Stability Training

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Introduction

Outline

Outline

  • Introduction:
    • Definition
    • Models
    • Stability training for performance enhancement
    • Stability training for rehabilitation
      • Healing tissues
      • Balance deficits
      • Chronic ankle sprain
      • Low back pain
    • Special Note: Corrective Exercise

  • Stability Training Research by Movement Pattern/Muscle Group:
    • Squatting
    • Comparing the squat, lunge, bulgarian split-squat and single leg squat
    • Comparing the squat, step-up and single-leg squat
    • Comparing unilateral lower body exercise on stable and unstable surfaces
    • Push-up
    • Chest Press
    • Overhead Press
    • Inverted Row
    • Planks and Side planks
    • Glute bridge
    • Quadrupeds

Quick Summary

Key Points about Stability Training:

  • Novice exercisers see larger changes in EMG activity than experienced exercisers.
  • A significant challenge is necessary to increase EMG activity.
  • Unstable loads result in larger changes in EMG activity than Unstable surfaces.
  • Additional adaptation to unstable load and surface training, beyond EMG activity, must be considered (i.e. balance, coordination), as significant performance benefits have been demonstrated in experienced exercises.
  • Stability training in a rehabilitation setting may be beneficial for increasing EMG activity without increasing force, increasing balance, improving function, and reducing pain for certain conditions.
  • Research suggests that EMG activity can only increase to a "peak level", and no additional changes in environment or load result in further increases in EMG activity.

Rehabilitation:

  • Unstable training may be beneficial for progressing exercise for individuals who may benefit from an increase in muscle activity without an increase in force output (e.g. strain, tendon repair, etc.).
  • Unstable surface training may improve balance and performance on functional tests for those with assessed balance deficits.
  • The addition of balance training to a rehabilitation program for chronic ankle instability improves self-reported and objective functional outcomes, but does not effect strength or self-reported pain.
  • Research demonstrates that rehabilitation programs for low back pain (LBP) using unstable surfaces improves function and reduces pain better than programs using stable exercise alone.
  • Stability training is unlikely to have a significant effect on altered kinematics.
  • Individuals must continue balance training exercises, even after the resolution of symptoms, to maintain benefits beyond 6 weeks.

Note on Corrective Exercise:

  • There are a few studies that suggest unstable environments may exaggerate altered recruitment patterns in those exhibiting dysfunction. This may imply that specific interventions (e.g. serratus anterior activation) should precede multi-joint exercises using unstable surfaces or loads.

Performance:

  • Balance training may be as effective as traditional strength training for improving performance in novice exercisers.
  • Experienced exercises may require longer balance training programs (6+ weeks) to see performance gains.

Lower Body Exercise

Squats

  • Adding unstable surfaces to a squat may increase prime mover activity for inexperienced lifters.
  • Adding unstable surfaces to a squat may not alter EMG activity for stabilizers or prime movers in experienced lifters.
  • Adding unstable loads to a squat significantly increases stabilizer and core muscle activity for experienced and inexperienced lifters.
  • More research is needed to determine how unstable surfaces contribute to the increases in performance noted above; for example, increased coordination, balance, reaction time.

Comparing squats, step-ups, lunges, Bulgarian split-squats, single-leg squats and single-leg deadlifts.

Upper Body Exercise

Push-ups

  • Instability and changing body position (elevating feet) during a push-up increases upper body muscle activity.
  • Some research suggests that unstable surfaces/loads may exaggerate compensation patterns correlated with dysfunction; implying corrective interventions should precede stability training.

Chest Press

  • Prime mover activity is greater for stable exercises when loads are attempted that could not be performed with unstable loads or surfaces; however, unstable loads may be appropriate when loads are low to moderate. 
  • Core muscle activity is similar for unstable and stable surfaces when loads are high, but greater core muscle activity is noted when unstable surfaces are compared to stable surfaces and loads are low to moderate.
  • Unstable loading during a chest press may increase the activity of ancillary muscles including the biceps brachii, middle trapezius and middle deltoid

Overhead Press

Inverted Row:

  • Unstable loads will increase activity of stabilizing muscles.
  • Prime mover muscle activity may be highest when high loads can be performed from an unstable apparatus.
  • Placing the feet on unstable surfaces does not have an effect on muscle activity.
  • Inverted rows are helpful for those recovering from low back pain, as these progressions result in smaller amounts of posterior to anterior force on the lumbar spine and lower erector spinae activity then many other back exercises (102).

Core Exercise:

Planks

  • Lower Extremity Support: Modified (knees), to bilateral (both feet), to unilateral (one foot)
  • Unstable Environment: Floor plank, to inflatable disks or balance pads, to stability ball or suspension trainer
  • Placement of Unstable Environment: Under the feet, to under the forearms, to under the feet and forearms.
  • Posterior Chain Muscles: Although studies demonstrate that some progressions increase erector spinae activity, the addition of unstable environments to planks are likely not ideal for improving Posterior chain muscle strength/endurance.

Glute Bridge

Quadrupeds:

  • Stability Progressions: Quadrupeds may be progressed from arm raise, to opposite arm/leg raise, to leg raise, to increasing abduction angle; and further, increasing hip flexion angle and/or decreasing weight shift may increase trunk muscle activity.
  • Addition of External Load: The addition of unstable loads has the potential to further increase trunk muscle activity during the quadruped exercise.

Exercise Progressions

Exercise Progressions:

Definitions

Human movement professionals have a variety of ways to progress exercise. One method of progressing exercise is challenging stability by introducing unstable loads and/or surfaces. The objective of this course is to review all research pertaining to stability training, transparently present research findings, and develop reasonably objective conclusions about those findings for application in practice.

Definitions

  • Center of mass (CoM) - an object's mean position of mass; that is, a point that is perfectly surrounded by an equal amount mass in all directions.
  • Base of support (BoS) - refers to the area beneath an object or person, and the area within the perimeter created by every point of contact that the object or person makes with the supporting surface. This may include the glutes of someone sitting on a chair, or the back of someone leaning against a wall.
  • Equilibrium - A state in which opposing forces or influences are balanced.
  • Balance - The ability to maintain a body’s center of mass over its base of support. Balance can be static or dynamic.
  • Stability - the ability of a body to produce forces that will restore equilibrium when disturbed.
  • Stability Training  - An exercise or rehabilitation program designed to enhance the body's ability to stabilize; the ability to maintain/restore balance.
  • Exercise Progression - Modification of an exercise that increases demand with the intent of promoting adaptation. This can be accomplished by increasing reps, load, tempo, range of motion, complexity, and/or challenge to an individual's stability.
    • Because load, reps, tempo and complexity are often explicitly noted, the term "exercise progression" is most often used throughout Brookbush Institute (BI) content to refer to an exercise or series of exercises that make it harder to maintain stability with good form.
  • Experienced Exercisers - Participants in a study who have at least six months of exercise experience.
  • Inexperienced Exercisers - Participants in a study who have less than six months of exercise experience.

Models

Panjabi proposed a model of stability that separates the spine into three subsystems; neural, active and passive (1). Although this model was originally proposed to describe spine stability, the Brookbush Institute asserts that the model may be useful in describing stability throughout the human movement system. The neural subsystem is comprised of the central and peripheral nervous system and acts on the active subsystem (muscles) to modify stability. Akuthota et al. summarizes the interaction between the neural and active subsystems; stability of the spine is dependent on sensory input and muscular strength, which allow for constant feedback and sufficient force to refine movement (2). The passive subsystem is comprised of the vertebrae, discs and ligaments of the spine. The passive subsystem may be affected by the active subsystem, provides sensory input for the neural system; however, it functions primarily to provide structural support and limit end range motion. The three subsystems are part of the holistic human movement system and must be considered as interdependent. Panjabi states that a dysfunction of one subsystem will lead to one or more of the following possibilities: compensation from the other subsystem(s), long-term adaptation by the other subsystem(s), and/or an injury to the subsystem(s) (1, 3). Compensation by a subsystem from another subsystem may result in seemingly normal function, but long-term adaptation will result in altered stability (1). Injury to a subsystem may result in pain (1), muscle atrophy (4), passive system injury (e.g. ligament or disc injury) or altered motion. In the case of the spine, altered motion was in reference to changes in vertebral kinematics, such as spondylolisthesis. In summary, Panjabi's model provides a framework for describing how stability of the spine is maintained, and how dysfunction may alter stability and lead to pain. This model may aid in describing how stability is maintained at other joints, and provides a framework for considering the research discussed below.

Comerford and Mottram's Model

Another model of stability proposed by Comerford and Mottram (5) divides the muscular system into global and local systems. The local stabilization system is comprised of single joint muscles and controls segmental stabilization, and the global stabilization system is comprised of multi-joint muscles that control multi-segmental motion. Comerford and Mottram (5) assert that the systems are interdependent, but stability training may preferentially target local stabilizers. Example, the multifidus are local stabilizers whose activity is more affected by unstable environments, and the erector spinae are global stabilizers whose activity is more effected by load. If the local or global system becomes dysfunctional, then higher levels of stress or strain may occur resulting in tissue damage, dysfunction and pain (6). The Comerford and Mottram model of stability accurately predicts the changes in muscle activity that are seen in studies comparing unstable environments and loads. Further, the model aids in describing how dysfunction of one or both systems may increase stress, resulting in tissue damage and pain. Conceptually, the Comerford and Mottram model could be viewed as a division of tthe "active system" described by Punjabi.

Summary:

  • Punjabi's Model: Three Subsystems - passive (connective tissue), active (muscles) and neural (nervous system)
  • Comerford and Mottram's Model: Two Subsystems - local muscles and global muscles
  • The Comerford and Mottram's model could be viewed as a division of Punjabi's "active system".
  • Both models describe the interdependent relationship of the body's systems, are predictive of how stability training may engage specific systems, and how dysfunction of one or more systems could result in tissue stress and pain.

Unstable Surface Training in a Rehabilitation Setting

Healing tissues (e.g. strains, ruptures, etc.):

Using unstable surface training may be beneficial in the rehabilitation setting for certain injuries that may be exacerbated by increases in force. A literature review by Behm et al. demonstrated that unstable surfaces reduced force output by an average of 29.3%; however, muscle activity was similar or greater when compared to stable surface training. This trend was especially true in novice exercisers (novice exercisers) (7). The reduction in force while maintaining muscle activity may be beneficial for conditions in which an increase in force would increase the risk of further tissue damage (e.g. muscle strain). That is, human movement professionals may be able to progress exercise from more to less stable, increasing motor unit recruitment, without increasing the force on healing tissues.

