data of subjects.

Subjects Mean Standard Deviation
Age (years) 21.00 1.34
Height(cm) 162 6.64
Weight(Kg) 54 7.12

Inter-rater Reliability
Table 2:- Inter-rater reliability of PBU in measuring strength of Transversus Abdominis (TrA).
Intraclass correlation coefficient (ICC) 95% confidence interval (CI)
Lower bound Upper bound
0.87 0.78 0.92

As shown in table 2 and graph 1, ICC value for inter-rater reliability of PBU in measuring strength of TrA was
analysed based on mean rating, absolute - consistency, 2-way random effect model was 0.87 with 95% CI (0.78-
0.92). The ICC values shows good to excellent reliability.
10

0
EXAMINER_A EXAMINER_B
Graph 1:- Inter-rater reliability for PBU in measurement of strength of TrA.

Intra-rater Reliability
Table 3:- Intra-rater reliability of PBU in measuring strength of Transversus Abdominis (TrA).
Intraclass correlation coefficient (ICC) 95% confidence interval (CI)
Lower bound Upper bound
0.86 0.79 0.93

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As shown in table 3 and graph 2, ICC value for intra-rater reliability of PBU in measuring strength of TrA
analysed based on mean rating, absolute – agreement, 2-way mixed effects model was 0.86 with 95% CI
(0.79 – 0.93). The ICC values shows good to excellent reliability

10

0
EXAMINER_A EXAMINER_A_retest
Graph 2:- Intra-rater reliability for PBU in measurement of strength of TrA.

Discussion:-
The purpose of this study was to find out reliability of the PBU in asymptomatic adults. Thus, inter-rater and intra-
rater reliability were done for PBU for measuring strength of Transversus Abdominis (TrA) in normal individuals.
We had considered pressure reduction on PBU up to 10 mmHg over 10 seconds to be positive response while
performing abdominal drawing in manoeuvre in prone lying position. The results of the reliability study found good
to excellent inter-rater reliability with Intraclass correlation coefficient (ICC) value 0.87 (0.78-0.92) analysed
based on mean rating, absolute-consistency, 2-way random effect model with 95% confidence interval (CI). Intra-
rater reliability was found to be good to excellent with ICC value 0.86 (0.79 – 0.93) analysed based on mean
rating, absolute – agreement, 2-way mixed effects model with 95% CI.

The PBU was found to congregate the need for quantification of the abdominal draw in action. As the TrA produces
narrowing of the abdominal wall, measurement of the amount of movement of the abdomen that is produced
provides a method of identifying a patient’s ability to perform the contraction. The principle of using the PBU was
that when the unit was placed under the abdomen, initially it conformed to the patient’s shape. As the patient drew
in the stomach off the pad, the pressure in the pad was indicated as reduced on the pressure dial. The pressure
reduction was proportional to the degree to which the subjects could elevate the abdominal wall.

Our study is in agreement with the study done by Dilipbhai JK et al. who demonstrated intra-class correlation
coefficient (ICC) with standard error of mean of 0.944 and 0.69725 for interrater reliability and 0.910 and 0.85814
for intrarater reliability and concluded that PBU has high inter-rater and intrarater reliability in asymptomatic
individuals.18

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However, our results did not agree with those of Storheim et al. who reported low test–retest reliability in a study of
trained physiotherapy students without a history of back pain. They concluded that the device would not be
sufficiently reproducible for use in training of healthy people, nor in low-back-pain research as an outcome
measurement or for purposes of diagnosis or patient classification.14

Conclusion:-
Pressure Biofeedback Unit shows good to excellent inter-rater and intra-rater reliability. Thus it can be used as an
objective measure to assess the Transverse Abdominis function.

Financial support & sponsorship:-

None.

Declaration of interest:-
Authors declare no conflict of interest.

Acknowledgment:-
We are thankful to Dr. Anjali Bhise, Principal, Government Spine Institute and Physiotherapy College and Dr
Yagna Shukla, Senior lecturer, Government Spine Institute and Physiotherapy College Civil hospital, Ahmadabad,
India. For their immense support and guidance to channelize the efforts.

