Introduction:

Note: Quadrupeds may be used as either a "transverse abdominis activation" or a "core integration" technique within the Brookbush Institute Templates. This was not intended to complicate optimal intervention order, and only implies that this exercise should likely be performed after more isolated activation techniques, or prior to other core integration techniques (see "Sample Program" below).

Target Musculature:

Target Subsystem:

Signs of Under-activity (TVA):

  • Manual Muscle Testing for an Active Population (MMT):
    • Spinal Flexion Manual Muscle Test MMT and Modifications (video coming soon): A common result indicating dysfunction is strong with compensation.  That is, the individual can resist considerable force, but does so with additional motion. The most common compensations is abdominal distension indicating altered recruitment of the transverse abdominis.

Overactive Synergists:

Muscles that commonly become synergistically dominant when the TVA and ISS is inhibited – Release and stretch prior to activation and cue joint motion to reciprocally inhibit these muscle during activation exercise.

  1. Latissimus Dorsi (inhibit w/ shoulder flexion and abduction)
    1. Release
    2. Stretch
  2. Psoas (inhibit w/ “drawing in maneuver”, hip extension, and/or posterior pelvic tilt)
    1. Stretch

Acute Variables:

  • Sets: 1- 3
  • Repetitions: 30 - 120 seconds
  • Frequency:
    • Strength: 2 - 3 days/week
    • Corrective/Therapeutic: Up to 1-2 submaximal sets performed 1-2 times daily

Sample Program (Anterior Pelvic Tilt)

Mobility

Activity

Summary:

Behavior: In asymptomatic individuals the TVA and ISS may be recruited prior to motion to aid in stabilization of the lumbar spine and pelvis. Latent firing and a reduction in activity (under-activity) of the TVA and ISS may result from, or increase the risk of, low back pain and injury, and may be an issue that warrants attention during therapeutic intervention. Recommendation: The Brookbush Institute recommends that mobility issues are addressed prior to active techniques, and that isolated activation techniques (e.g. Gluteus Medius Activation) precede more integrated techniques like quadrupeds. Note, quadrupeds may be used as either a "transverse abdominis activation" or a "core integration" technique within the Brookbush Institute Templates. This was not intended to complicate optimal intervention order, and only implies that this exercise should likely be performed after more isolated activation techniques, but prior to other core integration techniques. It should also be noted that the research below demonstrates that even when quadrupeds and quadruped progressions are performed alone, they are effective for increasing activity, recruitment and hypertrophy of core musculature.

Electromyographic Activity:

  • Muscle Activity in Healthy Individuals: Quadrupeds effectively recruit and challenge trunk stabilizers and rotators, reducing weight shift may increase trunk Muscle activity, and altered pelvic position (anterior or posterior tilt) may have a significant effect on Muscle activity.
  • Progressions: Quadrupeds may be progressed from arm raise, to opposite arm/leg raise, to leg raise, to increasing abduction angle, to the addition of external load, to potentially a decrease in hip flexion angle.
  • Effect on Upper Extremity: Quadrupeds may be beneficial for improving scapular stabilization, especially when performed with protraction, and further leg raise on the ipsilateral side may further increase serratus anterior activity and improve the serratus anterior to upper trapezius activity ratio.

Comparing Exercise

  • Targeting the TVA: When compared to other core exercise, quadrupeds are effective for increasing TVA and potentially internal oblique activity, without comparable increases in rectus abdominisexternal obliqueserector spinae and multifidus activity.
  • Compared to Anterior Trunk Muscle Exercise: Quadrupeds may be recommended when the intent is to target the TVA, but may be progressed to planks and side-planks when the intent is to increase recruitment and incorporate additional core musculature.
  • Compared to Extension Exercise: Quadrupeds increase erector spinae and multifidus muscle activity less than superman's and resisted lumbar extension exercise, but more than planks and seated exercises. Additionally, quadrupeds with leg raise may result in sufficient gluteus maximus activity to be beneficial for strengthening.
  • Scapula and Shoulder Stabilization: Quadruped with leg raise, especially the ipsilateral leg, and/or the addition of open- or closed-chain PNF patterns, or a vertically held Bodyblade (or Flexibar), may increase serratus anterior activity, improve the serratus anterior to upper trapezius activation ratio, and increase posterior and middle deltoid activity.
  • Incorporating External Devices: Electronic devices may have the potential to optimize form and recruitment, the addition of a Bodyblade or Flexi-bar may increase trunk muscle activity, and the addition of resistance to leg and arm raises may provide additional challenge.
  • Comparing Exercise Outcomes: Research suggests that the addition of quadrupeds (with ADIM) may result in both immediate and long-term benefits including improvements in transverse abdominis thickness, movement quality, stability, core endurance, balance and reactivity; however, quadrupeds are unlikely to have an effect on high-velocity activity.