Balance Deficits:

Research has also investigated unstable surface training in populations with assessed balance deficits. Elderly patients participating in a balance training program demonstrated improvements in balance tests, as well as the timed up-and-go test (8, 9). Note, an additional study has demonstrated that elderly participants without a balance deficit did not improve with an unstable surface training program (10). Research has also shown that children with balance deficits may benefit from unstable surface training, including children with visual impairments, cerebral palsy, Down's syndrome and autism (11-14). Again, further research demonstrates that children without a balance deficit do not demonstrate significant change on balance tests after an unstable surface training program (15 - 17). In summary, unstable surface training may improve balance and performance on functional tests for those with assessed balance deficits.

Unstable Surface Training for Chronic Ankle Instability

Research has demonstrated that adding balance exercises to a rehabilitation program for chronic ankle instability (CAI) improves functional outcome measures and objective scores on balance assessments (18-21). The tools used in these studies for functional outcomes measures include the Cumberland Ankle Instability Tool (CAIT), Foot and Ankle Ability Measure (FAAM), Single Assessment Numeric Evaluation (SANE) or Global Rating of Change (GROC)) (18, 19, 21), and the objective balance scores were attained using the Star Excursion balance Test (SEBT) (19, 21). Kim et al. and Cruz-Diaz et al. demonstrated that strength training with balance exercises elicits greater improvements in CAIT and SEBT scores when compared to strength training alone (18, 19). The balance training included marches, hopping, and unilateral/bilateral throwing exercises with the feet on an unstable surface. Although the balance training did not have an impact on self-reported pain or strength tests, patients demonstrated significant improvements in self-reported perception of function and objective functional outcomes (18, 19). Donovan et al. demonstrated that programs using unstable shoes (Myolux Athletik and Myolux II destabilization devices) and unstable surfaces (foam pad or balance disc) resulted in similar range of motion, self-reported pain, self-reported function and objective function outcomes in those with CAI (21). This study implies that unstable shoes do not provide additional benefit over more versatile and affordable unstable surface products. Interestingly, Kim et al. demonstrated that a 6-week rehabilitation program (balance, strengthening, plyometric and speed/agility exercises) reduced ankle eversion with walking and running, and inversion when landing from a jump in those with CAI (20). However, ankle eversion with walking and running returned to baseline values 24-weeks after exercises was discontinued (20). This implies that clients with CAI may need to continue rehabilitation programs to maintain kinematic improvements, even after function and pain have returned to baseline or better. In summary, research demonstrates that the addition of balance training to a rehabilitation program for CAI improves self-reported and objective functional outcomes, but does not improve strength or self-reported pain. Further, training must continue to maintain benefits beyond 6-weeks of training.

Unstable Surface Training for Low-back Pain

Research demonstrates that adding unstable surface exercises to a rehabilitation program for low-back pain (LBP) improves function, muscle strength, muscle endurance and range of motion outcomes (22 - 25). The tools used in these studies include the Oswestry Disability Index, visual analog pain scale, the Stork Balance Stand Test and the Beck Depression Inventory questionnaire (22-25). Javadian and Moon et al. demonstrated that a combination of unstable (stability ball and wobble board) and stable rehabilitation exercises elicits greater improvements in self-reported pain, self-reported function, lumbar range of motion, muscle endurance and strength compared to stable surface rehabilitation alone (22, 25). Kang et al.  demonstrated that the prone and side plank, curl-up and glute-bridge on an unstable surface (Dynair® ball cushion) elicits greater improvements in self-reported pain, self-reported function, objective function, depression and low-back strength compared to a stable surface rehabilitation program (23). A study by Ko et al. implied that improvements in outcome measures may be equipment specific, as ground based unstable surfaces (stability ball, wobble board or Dynair ball cushion) provide additional improvements in outcomes compared to stable surfaces, but suspension training provided no additional benefit (24). Interestingly, programs using unstable surfaces alone do not appear to alter lumbar lordosis angle, lumbosacral angle and sacral inclination in those with LBP (24), implying that more specific techniques may be necessary to alter motion. Research demonstrates that rehabilitation programs for LBP using unstable surfaces improves function and reduces pain better than programs using stable exercise alone.

Corrective Exercise First:

There are a few studies investigating muscle activity during pushing that suggest isolated corrective interventions should precede multi-joint stability exercises. Unfortunately, similar studies could not be located for pulling or lower body movement patterns. Individuals with scapular dyskinesis and/or shoulder pain demonstrate increased electromyographic (EMG) activity of the upper trapezius and a decrease in serratus anterior activity during the push-up exercise on an unstable surface (26, 27). Additionally, a study by Park et al. revealed that individuals with scapular winging compared to controls, presented with significantly higher pectoralis major EMG activity and significantly lower serratus anterior EMG activity during a "push-up with plus" (protraction) (28). The decrease in serratus anterior and lower trapezius  activity in these studies, is similar to the pattern noted in those with shoulder pain during arm elevation (29, 30). These studies imply that the addition of unstable environments may exaggerate the altered recruitment strategies noted in those individuals exhibiting dysfunction. This may imply that specific interventions should precede general strength training exercises using unstable surfaces or loads. 

Stability Training for Performance Enhancement

Research has demonstrated that unstable surface training can increase sport and athletic performance. In novice exercisers, unstable surface training has been shown to improve lower-leg muscle activity during a jump-landing task, stair climbing performance, rate of force development, vertical jump height, and may have a beneficial effects on flexibility (31-33). Kibele et al. demonstrated that novice exercisers improved as much from unstable surface training as a traditional strength training program for sprint times, shuttle run times, standing long jump distance and single-leg hop performance (34). These studies imply that novice exercises may gain a variety of benefits from a balance training program, potentially as much benefits as noted with a traditional strength training program. Experienced exercises may require longer training periods to attain performance benefits from stability training. A study by Yaggie et al. demonstrated that four weeks of balance training improved shuttle run time, but did not increase vertical jump height (35). However, studies investigating longer training programs (6+ weeks) consistently resulted in performance improvements including vertical jump heights, throwing and max strength (36-39). Myer et al. demonstrated an additional benefit for experienced exercisers; balance training may reduce impact forces during a jump-landing (36). In summary, balance training may be as effective as traditional strength training for improving performance in novice exercisers, and experienced exercisers may require longer balance training programs (6+ weeks) to see performance gains.

Summary:

Rehabilitation:

  • Unstable training may be beneficial for progressing exercise for individuals who may benefit from an increase in muscle activity without an increase in force output (e.g. strain, tendon repair, etc.).
  • Unstable surface training may improve balance and performance on functional tests for those with assessed balance deficits.
  • The addition of balance training to a rehabilitation program for chronic ankle instability improves self-reported and objective functional outcomes, but does not effect strength or self-reported pain.
  • Research demonstrates that rehabilitation programs for low back pain (LBP) using unstable surfaces improves function and reduces pain better than programs using stable exercise alone.
  • Stability training is unlikely to have a significant effect on altered kinematics.
  • Individuals must continue balance training exercises, even after the resolution of symptoms, to maintain benefits beyond 6 weeks.

Corrective Exercise:

  • There are a few studies that suggest unstable environments may exaggerate altered recruitment patterns in those exhibiting dysfunction. This may imply that specific interventions (e.g. serratus anterior activation) should precede multi-joint exercises using unstable surfaces or loads.

Performance:

  • Balance training may be as effective as traditional strength training for improving performance in novice exercisers.
  • Experienced exercises may require longer balance training programs (6+ weeks) to see performance gains.

Lower Body Stability Training

Squats

Prime mover muscle activity during the barbell squat may not be affected by unstable surfaces or loads. Prime movers are defined as the quadriceps and gluteal complex (gluteus maximus and gluteus medius), and research has investigated various unstable surfaces including foam pads, Reebok Core® Boards, balance boards, BOSU® balls and balance cones (40-44). Most research investigating vastus medialis and vastus lateralis activity demonstrate that training surface does not have a significant effect on activity (41-44). However, a study using novice exercisers found a significant increase in vastus medialis and vastus lateralis muscle activity when a foam pad was added to isometric squats (40). This study could be compared to a study using experienced exercises and a similar foam pad, demonstrating no change in muscle activity (43). This may imply novice exercisers exhibit an increase in EMG activity to accommodate unstable surfaces, however experience reduces the need for this increase (40, 43). Only one study was found comparing the glute complex activity of experienced lifters on stable and unstable surfaces, and no significant difference in muscle activity was noted (42). In summary, research suggests unstable surfaces have little effect on Prime mover muscle activity for experienced lifters, but may increase muscle activity in novice lifters. More research is needed to determine how unstable surfaces contribute to the increases in performance noted above; for example, increased coordination, balance, reaction time.

Stabilizer muscle activity during a barbell squat may be affected by unstable loads, but probably not unstable surfaces. Research has investigated lower-extremity stabilizers including the bicep femoristibialis anterior, gastrocnemius and soleus, as well as core muscles including the rectus abdominisexternal obliqueserector spinae, and multifidus (41-46). A study by Lawrence et al. demonstrated that weight plates suspended from a barbell by bands resulted in a significant increase in external oblique, rectus abdominis and soleus muscle activity (45), and Ditroilo et al. demonstrated that squats using a water-filled tube significantly increased external oblique and multifidus muscle activity (46). The research studies mentioned above also demonstrated that Stabilizer and core muscle activity were not significantly affected by unstable surfaces (41-44). One study by Saeterbakken et al. demonstrated an increase in soleus activity using a BOSU® ball during a squat, but the increase in activity did not reach clinical significance (44). These studies suggest that unstable loads have a much larger effect on Stabilizer and core muscle activity then unstable surfaces, and if the goal is an increase in muscle activity then unstable loads may be preferred. Again, more research is needed on unstable surface and balance training to determine the factors contributing to the increases in performance.

Summary

  • Adding unstable surfaces to a squat may increase prime mover activity for inexperienced lifters.
  • Adding unstable surfaces to a squat may not alter EMG activity for stabilizers or prime movers in experienced lifters.
  • Adding unstable loads to a squat significantly increases stabilizer and core muscle activity for experienced and inexperienced lifters.
  • More research is needed to determine how unstable surfaces contribute to the increases in performance noted above; for example, increased coordination, balance, reaction time.