Refrences:-
1. Richardson C, Hodges P, Hides J. Therapeutic exercise for lumbopelvic stabilization. Edinburgh: Churchill
Livingstone; 2004 May.
2. Cresswell AG, Oddsson L, Thorstensson A. The influence of sudden perturbations on trunk muscle activity and
intra-abdominal pressure while standing. Experimental brain research. 1994 Mar 1;98(2):336-41.
3. Hodges PW, Richardson CA. Delayed postural contraction of transversus abdominis in low back pain
associated with movement of the lower limb. Journal of spinal disorders. 1998 Feb 1;11(1):46-56.
4. Hodges PW, Richardson CA. Contraction of the abdominal muscles associated with movement of the lower
limb. Physical therapy. 1997 Feb 1;77(2):132-42.
5. Hodges PW, Richardson CA. Altered trunk muscle recruitment in people with low back pain with upper limb
movement at different speeds. Archives of physical medicine and rehabilitation. 1999;80(9):1005-12.
6. Hodges P, Richardson C, Jull G. Evaluation of the relationship between laboratory and clinical tests of
transversus abdominis function. Physiotherapy research international : the journal for researchers and clinicians
in physical therapy. 1996;1(1):30-40.
7. Ferreira ML, Ferreira PH, Latimer J, Herbert RD, Hodges PW, Jennings MD, et al. Comparison of general
exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial.
Pain. 2007;131(1-2):31-7.
8. Costa LO, Maher CG, Latimer J, Hodges PW, Shirley D. An investigation of the reproducibility of ultrasound
measures of abdominal muscle activation in patients with chronic non-specific low back pain. European spine
journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the
European Section of the Cervical Spine Research Society. 2009;18(7):1059-65.
9. Chattanooga-Group-Inc. Stabilizer Pressure Biofeedback. Operating instructions. Hixson2005.
10. Cairns MC, Harrison K, Wright C. Pressure Biofeedback: A useful tool in the quantification of abdominal
muscular dysfunction? Physiotherapy. 2000;86(3):127-38.
11. Richardson CA, Jull GA. Muscle control-pain control. What exercises would you prescribe? Manual therapy.
1995;1(1):2-10.
12. De Paula Lima PO, de Oliveira RR, Costa LO, Laurentino GE. Measurement properties of the pressure
biofeedback unit in the evaluation of transversus abdominis muscle activity: a systematic review.
Physiotherapy. 2011;97(2):100-6.
13. Costa LO, Costa Lda C, Cancado RL, Oliveira Wde M, Ferreira PH. Short report: intra-tester reliability of two
clinical tests of transversus abdominis muscle recruitment. Physiotherapy research international: the journal for
researchers and clinicians in physical therapy. 2006;11(1):48-50.
14. Storheim K, Bo K, Pederstad O, Jahnsen R. Intra-tester reproducibility of pressure biofeedback in measurement
of transversus abdominis function. Physiotherapy research international : the journal for Researchers and
clinicians in physical therapy. 2002;7(4):239-49.

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15. Rathod, S. Interrater and Intrarater reliability of pressure biofeedback unit in measurement of transverses
abdominis activity. Indian journal of physical therapy. 2016; 3: 81-84.
16. Richardson C, Jull G, Hodges P, Hides J. Therapeutic exercise for spinal segmental stabilization in low back
pain. 1st ed.: Churchill Livingstone; 1999.
17. Mehta RS, Nagrale S, Dabadghav R, Rairikar S. Assessment of lumbar lordosis and lumbar core strength in
information technology professionals. Asian spine journal. 2016 Jun 1; 10(3): p. 495-500.
18. Dilipbhai JK, Dibyendunarayan B. Intrarater and Interrater Reliability of Abdominal Drawing-In test In
asymptomatic individuals. Romanian journal of physical therapy/Revista Romana de Kinetoterapie. 2016 May
1;21(37).

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