Low Back Pain

  • Altered Muscle Activity: Low back pain patients performing quadrupeds exhibit higher levels of thoracic extensorlatissimus dorsi and potentially lumbar erector activity, "abdominal bracing" is likely an unreliable intervention for improving recruitment; however, quadrupeds with leg raise may be an ideal progression for low back patients attempting to optimize local to global Muscle activity ratios.
  • Optimizing/Normalizing Recruitment: Quadrupeds may aid in selectively recruiting the TVA, improve local to global muscle activity ratios, and improve onset timing, where as other core exercises, abdominal bracing, and unstable environments are likely to increase muscle activity without normalizing recruitment patterns.
  • Treatment Program Outcomes: Research demonstrates that 4 - 12 weeks of trunk stabilization exercise (including quadrupeds) may improve outcomes for low back pain patients, including normalized muscle activity, a decrease in guarding during forward bending, improved joint play, improved pain pressure sensitivity, decreased reported pain and pain-related disability, and improvements in sleep quality, depression level, and anxiety level.
  • Exercise Comparison: Stabilization exercise (including quadrupeds) may result in similar outcomes for pain, but is likely superior for improving function (decreasing disability) when compared to conventional physiotherapy, flexibility programs, extension based programs and Pilates.
  • Adding Stabilization Exercise to an Existing Program: Research suggest that replacing a program with stabilization exercise may be less beneficial than adding stabilization exercise to a program. Research has demonstrated that prevention and outcomes improved significantly when stabilization exercise was added to gluteal muscle strengthening, general strength training, integrated physical therapy program, and/or an educational brochure.

Quadrupeds for Other Pathologies

  • Additional Pathologies: These studies suggest that the addition of quadrupeds to a treatment plan should also be considered for neck pain and disability, hip pain and dysfunction, and perhaps post-partum pelvic pain.

Research Corner

Motor Behavior and Recommendations

The function of the transverse abdominis (TVA) has been relatively well researched, and may serve as a model for other muscles that have demonstrated similar characteristics. Further, behavior of the TVA may be representative of Intrinsic Stabilization Subsystem (ISS) behavior, a subsystem which is comprised of many of the same muscles. Studies have demonstrated synergistic recruitment of the TVA and lumbar multifidus during the abdominal drawing-in maneuver (ADIM), and research has demonstrated that the pelvic floor, diaphragm and TVA exhibit similar behavior relative to increased load (1, 7, 12, 20). A more detailed review and additional research regarding these relationships is discussed in the course: Intrinsic Stabilization Subsystem (ISS). The TVA contracts prior to planned activity, bilaterally regardless of the direction of limb motion, and activity increases with changes in posture including increased center of gravity height, increased respiration and speed of locomotion (1-5). The stabilizing function of the TVA likely occurs by two primary mechanisms. First, increased TVA activity increases tension of the anterior and middle layers of the thoracolumbar fascia (TLF), resulting in increased stiffness of the lumbar spine and force closure of the sacroiliac joint (SIJ) (6-12). Second, TVA contraction (along with the other muscles of the ISS) decreases intra-abdominal volume and increases intra-abdominal pressure, which increases rigidity of the spine, resists lumbar flexion forces, and may result in decompression forces (13-15). In studies by Morris et al. and Hodges et al., asymmetrical firing of the TVA was demonstrated with greater resistance and speed, and synergy was demonstrated between the TVAobliques and lumbar multifidus muscles (16-19). This implies that the TVA contracts bilaterally and relatively equally at lower intensities, and as larger forces are generated by the limbs (either due to increased weight or velocity), activity of the TVA on the more stressed side increases and additional muscles are recruited to match the additional load. These studies demonstrate that the TVA and ISS may be recruited in synergy, prior to motion, to aid in stabilization of the lumbar spine and pelvis in asymptomatic individuals. In 1996, Hodges et al. published a pivotal study that demonstrated the TVA fired prior to the initiation of arm swing in asymptomatic individuals, but fired after the initiation of arm swing in individuals with low back pain (20). Hodges et al. would follow-up this study with research demonstrating that the same pattern also occurred during leg movement, various speeds of arm movement, and demonstrated the same altered recruitment pattern could be replicated by injection induced low back pain (21-24). Further, they would show that low back pain results in not only decreased recruitment of intrinsic muscles (TVAobliques and lumbar multifidus), but increased reliance on “global muscles” (25). Studies have shown a decrease in TVA recruitment and multifidus atrophy post episodes of low back pain and injury (30, 31). More recent research has demonstrated that altered recruitment patterns increase the likelihood of low back pain/injury in the following year, that unresolved altered recruitment patterns result in worse outcomes a year post physical therapy, changes in TVA recruitment patterns correlate strongly with a disability index, and that even adductor/groin injury/pain may result in altered  TVA recruitment strategies (26-29). These studies suggest that alterations in recruitment of the TVA and ISS may result from, or increase the risk of low back pain and injury, and may be an issue that warrants attention during therapeutic intervention. Studies have also shown that the abdominal drawing-in maneuver (ADIM) and exercises like quadrupeds (described below) are effective for stabilizing the lumbar spine and SIJ, decreasing low back pain induced atrophy of the TVA and multifidus, and may reduce the number and severity of future episodes of low back pain (12, 30, 31 -34). Additionally quadrupeds and quadruped progressions have demonstrated efficacy for increasing activity, recruitment and hypertrophy of all muscles of the ISS. The Brookbush Institute recommends that mobility issues are addressed prior to active techniques, and that isolated activation techniques (e.g. Gluteus Medius Activation) should precede more integrated techniques like quadrupeds. Note, quadrupeds may be used as either a "transverse abdominis activation" or "core integration" within the Brookbush Institute Templates. This was not intended to complicate optimal intervention order, as it simply implies that this exercise should likely be performed after more isolated activation techniques, but prior to other core integration techniques. It should also be noted that the research below demonstrates that even when quadrupeds and quadruped progressions are performed alone, they are effective for increasing activity, recruitment and hypertrophy of core musculature.