Comparing the Squat, Lunge and Bulgarian Split-Squat

Muscle activity during squats has been compared to the lunge and Bulgarian split-squat (43, 47-52). Stuart et al. compared Muscle activity during squats and lunges using a 50 pound barbell; demonstrating higher quadriceps and hamstring muscle activity during the lunge (47). However, a study by DeForest et al. demonstrated that when lunges were performed with half the weight used for the squatlunges exhibited similar Muscle activity for the quadriceps and lower activity for the biceps femoris (48). In studies comparing squats to the Bulgarian split-squat, EMG activity for the vastus medialis and vastus lateralis were similar (48, 49), even when performed on an Airex pad (unstable surface) (43). Squatlunges, and Bulgarian split-squats demonstrated similar erector spinae activity, however, the Bulgarian split-squat elicited higher external obliquegluteus medius and gluteus maximus activity (43, 48-51). Biceps femoris activity was similar for the Bulgarian split squat and squats when using heavier external loading for the squat, but when using loads of 3-10 repetition maximus (RM) for each exercise, more biceps femoris activity was exhibited during the Bulgarian split squat (43, 48-51). One study by DeForest et al. (48) compared Muscle activity during the Bulgarian split-squat and lunges, with the Bulgarian split-squat requiring similar quadricep muscle activity and higher hamstring muscle activity. These studies imply that careful attention to the load used during the study is important for developing sound conclusions. Prime mover activity is likely similar during all exercises when loads are adjusted to ensure failure in the same rep range. Hip and trunk stabilizer Muscle activity is higher during lunges and Bulgarian split-squats when compared to squats. Bulgarian split squats exhibited the most biceps femoris activity, and the lunge exhibited the least, which may imply Bulgarian split-squats should be avoided due to the propensity of the biceps femoris to be over-active in those individuals exhibiting signs of Lower-Extremity Dysfunction (LED). In summary, the reduction in biceps femoris activity and increase in core and hip Muscle activity during lunges may imply this is an ideal progression from squats.

Comparing the Squat, Step-up and Single-leg Squat

Muscle activity during the squat has also been compared to the step-up and single-leg squat (52, 53). These exercises are discussed separate from the Bulgarian split-squat and lunge, because the step-up and single-leg squat are truly unilateral; performed on one limb without support from the other. When no external load is added, the step-up requires twice as much glute complex activity as the squat, and the single-leg squat requires significantly more glute complex activity than the step-up (52). When a barbell was used to add external load to the squat and single-leg squat, the squat exhibited similar gluteal complex and semitendinosus activity, but higher quadriceperector spinae and bicep femoris muscle activity (53). It is possible that during these loaded studies the gluteal complex reached a recruitment threshold, that reduced the differences noted when larger loads were used (52, 53). Interestingly, band resisted abduction around the knee increased gluteal complex muscle activity during the unweighted squat, but decreased gluteal complex muscle activity during the step-up and single-leg squat (53). This is likely due to the step-up and single-leg squat being open chain movements, and the gluteal complex being unable to contribute to abduction when the pelvis was not fixed (by the other leg on the ground). That is, the only means of resisting a valgus force at the knee during an "open-chain" lower extremity exercise is ankle eversion, because a planted foot on the ground creates a stable base to "push" from. In summary, an increase in gluteal complex muscle activity may be achieved by progressing from squats to step-ups to single-leg squats; however, difference in EMG activity decrease when external loads are used. Further, band around the knees resisted abduction only increases gluteal complex activity during close chain activities.

Comparing the Unilateral Lower Body Exercise on Stable and Unstable Surfaces

EMG activity has been compared during various unilateral lower-extremity exercises, on stable and unstable surfaces (43, 54, 55). Krause et al. demonstrated EMG activity during a body-weight lunge was  9 - 22% maximal voluntary isometric contraction (MVIC) for the rectus femoris, hamstrings, gluteus medius, gluteus maximus and adductor longus (54). Another study by Krause et al. demonstrated EMG activity during a body-weight single-leg squat was 50% MVIC for the gluteus medius (55). These same studies demonstrated that when an unstable surface was introduced, %MVIC increased for the lunge, but not for the single-leg squat (54, 55). A study by Andersen et al. reported that %MVIC for a loaded Bulgarian split squat was 140% MVIC for the bicep femoris, rectus abdominis and external oblique, and between 70-90% MVIC for the rectus femoris, vastus medialis, vastus lateralis and erector spinae (43). The much higher %MVIC in these studies is likely due to the use of external load; however, it is interesting to note that adding an unstable environment to the loaded Bulgarian split-squat actually reduced %MVIC of the erector spinae and biceps femoris. The reduction in activity when adding an unstable environment is likely due to an inability to produce the same amount of force, i.e. lift the same load, or lift the same load at the same speed. In summary, progression from a lunge to single leg squat may increase glute complex activity, adding an unstable surface to body-weight exercise is likely to increase EMG activity; where as, adding unstable surfaces to loaded exercise may reduce the capacity to produce force. Consideration of the phase of training and the client's goal may dictate whether stability or load is the appropriate progression. (Note, the Bulgarian split squat was omitted for the reasons mentioned above).

Muscle activity during the single-leg deadlift has been compared to the lunge, step-up and single-leg squat. Single-leg deadlifts elicits similar glute activity, but higher hamstring activity than the step-up or lunge (56, 57), and elicit similar hamstring and glute activity but less quadriceps activity than the single-leg squat (57). These findings should not be surprising, as the larger moment arm created by the trunk during deadlifts requires more recruitment of hip extensors, but the lack of significant knee flexion reduces the amount of quadriceps recruitment necessary at the knee. Boren et al. demonstrated that single-leg deadlifts elicited less glute activity than the single-leg squats (58); however, this is likely due to the study allowing the non-weight bearing leg to extend behind the individual and act as a counter-balance. Note, the Brookbush Institute does not recommend allowing the non-weight bearing leg to extend posteriorly, as it reduces load and may contribute to compensation. The findings of these studies are congruent with practical application which suggests the "level of difficulty" progresses from step-up, to lunge, to unilateral exercise like the single leg deadlift and single-leg squat, and further that deadlifts place greater emphasis on hip extensor strength.

 Single Leg Touch Down with Posterior Pull

Lower Body Stability Training Summary

Summary

Upper Body Stability Training

The Push-up on Stable and Unstable Surfaces

Muscle activity has been compared during push-ups on stable and unstable surfaces (59-73). The unstable surfaces investigated include the wobble board, suspension trainer, stability ball and BOSU® ball (59-73). Push-ups on unstable surfaces resulted in greater Muscle activity for prime movers (pectoralis major, anterior deltoid and triceps brachii), and core muscles (rectus abdominis, internal and external oblique, erector spinae and lumbar multifidus )(59, 62-66, 68-73). Latissimus dorsi muscle activity was only greater during the push-up on a suspension trainer, and only if the arms were adducted below 90 degrees (72).

Serratus anterior activity was greater during push-ups on unstable surfaces, or with increased upper body load (feet elevated) (59, 60, 65, 67, 68, 71). The unstable surfaces that increase serratus anterior activity include the wobble board, BOSU® ball (hands and feet) and suspension trainer with the feet elevated to the same height as the hands (59, 60, 65, 67, 68). Two studies found that serratus anterior activity was greater on a stable surface when compared to having hands on a suspension trainer, wobble board, or feet elevated, but these studies included multiple push-up variations in which fatigue may have influenced muscle activity (61, 66). Torres et al. (67) found that anterior and posterior deltoid muscle activity was greater during the push-up on a stable surface compared to the push-up with the hands and feet on a BOSU® ball. Conversely, a study by de Araujo et al. demonstrated that upper trapezius muscle activity was greater during the push-up with the hands on a wobble board (59). These studies demonstrating a decrease in serratus anterior activity, decrease in deltoid muscle activity, and increase in upper trapezius muscle activity match the altered activity exhibited by those with shoulder dysfunction (74). This may be further evidence of unstable surfaces exaggerating altered recruitment patterns, as discussed above. In summary, adding instability or changing body position during a push-up increases upper body muscle activity; however, more research is needed to investigate the potential for the increased activity to exaggerate compensation patterns.

Chest Press on Stable and Unstable Surfaces

Muscle activity has been investigated for the chest press with stable and unstable surfaces and loads (75-85). The unstable load tested was weights suspended from a BandBell™ Earthquake Bar or barbell (75-79), and the unstable surface tested was torso on a stability ball (80-85), . Lawrence et al. demonstrated that prime mover Muscle activity was greater during a chest press with a stable load, then a chest press with an unstable load when performing 1-set of 5-repetitions (75, 76); however, multiple sets resulted in similar prime mover Muscle activity for stable and unstable loads (77, 78). Similarly, the barbell chest press on a stable surface resulted in more prime mover Muscle activity when compared to a barbell on an unstable surface (79). (Note, performing barbell presses on a stability ball is not recommended). These studies may imply that prime mover activity is greater for stable exercises when loads are attempted that could not be performed with unstable loads or surfaces; however, unstable loads may be appropriate when loads are low to moderate. The dumbbell chest press requires similar prime mover Muscle activity when the torso is on a stable or unstable surface (80, 81), and anterior trunk Muscle activity is similar during high loads regardless of surface type (80, 82, 83). However, anterior trunk Muscle, and potentially prime mover activity is greater on an unstable surface when loads are low to moderate (79, 81, 84, 85). Again, this implies that anterior trunk Muscle activity is similar when loads are high, but more anterior trunk activity is noted when low to moderate loads are performed on an unstable surface. The chest press with unstable loading results in greater biceps brachii, middle trapezius and middle deltoid muscle activity (75, 76, 78). In summary, a trend is noted toward increased prime mover and core Muscle activity with unstable surfaces and loads when load is low to moderate. prime mover and core Muscle activity may be higher on stable surfaces using high loads, likely due to the increase in load that can be lifted.

Dr. Brent Brookbush cues Melissa through multi-planer dumbbell press on bench Dumbbell Press

The Overhead Press Exercise on Stable and Unstable Surfaces

Research has compared EMG activity with unstable loads and unstable surfaces, during an overhead press (80, 83, 86, 87). Research by Williams et al. demonstrated that an overhead press with weights suspended from a Bandbell® Earthquake bar (unstable load) elicited greater pectoralis major, scapular stabilizer (serratus anterior and rhomboids), trunk (rectus abdominis and erector spinae) and antagonist (latissimus dorsi and bicep) muscle activity when compared to stable loads (86). Prime mover (deltoid and tricep), external oblique and rotator cuff muscle activity was similar when using the same weight with stable and unstable loads (86). However, Kohler et al. demonstrated that weights too heavy to be performed with unstable loads, resulted in the greatest Prime mover and external oblique muscle activity (87). This implies that stabilizer muscle activity increases with unstable loads, Prime mover and external oblique muscle activity are similar when similar weight is used for stable and unstable loads, and Prime mover activity may be greatest when performing stable loads that could not be performed with unstable loads.

Stable and unstable loads with moderate to heavy weight elicited large amounts rotator cuff muscle activity in all condition (86). This may imply a "threshold" activation level that was reached, in which no higher level of activity can be achieved without the significant increases in load seen during stable 1-5 rep max (RM) training. This tendency is seen throughout the body of research comparing stable and unstable exercise, and may imply that an increase in muscle activity is only one of several methods the body uses to accommodate stable/unstable training.

Studies by Uribe et al., Lehman et al., and Kohler et al., compared dumbbell overhead press seated on a stability ball to sitting on a stable surface (80, 83, 87). The studies demonstrated similar muscle activity from prime movers and anterior trunk muscles (rectus abdominis and external oblique), with the exception of the study by Kohler et al. that noted small differences in rectus abdominis and erector spinae activity (87). Based on these findings it is likely that unstable surfaces do not have as large an effect on muscle activity as unstable loads do.

The Inverted Row with Stable and Unstable Environments

Muscle activity has been investigated during the inverted row with a barbell and suspension trainer, and with the feet on stable and unstable surfaces (63, 88-91). Research suggests that Muscle activity increases when hanging from an unstable apparatus like the TRX® suspension trainer, but unstable surfaces for the feet have little effect on Muscle activity. Prime mover (latissimus dorsi, posterior deltoid and middle trapezius) Muscle activity is similar when hanging from a barbell or TRX®, but only when the load is decreased by bending the knees to 90º (feet flat on the floor) (88, 89). McGill et al. (90) demonstrated that Prime mover Muscle activity is higher with the TRX® row, when the load is increased by straightening the legs. This implies that Prime mover activity is greatest when higher loads can be done on unstable apparatus. A potentially counter-intuitive finding, biceps brachii muscle activity was higher with a pronated grip when using a barbell (88, 89), but was highest with a supinated grip when using a TRX® (91). Further,  anterior trunk Muscle activity was greater during the TRX® row (63, 90), but erector spinae muscle activity was greater during a hanging barbell row (89). An interesting finding, the primary scapular stabilizer - serratus anterior exhibited similar activity in stable and unstable environments in novice exercisers (63), but exhibited more activity during a TRX® row in experienced exercisers (90). Although the study findings appear to suggest complex relationships, there does appear to be a general trend toward prime movers exhibiting higher activity in stable environments with larger loads, and stabilizing muscles exhibiting more activity in unstable environments. The only exception may be that Prime mover activity can be greater if large loads can be performed in less stable environments. Youdas et al. is the only study that could be found comparing feet on a stable and unstable surfaces (91). This study demonstrated that Prime mover, scapular stabilizer and anterior trunk Muscle activity were similar during the inverted row with one foot on the ground or feet on a BOSU® ball (91). In summary, unstable loads will increase stabilizer Muscle activity, and may increase Prime mover Muscle activity if load is sufficient. Placing the feet on unstable surfaces does not seem to have an effect on Muscle activity.

Only a couple of studies were located comparing additional back/pulling exercises and muscle EMG activity. Fenwick et al. and Saeterbakken et al. demonstrated that standing unilateral rows increased activity of muscles involved in rotational control of the lumbar spine when compared to standing bilateral rows (92, 93). Further, Fenwick et al., comparing 3 exercises, demonstrated that bent over horizontal rows resulted in the greatest upper back muscle activity, suspension rows resulted in the greatest latissimus dorsi and gluteus maximus activity, and again, unilateral standing rows resulted in the greatest activity for muscles involved in rotational control of the spine (e.g. external obliques) (92). The bent-over horizontal rows also resulted in the greatest erector spinae activity, likely due to the large moment arm on the lumbar spine and forward bending position; where as, the suspension rows resulted in the least erector spinae activity and most gluteus maximus activity (92). These findings support two recommendations made by the Brookbush Institute. Bent-over rows should likely be avoided unless their is a goal specific reason the exercise is better than other options, and suspension rows are a wonderful recommendation for those individuals recovering from low back pain and returning to a strength training program.

Upper Body Exercise Summary

Push-ups

  • Instability and changing body position (elevating fee) during a push-up increases upper body muscle activity.
  • Some research suggests that unstable surfaces/loads may exaggerate compensation patterns correlated with dysfunction; implying corrective interventions should precede stability training.

Barbell and Chest Press

  • Prime mover activity is greater for stable exercises when loads are attempted that could not be performed with unstable loads or surfaces; however, unstable loads may be appropriate when loads are low to moderate.
  • Core muscle activity is similar for unstable and stable surfaces when loads are high, but greater core muscle activity is noted when unstable surfaces are compared to stable surfaces and loads are low to moderate.
  • Unstable loading during a chest press may increase the activity of ancillary muscles including the biceps brachii, middle trapezius and middle deltoid.

Overhead Press

Inverted Row:

  • Unstable loads will increase activity of stabilizing muscles.
  • Prime mover muscle activity may be highest when high loads can be performed from an unstable apparatus.
  • Placing the feet on unstable surfaces does not have an effect on muscle activity.
  • Inverted rows are helpful for those recovering from low back pain, as these progressions result in smaller amounts of posterior to anterior force on the lumbar spine and lower erector spinae activity then many other back exercises (102).

Core Stability Training

The Front-Plank and Side-Plank on Stable vs Unstable Surfaces

The Front-Plank and Side-Plank on Stable vs Unstable Surfaces:

Unilateral versus Bilateral

Progressing a plank from bilateral to unilateral lower extremity support has been investigated in several studies. Cho et al. demonstrated that progressing from bilateral to unilateral lower extremity support significantly increased activity of the internal obliques, external obliques and rectus abdominis (94). Further, Escamilla et al. demonstrated that the addition of unilateral hip extension (resulting in unilateral support) increased activity of the internal obliques, external obliquesrectus abdominis and rectus femoris activity during a plank (95). These studies suggest that without additional equipment, progression to unilateral lower extremity support can be used to increase core muscle recruitment.

Inflatable Disks and Balance Pads

Progressing a plank by incorporating inflatable disks and balance pads has been investigated in four studies. Kim et al. used ultrasound to demonstrate increases in thickness of the transversus abdominis, internal obliques, external obliques and multifidus when the abdominal drawing-in maneuver (ADIM) was added to a floor plank, and/or planks were performed with feet on inflatable disks. The largest change in trunk muscle thickness was noted during planks with ADIM and feet on inflatable disks (96). Lee et al. compared conventional and modified planks (on knees), on the floor and with feet/knees on inflatable disks, demonstrating that an unstable surface resulted in a significant increase in rectus abdominis and external obliques activity for both conventional and modified planks (97). Another study by Lee et al. compared floor planks, to inflatable disks under the feet, to a suspension trainer supporting the ankles, demonstrating that inflatable disks and suspension trainers significantly increased activity of the external obliques, rectus abdominis and erector spinae; however, the suspension trainer did result in a larger increase in activity (98). Last, Park et al. demonstrated that balance pads significantly increased trunk muscle activity, but did not have a significant effect on hamstring activity (99). Based on these studies balance pads and inflatable disks may be used to progress planks with the intent of increasing trunk muscle activity, but not hamstring activity. Further, adding balance pads and disks to a plank likely increases demand less than the addition of a suspension trainer.

Stability Balls

Stability balls (and Bosu balls) have been a popular modality for progressing exercise, and many research studies have investigated their effect on muscle activity during a plank. Mirmohammad et al. demonstrated that compared to a floor plank, performing a plank with a Stability ball under the forearms, resulted in a significant increase in activity and thickness of the internal obliques, external obliquesrectus abdominis, multifidus and quadatus lumborum (100). Cho et al. demonstrated that planks with forearms on a Stability ball increased pectoralis major activity, feet on a Stability ball increased rectus femoris activity, and only both the legs and forearms on unstable surfaces increased erector spinae activity (101). Czaprowski et al. demonstrated that the activity of the transverse abdominis, internal obliques, external obliquesrectus abdominis was higher during a Stability ball plank, when compared to a floor plank or glute bridge on stable or unstable surfaces (102). Additionally, Imai et al. used fine wire electrodes to demonstrate that adding a bosu ball under the feet during a plank also increased internal obliques, external obliquesrectus abdominis, multifidus and erector spinae activity (103). These studies demonstrate that progressing a plank with the addition of a Stability ball is effective for increasing trunk muscle activity. Additionally, placing the ball under the forearms may increase upper extremity activity, and placing the ball under the feet/ankles may increase lower extremity muscle activity.

Additional studies have compared planks with the addition of a stability ball to planks with the addition of a suspension trainer. Atkins et al. compared a floor plank, plank with hands on a stability ball, and planks with hands on a suspension trainer, demonstrating that both unstable conditions increased activity of the external obliques, rectus abdominis and erector spinae compared to the floor plank, and that rectus abdominis activity was highest during the suspension trainer plank (104). Shin et al. compared a conventional floor plank to a TRX suspension trainer plank and a stability ball plank, demonstrating the suspension trainer plank resulted in a significant increase in activity of the transverse abdominis, internal obliques, external obliquesrectus abdominismultifidus and erector spinae, and a stability ball plank significantly increased activity of the same muscles except for the transverse abdominis (105). Kang et al. compared training with planks, planks on a stability ball, or planks on a sling apparatus, 3 times a week for 4 weeks, demonstrating that only the stability ball group exhibited a significant difference in internal obliques and external obliques muscle thickness when compared to the floor plank (106). These studies suggest that the addition of a stability ball to a plank significantly increases core muscle recruitment, and although activity may be slightly higher during a suspension trainer plank, a stability ball plank may result in more hypertrophy following training. Considering how small the differences are between suspension trainer and stability ball groups, and the somewhat contradictory findings, it may be more likely that these two modalities result in similar activity and outcomes, and the study findings are just normal observations of variance between study groups.