Electromyographic (EMG) Activity During Quadrupeds

Muscle Activity in Healthy Individuals Several studies have described Muscle electromyographic (EMG) activity during quadrupeds. Stevens et al. demonstrated that healthy participants performing the quadruped opposite arm/leg raise exhibited significant increases in activity of the ipsilateral multifidus, internal obliques, erector spinae and gluteus maximus, the contralateral external obliques, and relatively small increases in latissimus dorsi and rectus abdominis activity (35). 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 (36). And, Queiroz et al. compared pelvic positions during quadrupeds, demonstrating that a posterior pelvic tilt with lumbar flexion significantly increased external oblique and gluteus maximus Muscle activity, an anterior pelvic tilt with lumbar extension significantly increased multifidus Muscle activity, and a neutral pelvis and spine resulted in the lowest over-all Muscle activity. Note, rectus abdominis Muscle activity was similar in all positions (37). These recruitment patterns match what may be expected based on the moment arms, directions of rotational torque, and joint actions described in the variations of quadrupeds investigated in these studies. Quadrupeds effectively recruit and challenge trunk stabilizers and rotators, reducing weight shift may increase trunk Muscle activity, and altered pelvic position (anterior or posterior tilt) may have a significant effect on Muscle activity. Progressions Additional studies compare various quadruped Progressions. 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 (38). 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) (39). Further, Masaki et al. compared multifidus activity during quadrupeds, demonstrated 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 raise resulted in more activity than flexion/extension, and that the addition of resistance also resulted in more activity (40).  These studies suggest that quadrupeds may be progressed from arm raise, to opposite arm/leg raise, to leg raise, to increasing abduction angle, to the addition of external load, to potentially a decrease in hip flexion angle. Effect on Upper Extremity Additional studies have demonstrated that quadrupeds may have a significant effect on serratus anterior and upper trapezius Muscle activity. Kim et al. demonstrated an increase in serratus anterior and upper trapezius Muscle activity during a quadruped with leg raise, particularly for the serratus anterior and upper trapezius on the same side as the leg raised (41). Similarly, Nam et al. demonstrated that unilateral leg lift during a quadruped (with protraction) resulted in a significant increase in serratus anterior activity on the ipsilateral side and an increase in the serratus anterior to upper trapezius activity ratio (42). And, the study by Bae et al. mentioned above, demonstrated that cuing a reduction in weight shift during quadruped with leg raise significantly increased serratus anterior activity (36). These studies suggest that quadrupeds may be beneficial for improving scapular stabilization, especially when performed with protraction, and further leg raise on the ipsilateral side may further increase serratus anterior activity and improve the serratus anterior to upper trapezius activity ratio.

Comparing Exercises

Targeting the TVA Several studies suggest that quadrupeds and quadruped progressions may be ideal for selectively targeting the TVA. Teyhen et al. demonstrated (using ultrasound) that the crunch and side-plank resulted in the largest changes in internal oblique and TVA muscle thickness; however, the ADIM and quadruped opposite arm/leg raise resulted in a large change in TVA thickness with minimal change of the internal obliques (43). Kang et al. compared muscle thickness following the ADIM, quadrupeds with ADIM with arms in a suspension trainer, and planks with ADIM with arms in a suspension trainer. muscle thickness of the TVA and internal obliques increased following the ADIM, but was thickest during the quadruped variation, and the external obliques were thickest following the plank variation (44). Additional studies demonstrate that quadrupeds do not result in high levels of activity from global trunk musculature. Horsak et al. demonstrated that the quadruped (including advanced progressions) resulted in negligible rectus abdominis activity when compared to planks, side-planks and prone roll-outs (45). Ekstrom et al. (2008) demonstrated that erector spinae and multifidus activity was highest (more than 90% MVIC) during prone extension, resisted lumbar extension and "superman" opposite arm leg raise exercises, and lowest (less than 50% MVIC) during plank, side plank and quadruped opposite arm/leg raise (46). These studies suggest when compared to other core exercise, quadrupeds are effective for increasing TVA and potentially internal oblique activity, without comparable increases in rectus abdominisexternal obliqueserector spinae and multifidus activity.

Note: Quadrupeds over Deadbugs Emami et al. demonstrated that EMG activity of the transversus abdominis, internal obliques and multifidus was higher during quadrupeds when compared to supine "deadbugs", and further, trunk muscle activity was higher on the side of the moving extremity (47). Clinical experience suggests that quadrupeds are not more challenging exercise than deadbugs, which may imply quadrupeds are simply a superior exercise for targeting the TVA and ISS.