Suspension Trainers and Slings

Incorporating slings and suspension trainers into training has become increasingly popular in recent years. Bak et al. compared a conventional plank to knees supported by slings, ankles supported by slings, and ankles supported by slings with the addition of hip abduction, demonstrating that ankles supported by slings (with and without abduction) significantly increased internal obliques, external obliquesrectus abdominis and multifidus activity (107). Similarly, Snarr et al. demonstrated that the addition of a suspension trainer to the upper extremity, lower extremity, or both upper and lower extremity significantly increased external obliques, rectus abdominis and erector spinae when compared to a floor plank (108). A study by Bryne et al. compared activity depending on where the suspension trainer was incorporated, demonstrating that external obliques and rectus abdominis activity increased when progressing from floor to feet suspended, from feet suspended to arms suspended, and the highest activity was noted when feet and arms were suspended. Additionally, this study demonstrated that rectus femoris activity was greatest for an arms supported plank, and serratus anterior activity was greatest for a feet supported plank (109). This research demonstrates that the addition of a suspension trainer to a plank is effective for increasing trunk muscle activity; and further, may be used for multiple progressions from a floor plank to feet suspended, to arms suspended, to feet and arms suspended.

Previously mentioned studies compared slings and suspension trainers to other modalities. Lee et al. demonstrated that suspension trainer planks (feet supported) resulted in a larger increase in activity of the external obliques, rectus abdominis and erector spinae than inflatable disk planks (feet supported) (98). And, Kang et al., Atkins et al., and Shin et al. demonstrated that the addition of a stability ball or suspension trainer to a plank resulted in similar activity and hypertophy (104-106). These studies likely implies that floor planks may be progressed by incorporating inflatable disks/pads, and then either stability ball or suspension trainers.

Posterior Chain Muscles

Two studies have investigated the activity of posterior chain muscles during stable and unstable planks. Mentioned above, Park et al. reported no significant differences in hamstring activity when comparing floor planks, planks in a sling, and planks on a balance pad (99). And, a randomized controlled trial (RCT) by Wang et al. compared a floor plank to arms in slings planks, demonstrating that of the superficial back line muscles (erector spinae, biceps femoris, gastrocnemius) only the gastrocnemius exhibited a significant increase in activity (110). Although several studies mentioned above have demonstrated an increase erector spinae activity with the addition of unstable modalities (98, 101, 103-105, 109), planks are likely not ideal for improving posterior chain muscle strength.

Interesting Tidbit:

Various texts and publications have implied that addressing core endurance and stability may improve balance during functional tasks. However, Imai et al. demonstrated that core exercise had no immediate effect, and stability/balance exercise had an immediate positive effect on posterolateral and posteromedial directions scores on the Star Excursion balance Test (SEBT) (111). This study likely implies that core stabilization exercises improve core stability; however, those outcomes may not be generalized to balance during functional tasks.

  • Stable versus Unstable: Research suggest the following progressions will increase core muscle activity:
    • Lower Extremity Support: Modified (knees), to bilateral (both feet), to unilateral (one foot)
    • Unstable Environment: Floor plank, to inflatable disks or balance pads, to stability ball or suspension trainer
    • Placement of Unstable Environment: Under the feet, to under the forearms, to under the feet and forearms.
  • Posterior Chain Muscles: Although studies demonstrate that some progressions increase erector spinae activity, the addition of unstable environments to planks are likely not ideal for improving Posterior chain muscle strength/endurance.

The Glute Bridge on Stable vs Unstable Surfaces

Reducing stability is a common method for progressing the bridge exercise, and is well-supported by a growing number of research studies. Ekstrom et al. demonstrated that gluteus medius and gluteus maximus activity was nearly double when comparing a single-leg bridge to a bilateral bridge (112). This might be expected considering a unilateral bridges results in a single leg lifting the weight of the body. Further, Cho et al. demonstrated that a single-leg bridge increased gluteus maximus and core muscle activity when compared to a bilateral bridge, and the introduction of an unstable environment further increased the activity of core muscles (113). Youdas et al. demonstrated that gluteus maximus activity was highest during a single-leg bridge on a stable surface, gluteus medius activity was highest during a single-leg bridge on an unstable surface, both unilateral variations (stable and unstable) resulted in more muscle activity than bilateral variations, and multifidus activity was similar for all variations (114). The higher gluteus maximus activity on a stable surface may be related to the ability to generate more force from a stable surface. Conversely, Yoo et al. demonstrated that using balance boards during bridges increased external oblique and gluteus maximus activity (but not erector spinae activity) in elderly individuals (115). These studies demonstrate that progressing from a bilateral bridge to a single-leg bridge nearly doubles gluteus maximus and gluteus medius activity, and increases trunk muscle activity. Further, adding an unstable surface may further increase gluteus medius and gluteus maximus activity (unless force output decreases), and will significantly increase trunk muscle activity.

Additional studies, have focused on core muscle recruitment patterns and the effect of reducing stability during a bridge. Lee et al. used ultrasound (US) to compare anterior abdominal muscle thickness during a bridge with stable and unstable support, demonstrating that only the internal obliques increased in thickness during the unstable bridge (116). Kang et al. demonstrated that internal oblique thickness was greatest during a bridge using a stability ball, where as transverse abdominis and multifidus thickness was greatest during a bridge using a sling (117). Note, both the sling and stability ball increased muscle activity of all monitored muscles. Kong et al. demonstrated that external oblique, internal oblique and transverse abdominis activity was higher during a stability ball bridge than a floor bridge (and highest during a plank). Further, erector spinae activity was highest during a stability ball bridge, followed by a floor bridge (and lowest during a plank )(118). Son et al. demonstrated that the internal oblique to rectus abdominis activity ratio was highest during a bridge with shoulders on a stable surface; however, external oblique, internal oblique and rectus abdominis activity was highest during the bridge with shoulders on an unstable surface (activity was lowest during a conventional floor bridge) (119). Last, Kim et al. demonstrated that resisted adduction with a pilates ring increased rectus abdominis, transverse abdominis and internal oblique activity, and the addition of a stability ball to the resisted adduction bridge further increased external oblique activity (120). These studies may imply that an increase in internal oblique activity (and perhaps transverse abdominis activity) may match initial demand when progressing from stable to unstable environments; however, as demand increases, activity of the external obliques and rectus abdominis may aid in compensating for further increases.

A similar relationship may exist between the multifidus and erector spinae. Mello et al. demonstrated that lumbar multifidus activity was greater than erector spinae activity, but activation was only about 30% of maximal voluntary isometric contraction (MVIC) with no signs of fatigue at the end of a set of bridges (121). As mentioned above, Yoo et al. demonstrated that using balance boards during bridges increased external oblique and gluteus maximus activity, but not erector spinae activity in elderly individuals (115). Kang et al. used ultrasound to demonstrate that multifidus thickness increased during an unstable bridge when compared to a floor bridge (117). And, Park et al. demonstrated that an unstable bridge (sling) increased rectus abdominisinternal oblique, and multifidus activity, and further, that adding contralateral hip abduction (un-resisted) increased internal oblique activity relative to rectus abdominis activity, and multifidus activity relative to erector spinae activity (122). These studies may imply that progressing the bridge from stable to unstable environments results in an initial increase in multifidus activity followed by erector spinae activity when demand increases.

Several studies have demonstrated it may be beneficial to incorporate the abdominal drawing-in maneuver (ADIM) into unstable bridge progressions. Cho et al. demonstrated that adding an unstable base to a bridge increased internal oblique and transverse abdominis activity; however, the most activity (and a reduction in lumbar spine motion) was observed when the ADIM was added to the unstable bridge (123, 124). And, Gong et al. demonstrated that 6 weeks of performing an unstable bridge improved static and dynamic lumbar stability, only if the ADIM was included in training (125). These studies suggest that incorporating the ADIM may result in additional benefit when progressing to unstable variation of a bridge.

Another common progression for unilateral bridge variations is the addition of un-resisted abduction of the contra-lateral leg. Yoon et al. demonstrated that trunk muscle activity increased when bridges were progressed from bilateral, to single-leg, to single-leg on an unstable surface (inflatable disk), to single-leg with contralateral leg abduction (126). In a study mentioned above, Park et al. demonstrated that adding contralateral hip abduction increased internal oblique activity relative to rectus abdominis activity, and multifidus activity relative to erector spinae activity (122). Bak et al. demonstrated that progressing from a bilateral to a single-leg bridge increased gluteus maximus and external oblique activity, and the addition of hip abduction resulted in an increase in erector spinae, external oblique and internal oblique activity (127). Saliba et al. used ultrasound to demonstrate that bridges (straight-leg) on stable or unstable (sling) surfaces resulted in similar increases in transverse abdominis thickness in individuals with low back pain; however, the addition of abduction during the unstable variation significantly increased transverse abdominis thickness (128). These studies suggest that the addition of un-resisted abduction of the contralateral leg during a unilateral bridge is likely to increase core muscle activity, and may improve recruitment by increasing transverse abdominisinternal oblique and multifidus activity relative to rectus abdominis and erector spinae activity.

Two studies were located that reported no significant difference in muscle activity when comparing stable and unstable progressions of a bridge. Imai et al. demonstrated that inexperienced participants did not exhibit differences in trunk muscle activity when comparing floor bridges to bridges with feet on a BOSU® ball (129). Similarly, Czaprowski et al. demonstrated no significant difference in anterior abdominal muscle activity when floor bridges were compared to bridges with feet on a BOSU® ball (130). Based on the results of the previously mentioned studies demonstrating that unstable progressions of a bridge increase muscle activity, these studies may be demonstrating that the BOSU® ball is an insufficient stimulus to result in significant changes in recruitment. However, it is also worth noting that both of these studies allowed participants to keep both arms on the floor, slightly abducted away from the body, which may have provided an alternative method for maintaining stability.

Quadrupeds and Progressions

Reducing stability is likely the most common method for progressing the quadruped exercise, and research has demonstrated that reductions in stability increase trunk muscle activity. Pirouzi et al. demonstrated that muscle activity of the transversus abdominis, internal oblique and multifidus increased when progressing from quadruped with arm raise, to opposite arm/leg raise, to leg raise (131). Bae et al. investigated the effects of weight shift on muscle activity during quadrupeds with one leg extended, demonstrating that cuing a decrease in weight shift significantly increased serratus anterior activity and internal oblique activity (132). Lee et al. demonstrated that rectus abdominis activity significantly increased during quadrupeds when hip flexion angle decreased from 90° to 80° to 70° (feet further from hands) (133). And, Masaki et al. compared multifidus activity during quadrupeds, demonstrating that raising an ipsilateral extremity resulted in more activity than a contralateral extremity, that raising a lower extremity resulted in more activity than raising an upper extremity, that the addition of abduction to a leg or arm raise resulted in more activity than flexion/extension, and that the addition of resistance also resulted in more activity (134). These studies suggest that quadrupeds may be progressed from arm raise, to opposite arm/leg raise, to leg raise, to increasing abduction angle, and further that increasing hip flexion angle and/or decreasing weight shift may increase trunk muscle activity.

A few studies have investigated the addition of external loads, which may also effect stability. As mentioned above, Masaki et al. demonstrated that adding additional load to the limbs may increase trunk muscle activity (134). Kang et al. demonstrated that holding a Bodyblade vertical resulted in a larger increase in serratus anterior activity and a more favorable serratus anterior to upper trapezius ratio than holding a Bodyblade horizontally, and that further increases of internal oblique activity where noted when raising the contralateral leg (135). Last, Kim et al. demonstrated that the use of a Flexi-bar (similar to a Bodyblade) during quadrupeds significantly increased activity of the internal obliques, external obliques, erector spinae, and rectus abdominis (136). These studies suggest that the addition of unstable loads has the potential to further increase trunk muscle activity during the quadruped exercise.

Core Exercise Summary

Planks

  • Lower Extremity Support: Modified (knees), to bilateral (both feet), to unilateral (one foot)
  • Unstable Environment: Floor plank, to inflatable disks or balance pads, to stability ball or suspension trainer
  • Placement of Unstable Environment: Under the feet, to under the forearms, to under the feet and forearms.

Glute Bridge

  • Bilateral to Unilateral: Progressing from a Bilateral bridge to a single-leg bridge nearly doubles gluteus maximus and gluteus medius activity, and increases trunk muscle activity. Further, adding an unstable surface may further increase gluteus medius and gluteus maximus activity (unless force output decreases), and will significantly increase trunk muscle activity.
  • Trunk Muscle Activity: An increase in internal oblique activity (and perhaps transverse abdominis activity) may match initial demand when progressing from stable to unstable environments; however, as demand increases, activity of the external obliques and rectus abdominis may aid in compensating for further increases. Similarly, multifidus activity increases initially, followed by erector spinae activity when demand increases.
  • Adding Un-resisted Abduction: The addition of un-resisted abduction of the contralateral leg during a unilateral bridge is likely to increase core muscle activity, and may improve recruitment by increasing transverse abdominisinternal oblique and multifidus activity relative to rectus abdominis and erector spinae activity.
  • Not Enough: Two studies reported no significant difference when comparing a floor bridge to a bridge on an unstable surface. Based on the effects demonstrated in previous studies, these studies may be demonstrating that the BOSU® ball is an insufficient stimulus to result in significant changes in recruitment, or that allowing clients to keep their arms on the floor may provide an alternative method for maintaining stability.

Quadrupeds:

  • Stability Progressions: Quadrupeds may be progressed from arm raise, to opposite arm/leg raise, to leg raise, to increasing abduction angle; and further, increasing hip flexion angle and/or decreasing weight shift may increase trunk muscle activity.
  • Addition of External Load: The addition of unstable loads has the potential to further increase trunk muscle activity during the quadruped exercise.