Compared to Anterior Trunk Muscle Exercise Several studies have compared quadrupeds to other exercises intended to target Anterior trunk musculature. As mentioned above, Teyhen et al. (43) demonstrated that crunches and side planks resulted in a larger increase in TVA and internal oblique thickness than quadrupeds, and Kang et al. (44, 48) demonstrated that planks with ADIM in slings resulted in a larger increase in external oblique thickness than quadrupeds with ADIM in slings. Similarly, Willardson et al. demonstrated that quadrupeds with opposite arm/leg raise, crunches, and side planks, resulted in similar internal oblique activity; however, crunches elicited more rectus abdominis activity and side planks elicited more external oblique activity (49). Okubo et al. demonstrated that planks with opposite arm/leg raise resulted in greater TVA activity than quadrupeds with opposite arm/leg raise; however, clinical experience suggests that this plank progression may only be performed with good form by the most advanced exercisers. Additionally, this study demonstrated that prone leg lifts resulted in the most TVA activity of the exercises tested; however, they also sharply increased erector spinae activity, which may be hazardous for individuals exhibiting signs of lumbo pelvic hip complex dysfunction or low back pain (50). Based on these studies and the sections above, quadrupeds may be recommended when the intent is to target the TVA, but may be progressed to planks and side-planks when the intent is to increase recruitment and incorporate additional core musculature. Compared to Extension Exercise: Quadrupeds have also been compared to various exercises intended to target the lumbar and hip extensors. Kelly et al. demonstrated that compared to sitting exercises, quadruped opposite arm/leg raise resulted in more activity of the  ilioc0stalis lumborum and multifidus based on percentage of maximum voluntary isometric contraction (MVIC) (51). Saranya et al. demonstrated that quadrupeds resulted in erector spinae and multifidus activity that was approximately 60% MVIC, compared to boat/superman prone extension exercise which resulted in 80-100% MVIC (52). As mentioned above, Ekstrom et al. (2008) demonstrated that erector spinae and multifidus activity was highest (more than 90% MVIC) during resisted lumbar extension and superman opposite arm leg/raise exercises, and lowest (less than 50% MVIC) during plank, side plank, bridge and quadruped opposite arm/leg raise (46). Another study by Ekstrom et al. (2007) compared active hip abduction, bridges, unilateral-bridgesplank, side plank, quadruped opposite arm/leg raise, lateral step-ups, and static body-weight lunges, demonstrating that quadruped opposite arm/leg raise resulted in gluteus maximus activity of more than 45% MVIC, suggesting it may be beneficial for gluteus maximus strengthening (53). In summary, quadrupeds recruit erector spinae and multifidus less than superman's and resisted lumbar extension exercise, but more than planks and seated exercises. Additionally, quadrupeds with leg raise may result in sufficient gluteus maximus activity to be beneficial for strengthening. Scapula and Shoulder Stabilization Quadrupeds and quadruped progressions have demonstrated efficacy for targeting scapula and shoulder stabilizers, and various shoulder exercises may be added to the quadruped position. As discussed above, Kim et al. demonstrated an increase in serratus anterior and upper trapezius Muscle activity during quadrupeds with leg raise, especially on the side of the leg raised (41), Further, Nam et al. demonstrated this progression improved the serratus anterior to upper trapezius activation ratio (42), and Bae et al. demonstrated that cuing a reduction in weight shift during this progression significantly increased serratus anterior activity (36). Additional studies have investigated the addition of shoulder motion. Park et al. compared the activity of the serratus anteriorlower trapezius and upper trapezius during quadrupeds with scapular protraction (quadrupeds with push-up plus), and quadrupeds with the addition of arms pushing the body toward the heels using a combination of shoulder flexion, abduction and external rotation (quadrupeds with closed-chain PNF). The quadrupeds with push-up plus resulted in high levels of middle serratus anterior activity; however, the quadrupeds with closed-chain PNF resulted in higher levels of lower serratus anterior and lower trapezius activity. Further, the quadrupeds with closed-chain PNF resulted in a much higher lower serratus anterior to upper trapezius activation ratio (54). Tsuruike et al. demonstrated that quadrupeds with arm raise into shoulder abduction, flexion and external rotation (open-chain PNF) resulted in similar serratus anterior and lower trapezius activity as standing shoulder external rotation and press (serratus Anterior activation), which was more activity than exhibited during bent-over rows with trunk rotation (lawn mowers). Additionally, of the exercises investigated, shoulder external rotation resulted in the most infraspinatus activity, but the quadruped with open-chain PNF resulted in the second most activity (55). Ju et al. compared deltoid activity during shoulder flexion in plank, quadruped and standing positions, demonstrating significantly more posterior and middle deltoid activity in the plank and quadruped positions (56). Last, Kang et al. compared variations of the quadruped exercise performed on a workout bench incorporating the body blade, demonstrating that holding the body blade vertical (compared to horizontal) resulted in a larger increase in serratus anterior activity