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  11. Abd El-Kafy, E. M. and El-Basatiny, H. M. Y. M. (2014) Effect of postural balance training on gait parameters in children with cerebral palsy. American Journal of Physical Medicine & Rehabilitation, 93(11), 938-947.
  12. Gupta, S., Rao, krishna Rao, B. and Kumaran, S. D. (2011) Effect of strength and balance training in children with Down's syndrome: a randomized controlled trial. Clinical Rehabilitation, 25, 425-432
  13. Jazi, S. D., Purrajabi, F., Movahedi, A. and Jalali, S. (2012) Effect of selected balance exercises on the dynamic balance of children with visual impairments. Journal of Visual Impairment & Blindness, 106(8), 466-474
  14. Cheldavi, H., Shakerian, S., Bosheri, S. N. S. and Zarghami, M. (2014) The effects of balance training intervention on postural control of children with autism spectrum disorder: role of sensory information. Research in Autism Spectrum Disorder, 8, 8-14
  15. Granacher, U., Muehlbauer, T., Maestrini, L., Zahner, L. and Gollhofer, A. (2011) Can balance training promote balance and strength in prepubertal children? Journal of Strength and Conditioning Research, 25(6), 1759-1766
  16. Bruhn, S., Kullmann, N. and Gollhofer, A. (2004) The effects of a sensorimotor training and a strength training on postural stabilisation, maximum isometric contraction and jump performance. International Journal of Sports Medicine, 25(1), 56-60
  17. Kibele, A. and Behm, D. G. (2009) Seven weeks of instability and traditional resistance training effects on strength, balance and functional performance. Journal of Strength and Conditioning Research, 23(9), 2443-2450
    • Balance Training for Chronic Ankle Instability
  18. Kim, K. J., Kim. Y. E., Jun, H. J., Lee, J. S., Ji, S. H., Ji, S. G., Seo, T. H. and Kim, Y. O. (2014) Which treatment is more effective for functional ankle instability: strengthening or combined muscle strengthening and proprioceptive exercises? Journal of Physical Therapy Science, 26, 385-388
  19. Cruz-Diaz, D., Lomas-Vega, R., Osuna-Perez, M. C., Contreras, F. H. and Martinez-Amat, A. (2015) Effect of 6 weeks of balance training on chronic ankle instability in athletes: a randomized controlled trial. International Journal of Sports Medicine, 36, 754-760
  20. Kim, E., Choi, H., Cha, J. H., Park, J. C. and Kim, T. (2017) Effects of neuromuscular training on the rear-foot angle kinematics in elite women field hockey players with chronic ankle instability. Journal of Sports Science and Medicine, 16, 137-146
  21. Donovan, L., Hart, J. M., Saliba, S. A., Park, J., Feger, M. A., Herb, C. C. and Hertel, J. (2016) Rehabilitation for chronic ankle instability with or without destabilization devices: a randomized controlled trial. Journal of Athletic Training, 51(3), 233-251
    • Unstable Training for Low-Back Pain
  22. Javadian, Y., Behtash, H., Akbari, M., Taghipour-Darzi, M. and Zekavat, H. (2012) The effects of pain on disability of patients with lumbar segmental instability. Journal of Back and Musculoskeletal Rehabilitation, 25, 149-155
  23. Kang, T. W., Lee, J. H., Park, D. H., Cynn, H. S. (2018) Effect of 6-week lumbar stabilization exercise performed on stable versus unstable surfaces in automobile assembly workers with mechanical chronic low back pain. Work, 60(3), 445-454
  24. Ko, K. J., Ha, G. C., Yook, Y. S. and Kang, S. J. (2018) Effects of 12-week lumbar stabilization exercise and sling exercise on lumbosacral region angle, lumbar muscle strength, and pain scale of patients with chronic low back pain. The Journal of Physical Therapy Science, 30, 18-22
  25. Moon, H, J., Choi, K. H., Kim, D. H., Kim, H. J., Cho, Y. K., Lee, K. H., Kim, J. H. and Choi, Y. J. (2013) Effect of lumbar stabilization and dynamic lumbar strengthening exercises in patients with chronic low back pain. Annals of Rehabilitation Medicine, 37(1), 110-117
    • Corrective Exercise First:
  26. Pirauá, A. L. T., Pitangui, A. C. R., Silva, J. P., dos Passos, M. H. P., de Oliveira, V. M. A., Batista, L. D. S. P., & de Araújo, R. C. (2014). Electromyographic analysis of the serratus anterior and trapezius muscles during push-ups on stable and unstable bases in subjects with scapular dyskinesis. Journal of Electromyography and Kinesiology24(5), 675-681.
  27. de Araujo, R. C., Piraua, A. L. T., Beltrao, N. B. and Pitangui, A. C. R. (2018) Activity of periscapular muscles and its correlation with external oblique during push-up: does scapular dyskinesis change the electromyographic response? Journal of Sports Science, 36(5), 571-577
  28. Park, K. M., Cynn, H. S., Kwon, O. Y., Yi, C. H., Yoon, T. L., & Lee, J. H. (2014). Comparison of pectoralis major and serratus anterior muscle activities during different push-up plus exercises in subjects with and without scapular winging. The Journal of Strength & Conditioning Research, 28(9), 2546-2551.
  29. Cools, A.M., Witvrouw, E.E., Declercq, G.A., Danneels, L.A., Cambier, D.C. (2003) Scapular muscle recruitment patterns: Trapezius muscle latency with and without impingement symptoms. The American Journal of Sports Medicine 31(4). 542-549
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    • Stability Training for Performance Enhancement
  31. Bruhn, S., Kullmann, N. and Gollhofer, A. (2004) The effects of a sensorimotor training and a strength training on postural stabilisation, maximum isometric contraction and jump performance. International Journal of Sports Medicine, 25(1), 56-60
  32. Nepocatych, S., Ketcham, C. J., Vallabhajosula, S. and Balilionis, G. (2018) The effects of unstable surface balance training on postural sway, stability, functional ability and flexibility in women. The Journal of Sports Medicine and Physical Fitness, 58(1-2), 27-34
  33. Sparkes, R. and Behm, D. G. (2010) Training adaptations associated with an 8-week instability resistance training program with recreationally active individuals. Journal of Strength and Conditioning Research, 24(7), 1931-1941
  34. Kibele, A. and Behm, D. G. (2009) Seven weeks of instability and traditional resistance training effects on strength, balance and functional performance. Journal of Strength and Conditioning Research, 23(9), 2443-2450
  35. Yaggie, J. A. and Campbell, B. M. (2006) Effects of balance training on selected skills. Journal of Strength and Conditioning Research, 20(2), 422-428
  36. Saeterbakken, A. H., van den Tillaar, R. and Seiler, S. (2011) Effect of core stability training on throwing velocity in female handball players. The Journal of Strength and Conditioning Research, 25(3), 712-718
  37. Myer, G. D., Ford, K. R., Brent, J. L. and Hewett, T. E. (2006) The effects of plyometric vs. dynamic stabilization and balance training on power, balance, and landing force in female athletes. Journal of Strength and Conditioning Research, 20(2), 345-353
  38. Kean, C. O., Behm, D. G. and Young, W. B. (2006) Fixed foot balance training increases rectus femoris activation during landing and jump height in recreationally active women. Journal of sports Science and Medicine, 5(1), 138-148
  39. Taube, W., Kullman, N., Leukel, C., Kurz, O., Amtage, F. and Gollhofer, A. (2007) Differential reflex adaptations following sensorimotor and strength training in young elite athletes. International Journal of Sports Medicine, 28, 999-1005
    • Squats
  40. Park, J. K., Lee, D. Y., Kim, J. S., Hong, J. H., You, J. H. and Park, I. M. (2015) Effects of visibility and types of the ground surface on the muscle activities of the vastus medialis oblique and vastus lateralis. Journal of Physical Therapy Sciences, 27, 2435-2437
  41. Han, D., Nam, S., Song, J., Lee, W. and Kang, T. (2017) The effect of knee flexion angles and ground conditions on the muscle activation of the lower extremity in the squat position. The Journal of Physical Therapy Science, 29, 1852-1855.
  42. Li, Y., Cao, C. and Chen, X. (2013) Similar electromyographic activities of lower limbs between squatting on a reebok core board and ground. Journal of Strength and Conditioning Research, 27(5), 1349-1353
  43. Andersen, V., Fimland, M. S., Brennset, O., Haslestad, L. R., Lundteigen, M. S., Skalleberg, K. and Saeterbakken, A. H. (2014) Muscle activation and strength in squat and Bulgarian squat on stable and unstable surface. Sports Medicine, 35, 1196-1202
  44. Saeterbakken, A. H. and Fimland, M. S. (2013) Muscle force output and electromyographic activity in squats with various unstable surfaces. The Journal of Strength and Conditioning Research, 27(1), 130-136
  45. Lawrence, M. A. and Carlson, L. A. (2015) Effects of an unstable load on force and muscle activation during a parallel back squat. Journal of Strength and Conditioning, 29(10), 2949-2953
  46. Ditroilo, M., O'Sullivan, R., Harnan, B., Crossey, A., Gillmor, B., Dardis, W. and Grainger, A. (2018) Water-filled training tubes increase core muscle activation and somatosensory control of balance during squat. Journal of Sports Sciences, 36(17), 2002-2008
    • Compared Squats, Lunges and Bulgarian Split Squats (including source #43)
  47. Stuart, M. J., Meglan, D. A., Lutz, G. E., Growney, E. S. and An, K. N. (1996) Comparison of intersegmental tibiofemoral joint forces and muscle acdtivity during various closed kinetic chain exercises. The American Journal of Sports Medicine, 24(6), 792-799
  48. DeForest, B. A., Cantrell, G. S. and Schilling, B. K. (2014) Muscle activity in single- vs. double-leg squats. International Journal of Exercise Science, 7(4), 302-310
  49. Jones, M. T., Ambegaonkar, J. P., Nindl, B. C., Smith, J. A. and Headley, S. A. (2012) Effects of unilateral and bilateral lower-body heavy resistance exercise on muscle activity and testosterone responses. The Journal of Strength and Conditioning Research, 26(4), 1094-1100
  50. McCurdy, K., O'Kelley, E., Kutz, M., Langford, G., Ernest, J. and Torres, M. (2010) Comparison of lower extremity EMG between the 2-leg squat and modified single-leg squat in female athletes. Journal of Sport Rehabilitation, 19, 57-70
  51. McCurdy, K., Walker, J. and Yuen, D. Gluteus maximus and hamstring activation during selected weight-bearing resistance exercises. Journal of Strength and Conditioning Research,
    • The squat, step-up and single-leg squat
  52. Lubahn, A. J., Kernozek, T. W., Tyson, T. L., Merkitch, K. W., Reutemann, P. and Chestnut, J. M. (2011) Hip muscle activation and knee frontal plane motion during weight bearing therapeutic exercises. The International Journal of Sports Physical Therapy, 6(2), 92-103
  53. Eliassen, W., Saeterbakken, A. H. and van den Tillaar, R. (2018) Comparison of bilateral and unilateral squat exercises on barbell kinematics and muscle activation. The International Journal of Sports Physical Therapy, 13(5), 871-881
    • Comparing Unilateral Exercises on Stable and Unstable Surfaces (including source #43)
  54. Krause, D. A., Elliott, J. J., Fraboni, D. F., McWilliams, T. J., Rebhan, R. L. and Hollman, J. H. (2018) Electromyography of the hip and thigh muscles during two variations of the lunge exercise: a cross-sectional study. The International Journal of Sports Physical Therapy, 13(2), 137-14
  55. Krause, D. A., Jacobs, R. S., Pilger, K. E., Sather, B. R., Sibunka, S. P. and Hollman, J. H. (2009) Electromyographic analysis of the gluteus medius in five weight-bearing exercises. Journal of Strength and Conditioning Research, 23(9), 2689-2694.
  56. DiStefano, L. J., Blackburn, J. T., Marshall, S. W. and Padua, D. A. (2009) Gluteal muscle activation during common therapeutic exercises. Journal of Orthopaedic and Sports Physical Therapy, 39(7), 532-540
  57. Begalle, R. L., DiStefano, L. J., Blackburn, T. and Padua, D. A. (2012) Quadriceps and hamstrings coactivation during common therapeutic exercises. Journal of Athletic Training, 47(4), 396-405
  58. Boren, K., Conrey, C., Le Coguic, J., Paprocki, L., Voight, M. and Robinson, T. K. (2011) Electromyographic analysis of gluteus medius and gluteus maximus during rehabilitation exercises. The International Journal of Sports Physical Therapy, 6(3), 206-223
    • Push-up on Stable and Unstable Surfaces
  59. de Araujo, R. C., Piraua, A. L. T., Beltrao, N. B. and Pitangui, A. C. R. (2018) Activity of periscapular muscles and its correlation with external oblique during push-up: does scapular dyskinesis change the electromyographic response? Journal of Sports Sciences, 36(5), 571-577
  60. Park, S. Y. and Yoo, W. G. (2011) Differential activation of parts of the serratus anterior muscle during push-up variations on stable and unstable bases of support. Journal of Electromyography and Kinesiology, 21, 861-867
  61. Gioftsos, G., Arvanitidis, M., Tsimouris, D., Kanellopoulos, A., Paras, G., Trigkas, P. and Sakellari, V. (2016) EMG activity of the serratus anterior and trapezius muscles during different phases of the push-up plus exercise on different support surfaces and different hand positions. The Journal of Physical Therapy Science, 28, 2114-2118
  62. McGill, S. M., Cannon, J. and Andersen, J. T. (2014) Analysis of pushing exercises: muscle activity and spine load while contrasting techniques on stable surfaces with a labile suspension strap training system. Journal of Strength and Conditioning, 28(1), 105-116
  63. Harris, S., Ruffin, E., Brewer, W. and Ortiz, A. (2017) Muscle activation patterns during suspension training exercises. International Journal of Sports Physical Therapy, 12(1), 42-52.
  64. Snarr, R. and Esco, M. R. (2013) Electromyographic comparison of traditional and suspension push-ups. Journal of Human Kinetics, 39, 75-83
  65. Borreani, S., Calatayud, J., Colado, J. C., Moya-Najera, D., Triplett, N. T. and Martin, F. (2015) Muscle activation during push-ups performed under stable and unstable conditions. Journal of Exercise Science and Fitness, 13(2), 94-98
  66. Calatayud, J., Borreani, S., Colado, J. C., Martin, F. and Rogers, M. E. (2014) Muscle activity levels in upper-body push exercises with different loads and stability conditions. The Physician and Sportsmedicine, 42(4), 106-119
  67. Torres, R. J. B., Piraua, A. L. T., Nacimento, V. Y. S., dos Santos, P. S., Beltrao, N. B., de Oliveira, V. M. A., Pitangui, A. C. R. and de Araujo, R. C. (2016) Shoulder muscle activation levels during the push-up plus exercise on stable and unstable surfaces. Journal of Sport Rehabilitation, doi: 10.1123/jsr.2016-0050
  68. de Araujo, R. C., Nascimento, V. Y. S., Torres, R. J. B., Behm, D. and Ptinagui, C. R. (2019) Can the use of unstable surfaces and instruction for conscious abdominal contraction increase the EMG activity of the periscapular muscles during the dynamic push-up? Journal of Sport Rehabilitation, doi: 10.1123/jsr.2018-0165
  69. Seo, S. H., Jeon, I. H., Cho, Y. H., Lee, H. G., Hwang, Y. T. and Jang, J. H. (2013) Surface EMG during the push-up plus exercise on a stable support or swiss ball: scapular stabilizer muscle exercise. Journal of Physical Therapy Science, 25(7), 833-837
  70. Lehman, G. J., MacMillan, B., MacIntyre, I., Chivers, M., & Fluter, M. (2006). Shoulder muscle EMG activity during push up variations on and off a Swiss ball. Dynamic Medicine, 5(1), 7.
  71. Lehman, G. J., Gilas, D., & Patel, U. (2008). An unstable support surface does not increase scapulothoracic stabilizing muscle activity during push up and push up plus exercises. Manual therapy13(6), 500-506.
  72. Beach, T. A. C., Howarth, S. J. and Callaghan, J. P. (2008) Muscular contribution to low-back loading and stiffness during standard and suspended push-ups. Human Movement Science, 27, 457-472
  73. Maeo, S., Chou, T., Yamamoto, M. and Kanehisa, H. (2014) Muscular activities during sling- and ground-based push-up exercise. BMC Research Notes, 7, 192-198
  74. Scovazzo, M. L., Browne, A., Pink, M., Jobe, F. W., & Kerrigan, J. (1991). The painful shoulder during freestyle swimming: an electromyographic cinematographic analysis of twelve muscles. The American journal of sports medicine19(6), 577-582.
    • Chest Press on Stable and Unstable Surfaces
  75. Lawrence, M. A., Ostrowski, S. J., Leib, D. J. and Carlson, L. A. (2018) Effect of unstable loads on stabilizing muscles and bar motion during the bench press. Journal of Strength and Conditioning Research,
  76. Lawrence, M. A., Leib, D. J., Ostrowski, S. J. and Carlson, L. A. (2017) Nonlinear analysis of an unstable bench press bar path and muscle activation. Journal of Strength and Conditioning, 31(5), 1206-1211
  77. Dunnick, D. D., Brown, L. E., Coburn, J. W., Lynn, S. K. and Barillas, S. R. (2015) Bench press upper-body muscle activation between stable and unstable loads. The Journal of Strength and Conditioning Research, 29(12), 3279-3283
  78. Ostrowski, S. J., Carlson, L. A. and Lawrence, M. A. (2017) Effect of an unstable load on primary and stabilizing muscles during the bench press. The Journal of Strength and Conditioning Research, 31(2), 430-434
  79. Campbell, B. M., Kutz, M. R., Morgan, A. L., Fullenkamp, A. M. and Ballenger, R. (2014) An evaluation of upper-body muscle activation during coupled and uncoupled instability resistance training. Journal of Strength and Conditioning Research, 28(7), 1833-1838
  80. Uribe, B. P., Coburn, J. W., Brown, L. E., Judelson, D. A., Khamoui, A. V. and Nguyen, D. (2010) Muscle activation when performing the chest press and shoulder press on a stable bench vs. a Swiss ball. The Journal of Strength and Conditioning Research, 24(4), 1028-1033
  81. Marshall, P. W. M. and Murphy, B. A. (2006) Increased deltoid and abdominal muscle activity during Swiss ball bench press. Journal of Strength and Conditioning Research, 20(4), 745-750
  82. Goodman, C. A., Pearce, A. J., Nicholes, C. J., Gatt, B. M. and Fairweather, I. H. (2008) No difference in 1RM strength and muscle activation during the barbell chest press on a stable and unstable surface. Journal of Strength and Conditioning Research, 88-94
  83. Lehman, G. J., Gordon, T., Langley, J., Pemrose, P. and Tregaskis, S. (2005) Replacing a Swiss ball for an exercise bench causes variable changes in trunk muscle activity during limb strength exercises. Dynamic Medicine, 4(6), doi: 10.1186/1476-5918-4-6
  84. Saeterbakken, A. H. and Fimland, M. S. (2013) Electromyographic activity and 6RM strength in bench press on stable and unstable surfaces. Journal of Strength and Conditioning Research, 27(4), 1101-1107
  85. Norwood, J., Anderson, G. S., Gaetz, M. and Twist, P. (2007) Electromyographic activity of the trunk stabilizers during stable and unstable bench press. Journal of Strength and Conditioning Research, 21(2), 497-502
    • Overhead Press Exercise on Stable and Unstable Surfaces
  86. Williams Jr., M. R., Hendricks, D. S., Dannen, M. J., Arnold, A. M. and Lawrence M. A. (2018) Activity of shoulder stabilizers and prime movers during an unstable overhead press. Journal of Strength and Conditioning Research, doi: 10.1519/JSC.0000000000002660
  87. Kohler, J. M., Flanagan, S. P. and Whiting, W. C. (2010) Muscle activation patterns while lifting stable and unstable loads on stable and unstable surfaces. Journal of Strength and Conditioning Research, 24(2), 313-321.
    • The Inverted Row with Stable and Unstable Environments (and 63)
  88. Snarr, R. L. and Esco, M. R. (2013) Comparison of electromyographic activity when performing an inverted row with and without a suspension device. Journal of Exercise Physiology Online, 16(6), 51-58
  89. Snarr, R., Nickerson, B. S. and Esco, M. R. (2014) Effects of hand-grip during the inverted row with and without a suspension device: an electromyographic investigation. European Journal of Sports and Exercise Science, 3(4), 1-5
  90. McGill, S., Cannon, J. and Andersen, J. (2014) Muscle activity and spine load during pulling exercises: influence of stable and labile contact surfaces and technique coaching. Journal of Electromyography and Kinesiology, doi: 10.1016/j.jelekin.2014.06.002
  91. Youdas, J. W., Hubble, M. W., Johnson, P. G., McCarthy, M. M., Saenz, M. M. and Hollman, J. H. (2018) Scapular muscle balance and spinal stabilizer recruitment during an inverted row. Physiotherapy theory and practice, doi: 10.1080/09593985.2018.1486491
  92. Fenwick, C. M., Brown, S. H., & McGill, S. M. (2009). Comparison of different rowing exercises: trunk muscle activation and lumbar spine motion, load, and stiffness. The Journal of Strength & Conditioning Research23(5), 1408-1417.
  93. Saeterbakken, A., Andersen, V., Brudeseth, A., Lund, H., & Fimland, M. S. (2015). The effect of performing bi-and unilateral row exercises on core muscle activation. International journal of sports medicine94(11), 900-905.
    • The Front-Plank and Side-Plank on Stable vs Unstable Surfaces:
  94. Cho, M., Shim, S., Jung, J., & Chung, Y. (2019). Comparison of trunk muscle activity according to hip abduction angle during plank exercise. Physical Therapy Rehabilitation Science8(3), 162-169.
  95. Escamilla, R. F., Lewis, C., Pecson, A., Imamura, R., & Andrews, J. R. (2016). Muscle activation among supine, prone, and side position exercises with and without a Swiss ball. Sports health8(4), 372-379.
  96. Kim, E. S., Gil, D. S., Kim, S. B., Hong, J. H., Lee, D. Y., Yu, J. H., & Kim, J. S. (2019). The Comparisons of Different Abdominal Drawing-in Maneuver During Plank exercises on trunk stability. Medico Legal Update19(2), 404-410.
  97. Lee, D., Lee, Y., Cho, H. Y., Lee, K. B., Hong, S., Pyo, S., & Lee, G. (2017). Investigation of trunk muscle activity for modified plank exercise: a preliminary study. Isokinetics and Exercise Science25(3), 209-213.
  98. Lee, J., Jeong, K. H., Lee, H., Shin, J. Y., Choi, J. L., Kang, S. B., & Lee, B. H. (2016). Comparison of three different surface plank exercises on core muscle activity. Physical Therapy Rehabilitation Science5(1), 29-33.
  99. Park, Y. A., Kim, E. J., Cha, H. Y., Ryu, H. W., Seo, Y. H., Seong, J. Y., … & Choi, B. R. (2020). Effects of various plank exercises on activation of hamstring muscle. Journal of Korean Physical Therapy Science27(1), 51-55.
  100. Mirmohammad, R., Minoonejhad, H., & Sheikhhoseini, R. (2019). Ultrasonographic Comparison of Deep Lumbopelvic Muscles Activity in Plank Movements on Stable and Unstable Surface. Physical Treatments-Specific Physical Therapy Journal9(3), 147-152.
  101. Cho, Yong-Ho, and Jin-Ho Choi. "Difference in Muscle Activities According to Stability on Support Surface During Plank Exercise." Korean Society of Physical Medicine 12.3 (2017): 73-77.
  102. Czaprowski, D., Afeltowicz, A., Gębicka, A., Pawłowska, P., Kędra, A., Barrios, C., & Hadała, M. (2014). Abdominal muscle EMG-activity during bridge exercises on stable and unstable surfaces. Physical therapy in sport, 15(3), 162-168.
  103. Imai, A., Kaneoka, K., Okubo, Y., Shiina, I., Tatsumura, M., Izumi, S., & Shiraki, H. (2010). Trunk muscle activity during lumbar stabilization exercises on both a stable and unstable surface. Journal of orthopaedic & sports physical therapy40(6), 369-375.
  104. Atkins, S. J., Bentley, I., Brooks, D., Burrows, M. P., Hurst, H. T., & Sinclair, J. K. (2015). Electromyographic response of global abdominal stabilizers in response to stable-and unstable-base isometric exercise. The Journal of Strength & Conditioning Research29(6), 1609-1615.
  105. Shin, Y. A. (2014). Comparison of core stabilizer muscle activity according to movement difficulty and stability during various trx plank. The Official Journal of the Korean Academy of Kinesiology, 16(4), 31-41.
  106. Kang, K. W., Son, S. M., & Ko, Y. M. (2016). Changes in abdominal muscle thickness and balance ability on plank exercises with various surfaces. The Journal of Korean Physical Therapy28(5), 264-268.
  107. Bak, J., Shim, S., Cho, M., & Chung, Y. (2017). The effect of plank exercises with hip abduction using sling on trunk muscle activation in healthy adults. The Journal of Korean Physical Therapy, 29(3), 128-134.
  108. Snarr, R. L., & Esco, M. R. (2014). Electromyographical comparison of plank variations performed with and without instability devices. The Journal of Strength & Conditioning Research28(11), 3298-3305.
  109. Byrne, J. M., Bishop, N. S., Caines, A. M., Crane, K. A., Feaver, A. M., & Pearcey, G. E. (2014). Effect of using a suspension training system on muscle activation during the performance of a front plank exercise. The Journal of Strength & Conditioning Research28(11), 3049-3055.
  110. Wang, J. (2019). Effects of Sling Forearm Plank Exercises on Superficial Back Line Muscle Tone and Stiffness. Journal of International Academy of Physical Therapy Research10(1), 1695-1699.
  111. Imai, A., Kaneoka, K., Okubo, Y., & Shiraki, H. (2014). Comparison of the immediate effect of different types of trunk exercise on the star excursion balance test in male adolescent soccer players. International journal of sports physical therapy9(4), 428.
    • Glute Bridge
  112. Ekstrom, R. A., Donatelli, R. A and Carp, K. C. (2007) Electromyographic analysis of core trunk, hip, and thigh muscles during 9 rehabilitation exercises. Journal of Orthopaedic and Sports Physical Therapy, 37(12), 754-762
  113. Cho, M., Bak, J., & Chung, Y. (2016). The effects of performing a one-legged bridge with use of a sling on trunk and gluteal muscle activation. Physical Therapy Rehabilitation Science5(2), 70-77.
  114. Youdas, J. W., Hartman, J. P., Murphy, B. A., Rundle, A. M., Ugorowski, J. M. and Hollman, J. H. (2015) Magnitudes of muscle activation of spine stabilizers, gluteals, and hamstrings during supine bridge to neutral position. Physiotherapy theory and practice, doi: 10.3109/09593985.2015.1010672
  115. Yoo, I. G., & Yoo, W. G. (2012). Effects of different bridge exercises for the elderly on trunk and gluteal muscles. Journal of Physical Therapy Science24(4), 319-320.
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