and more favorable serratus anterior to upper trapezius ratio, and further that lifting the contralateral leg increased internal oblique activity more than lifting the ipsilateral leg (57). These studies suggest that quadruped with leg raise, especially the ipsilateral leg, and/or the addition of open- or closed-chain PNF patterns, or a vertically held Bodyblade, may increase serratus anterior activity, improve the serratus anterior to upper trapezius activation ratio, and increase posterior and middle deltoid activity. Incorporating External Devices A few studies have investigated the addition of devices and equipment to quadrupeds to improve efficacy. Yoon et al. investigated the use of a smartphone as a level on the low back with an app that provided feedback via a laptop to aid the user in maintaining optimal lumbar spine and pelvic position. Use of the app increased internal oblique activity, reduced multifidus activity, and improved pelvic position during the exercise (58). As mentioned above, Masaki et al. compared multifidus activity during various progressions of quadrupeds, demonstrating that the addition of resistance to arm and leg raises increased activity (40). Kim et al. demonstrated that the use of a Flexi-bar (similar to a body blade) during quadrupeds significantly increased activity of the internal obliques, external obliques, erector spinae, and rectus abdominis (59). And, also mentioned above, Kang et al. demonstrated that holding the body blade vertical resulted in a larger increase in serratus anterior activity and a more favorable serratus anterior to upper trapezius ratio, as well as increasing internal oblique activity when raising the contralateral leg (57). These studies demonstrate the potential of electronic devices to optimize form and recruitment, that the addition of a Bodyblade or Flexi-bar may increase trunk Muscle activity, and that the addition of resistance to leg and arm raises may provide additional challenge. Comparing Exercise Outcomes: Several studies have compared the effects of incorporating quadrupeds into a training program. Kim et al. (2019) demonstrated that several sets of deadbugs, deadbugs on a foam roll, or quadrupeds, each variation incorporating the ADIM and slow unilateral hip/knee extension, had an immediate and significant effect on pelvic rotation in asymptomatic individuals with assessed reductions in pelvic rotation (60). Lee et al. compared 5-weeks of either multiple repetitions of 10-second holds of the ADIM while maintaining a pressure of 50 mm Hg on a cuff placed under the lumbar spine in prone position, to a protocol of lumbar stabilization exercises including curl-ups, side-planks and quadruped opposite arm/leg raise. Both groups demonstrated similar increases in transverse abdominis thickness, and increases in the amount of time that single-leg sitting on a stability ball could be maintained (61). These studies suggest that quadrupeds with ADIM, along with various other core stabilization exercises, may have both immediate and long-term efficacy for increasing pelvic position, transverse abdominis thickness and balance. Two additional studies suggest that quadrupeds may have a positive impact on movement quality. Kim et al. (2013) compared standard training for adolescent female basketball players with and without 8-weeks of unilateral quadrupeds and unilateral bridges targeting the non-dominant side, demonstrating that the addition of these unilateral exercises significantly improved right to left activation and reduced recruitment asymmetries, and also improved the amount of forward displacement resulting from sudden unexpected perturbation (reactivity) (62). Bagherian et al. compared college athletes in off-season training with and without the addition of 8-weeks (3x's/week) of core stability training (including quadrupeds), demonstrating significant improvement in Functional Movement Screen (FMS), lateral step-down, and Y-balance test scores with the largest improvements made by those with the worst initial scores (63). These studies suggest that unilateral quadrupeds may be effective for reducing right to left asymmetries, and that core stability training including quadrupeds may improve FMS movement quality scores, balance or reactive recruitment of trunk musculature. Additional studies demonstrate that adding quadrupeds to core or strength training programs may be beneficial for sports performance; however, the results suggest outcomes may be specific. Imai et al. compared the outcomes of soccer players performing a variety of performance related tests, following the addition of 12 weeks (3x's week) of either conventional trunk exercises or stabilization trunk exercises (including quadrupeds). The stabilization trunk exercise group demonstrated significantly better scores on the posterior and Anterior components of the Star Excursion balance test (SEBT), and within group changes suggested stabilization exercise may have a larger effect on "Cooper's test" (aerobic test) and rebound jumps. Both groups improved on vertical jump tests, and neither group significantly improved in the 50m step test (64). Lust et al. compared training for baseball athletes with and without the addition of core exercise (including quadrupeds), demonstrating no significant change in throwing accuracy or proprioception; however, some significant differences were noted in tests specific to core endurance (65). These studies suggest that core training, including quadrupeds, may be an appropriate intervention for improving balance and activities requiring stability, but these exercises are unlikely to have an effect on high-velocity activities.

Low Back Pain

Altered Muscle Activity Individuals with a history of low back pain exhibit altered Muscle activity during quadrupeds when compared to asymptomatic controls. Masaki et al. demonstrated that young participants with a history of low back pain performing quadrupeds with opposite arm/leg raise exhibited an increase in the lumbar lordotic curve, more thoracic extensor and latissimus dorsi activity, but similar lumbar multifidus activity as asymptomatic participants (66). Conversely, Shah et al. demonstrated that when quadrupeds were performed with an increased lumbar lordosis, patients with chronic low back pain exhibited more multifidus activity and asymptomatic participants did not (67). Additionally, Marshall et al. demonstrated that low back pain patients exhibited lower erector spinae activity during quadrupeds when compared to asymptomatic controls, and that the addition of abdominal bracing resulted in inconsistent changes in Muscle activity (68). Yoon et al. demonstrated that low back pain patients exhibited significantly higher lumbar extensor activity than asymptomatic controls when performing quadrupeds with opposite arm/leg raise, but similar lumbar extensor activity during leg raise only, or arm raise only variations. Further, low back pain patients performing the opposite arm/leg raise variations also exhibited higher local to global Muscle activity ratios. Last, performing the quadruped with leg raise only resulted in higher levels of internal oblique activity, the highest local to global Muscle activity ratios, and similar lumbar extensor activity as asymptomatic individuals. This study suggests that the variation of quadruped used in previously mentioned studies may explain the contradictory findings regarding lumbar extensor activity, and that quadrupeds with unilateral leg raise may be an ideal progression for low back pain patients (69). In summary, these studies suggest that low back pain patients performing quadrupeds exhibit higher levels of thoracic extensorlatissimus dorsi and potentially lumbar erector activity, "abdominal bracing" is likely an unreliable intervention for improving recruitment; however, quadrupeds with leg raise may be an ideal progression for low back patients attempting to optimize local to global Muscle activity ratios. Optimizing/Normalizing Recruitment For low back patients, quadrupeds with ADIM may be ideal for targeting the TVA and normalizing trunk Muscle recruitment. Gorbet et al. demonstrated that quadrupeds with ADIM resulted in similar TVA activity in both asymptomatic individuals and those with low back pain (70). Desai et al. demonstrated that low back pain patients exhibited altered recruitment patterns during the side-plank and modified push-up, but similar recruitment during quadrupeds. Further, the addition of unstable environments only increased activity, and did not alter or normalize recruitment patterns (71). As mentioned above, Yoon et al. (68) demonstrated that quadrupeds with leg raise improved local to global activity ratios. Also mentioned above, Marshall et al. (69) demonstrated that abdominal bracing did not result in reliable improvements in recruitment. An RCT by Selkow et al. compared the recruitment timing of the TVA during upper extremity motion in low back pain patients and asymptomatic participants, following a control procedure or 4 weeks (2x's week) of an exercise program including deadbugs, side-planks and quadrupeds. Both low back pain patients and asymptomatic controls exhibited significant improvements in TVA activation timing following the exercise program, with the largest changes seen in those individuals with the greatest delay in onset timing (72). These studies suggest that quadrupeds may aid in selectively recruiting the TVA, improve local to global Muscle activity ratios, and improve onset timing, where as other core exercises, abdominal bracing, and unstable environments are likely to increase Muscle activity without normalizing recruitment patterns. Outcomes following Intervention Plans that include Quadrupeds Several studies have investigated the efficacy of stabilization exercise, including quadrupeds, for the treatment of low back pain. Nelson-Wong et al. demonstrated that patients with low back pain, exacerbated by standing, exhibited decreased pain and normalized Muscle activity after 4-weeks of lumbar stabilization exercises (including quadrupeds) (73). Marshal et al. demonstrated that low back pain patients exhibited a significant decrease in pain, disability and Muscle activity during the passive portion of the flexion/relaxation response following a 12-week exercise intervention (including quadrupeds) (74). Note, this study likely demonstrates a reduction in "guarding/spasm" during forward bending. Sung et al. demonstrated that 4-weeks (3x's/week) of trunk stabilization exercise (including quadrupeds) resulted in significant improvements in disability and pain, but did not significantly improve lumbar extensor endurance (75). Akodu et al. (2015) demonstrated that 4-weeks (2x's week) of a core stabilization exercise program (including quadruped progressions) improved pain, function, quality of life and psychology health (76). And, another study by Akodu et al. (2018) demonstrated that chronic low back pain patients, following 8-weeks of stabilization exercise (including quadruped progressions), exhibited significant improvements in pain-related disability, sleep quality, depression level, and anxiety level (77). These studies demonstrate that 4 - 12 weeks of trunk stabilization exercise (including quadrupeds) may improve outcomes for low back pain patients, including normalized Muscle activity and a decrease in guarding during forward bending, decreased pain and pain-related disability, and improvements in sleep quality, depression level, and anxiety level. Randomized controlled trials (RCT) have also been published investigating the efficacy of stabilization exercise (including quadrupeds) for the treatment of low back pain. An RCT by Rydeard et al. compared a 4-week program of Pilates-based therapeutic exercises (including quadruped variations on specialized equipment) to standard physician and medical care for chronic low back pain. Results demonstrated that the Pilates-based therapeutic exercise resulted in larger improvements in pain and disability at 3-, 6-, and 12-month follow-ups (78). An RCT by Kumar et al. (2011) compared a program of various quadruped progressions to prone-lying for an equivalent amount of time, demonstrating that the exercise program resulted in significant improvements in joint play and pain pressure sensitivity after the 1st and 2nd sessions (79). As mentioned above, an RCT by Selkow et al. compared the recruitment timing of the TVA during upper extremity motion in low back pain patients and asymptomatic participants, followed by 4-weeks (2x's week) of an exercise program including deadbugs, side-planks and quadrupeds or 4-weeks of a continuation of normal activity. The exercise protocol improved TVA activation timing for low back pain patients and asymptomatic participants, with the largest changes seen in those individuals with the greatest delay in onset timing (72). An RCT by Hicks et al. investigated the potential for a clinical prediction rule (CPR) that may improve outcomes by determining which low back patients are most likely to improve following a stabilization exercise program. The highest positive likelihood ratio was achieved when patients exhibited 3 or 4 of the following variables: age less than 40, positive straight-leg raise test, positive prone instability test, aberrant motions, lumbar hypermobility, and fear-avoidance beliefs (80). These RCTs demonstrate the efficacy of trunk stabilization programs (including quadrupeds) for improving joint play, pain pressure sensitivity, global pain and disability for low back pain patients, and TVA activation timing for both symptomatic and asymptomatic individuals exhibiting a delay in activation timing. Exercise Comparison In comparison to various interventions, stabilization exercises (including quadrupeds) have demonstrated superior results. Salavati et al. compared the effects of 4-weeks (3x's/week) of stabilizations exercise (including quadrupeds) to conventional physiotherapy for chronic low back pain patients. Findings demonstrated that the stabilization exercise group exhibited significantly larger improvements in stability and function, but improvements in pain were similar for both groups (81). Sung et al. compared 4-weeks of core stabilization exercises (including quadrupeds) to a lumbar flexibility program, demonstrating that only the stabilization exercise group had a significant decrease in disability. Note, neither group exhibited significant changes in lumbar extensor endurance time (82). Sundaram et al. demonstrated that low back pain patients exhibited larger improvements in pain and function following 4-weeks of core stabilization exercise (quadruped exercise, curl ups, bridge) when compared to Pilates exercise (hundred, side bend, swan rising) (83). An RCT by Rohini et al. compared 4-weeks (5x's/week) of extension exercises, stabilization exercises and no-exercise controls for the treatment of lumbar disk herniation (as diagnosed by MRI), demonstrating that both intervention groups made significant improvements in pain and disability; however, the stabilization group also exhibited positive changes in motor control of the TVA (84). And, Ko et al. compared chronic low back pain patient outcomes following 12 weeks (3x's per week for 60 minutes) of a lumbar stabilization exercise program, a sling exercise program, and controls continuing daily activity, demonstrating that patients with chronic low back pain exhibited similar improvements in pain, lumbar flexion/extension strength, and range of motion following the stabilization exercise and sling exercise programs (85). These studies suggest that stabilization exercise (including quadrupeds) may result in similar outcomes for pain, but is likely superior for improving function (decreasing disability) when compared to conventional physiotherapy, flexibility programs, extension based programs and Pilates. Note, these studies compare these exercise modalities to one another; however, there may be additional benefit to combining these programs (discussed below). Adding Stabilization Exercise to an Existing Program: Studies have also investigated whether additional benefits can be attained from adding stabilization exercise (including quadrupeds) to a therapeutic program. Jeong et al. demonstrated that the addition of gluteal Muscle strengthening to a lumbar segmental stabilization program (including quadrupeds) improved disability scores, lumbar Muscle strength and balance for individuals with chronic low back pain (86). An RCT by Javadian et al. demonstrated that the addition of core stability exercise (including quadrupeds) to an 8-week general strengthening program resulted in significantly less anterior translation during forward bending when compared to general strengthening alone (87). An RCT by Kumar et al. (2017) investigated 3 weeks (5x's/week) of a progressive, integrated program including soft tissue, "knee to chest exercise" and stabilization exercise (including quadrupeds) and compared it to a conventional physical therapy program that included heat, E-stim and flexion exercises. The integrated exercise program resulted in significantly larger improvements in pain, quality of life, lumbar range of motion and neurodynamic tests results (88). Last, a prospective RCT by Pillastrini et al. demonstrated that the addition of an extension based exercise program (including quadruped variations) to education via an ergonomics brochure significantly decreased the rate of development, and/or decreased the severity of neck and low back pain and disability, during a 2-month follow-up of nursery school teachers (89). In contrast to the comparisons made in the previous section, these studies suggest that replacing a program with stabilization exercise may be less beneficial than adding stabilization exercise to an effective program. In these studies, prevention and outcomes improved significantly when stabilization exercise was added to gluteal Muscle strengthening, general strength training, integrated physical therapy program, and/or an educational brochure.

Quadrupeds for Other Pathologies

A few additional studies have demonstrated that quadrupeds may be effective as part of a treatment plan for conditions other than low back pain. As mentioned above, the RCT by Pillastrini et al. demonstrated that the addition of a program including quadrupeds to patient education may aid in the prevention and reduction of neck pain and disability (89). Im et al. demonstrated that a scapular stabilization exercise protocol including quadruped arm raise, performed for 4-weeks (30 min., 3x's/week) resulted in significant improvements in cervical pain and disability, upper trapezius and serratus anterior muscle activity and craniovertebral angle (90). Aoyama et al. investigated the effects of adding planks and quadrupeds (trunk stabilization) to a a protocol of hip abduction, hip extension and pelvic tilts (standard care) for the treatment of femoral acetabular impingement syndrome (FAI). The finding demonstrated that when compared to the standard care protocol, the trunk stabilization group demonstrated significant improvements in hip range of motion and strength at 4 weeks, and significant improvements in pain and function at 8 weeks (91). Ehsani et al. compared general strengthening to specific stabilization exercise (including quadrupeds) for the treatment of post partum lumbo-pelvic pain in woman after pregnancy. Ultrasound imaging demonstrated significant changes in TVA and pelvic floor muscle thickness and activation following specific intervention; however, significant differences in pain relief were not demonstrated (92). A larger participant pool and longer-term follow-up may be recommended to determine if muscular changes resulted in better carry-over and outcomes during long-term follow-up. These studies suggest that the addition of quadrupeds to a treatment plan should also be considered for neck pain and disability, hip pain and dysfunction, and perhaps post-partum pelvic pain.


Plank Progressions, Form and Videos

Quick Summary of Evidence-based Progression Recommendations

  • Progressions: Quadrupeds may be progressed from arm raise, to opposite arm/leg raise, to leg raise, to increasing abduction angle, to the addition of external load, to potentially a decrease in hip flexion angle.
  • Scapula and Shoulder Stabilization: Quadruped with leg raise, especially the ipsilateral leg, and/or the addition of open- or closed-chain PNF patterns may increase serratus anterior activity, improve the serratus anterior to upper trapezius activation ratio, and increase posterior and middle deltoid activity.
  • Incorporating External Devices: Electronic devices may have the potential to optimize form and recruitment, the addition of a BodyBlade or Flexi-bar may increase trunk and shoulder girdle muscle activity, and the addition of resistance to arm and leg raises may provide additional challenge.

Isolated Activation Progression:

  1. Quadruped
  2. Quadruped arm raise
  3. Quadruped opposite arm/leg raise
  4. Quadruped leg raise
  5. Dynamic Quadruped
    • Sagittal
    • Frontal
    • Transverse
    • Resisted
      • Alternate Progressions: Gamification ("Simon Says")
      • Alternate Progression: Gali-peds
      • Alternate Progression: Quadruped with Glute Activation
      • Alternate Progression: Quadruped with Ball Resisted Cervical Retraction
      • Alternate Progression: Hardest Quadruped Progression Ever

Optimal Form:

Optimal form for any exercise should be modeled with the intent of reducing signs that have been correlated with an increased risk of future pain and/or injury (e.g. absence of forward head, knees bow in, etc.). Generally, this results in cues that focus on the alignment of joints.

  • Cervical and thoracic spine neutral
  • Scapula protracted and depressed
  • Neutral lumbar spine with abdominal drawing-in maneuver (ADIM)
  • Neutral pelvis (no anterior pelvic tilt)
    • Cuing a posterior pelvic tilt may be appropriate
  • Hips, knees and ankles in alignment
  • Ankles dorsiflexed

Notes on Form: The exercises below differ from many of the other exercises recommended for activation and core integration. Although resistance is commonly used to progress exercise, the progressions below challenge one's ability to maintain optimal form during increasingly less stable progressions. During all progressions the goal is to maintain the abdominal drawing-in maneuver (ADIM), maintain the spine and pelvic position, and challenge stability and endurance

  • Abdominal Drawing-in Maneuver (ADIM) - a light contraction of the TVA, achieved by gently pulling the lower abdominal region away from one's waist band. This should have minimal impact on breathing, should not be confused with a "vacuum pose" (maximal contraction of the TVA resulting in a "vacuum pose", and is not a rectus abdominis contraction. Contracting the rectus abdominis generally results in a posterior tilt of the pelvis, flexion of the lumbar spine, or flexion of the thoracic spine. If these movements are noted while performing the exercises below, re-establish optimal pelvic and lumbar spine position and attempt the ADIM again.

Transverse Abdominis Isolated Activation (Quadrupeds):

  1. Instruct your patient/client to start with their hands underneath their shoulders and knees underneath their hips in quadruped position.
    • Clinched fists or push up handles may be appropriate for individuals experiencing wrist discomfort or dysfunction.
  2. Ensure your client/patient's hips, knees and ankles are in alignment.
  3. Have your patient/client dorsiflex their ankles and extend their toes, placing as much of the plantar surface of the toes on the floor as possible. This will enable them to press back into the balls of their feet and better engage their gluteus maximus.
  4. Address any deviations in cervical or thoracic alignment ("head back with chin tucked" and "reaching with the top of the head as if trying to get taller" are often helpful cues).
  5. Have your patient/client perform the abdominal drawing-in maneuver (ADIM) and verbally cue "squeeze the glutes" (press back into the toes).
  6. Inform your patient/client that the goal of the exercise is to prevent any motion of the torso.
  7. Have your patient/client hold the ADIM for as long as optimal alignment and comfortable breathing can be maintained.
    • Note: Place a softball or light medicine ball on the back (within the lumbar trough), to aid in kinesthetic awareness of lumbar spine and create an additional balance challenge.

Progressions:

  • March with Hands: Have your patient/client slowly "march" with their hands; slowly lifting each hand a few inches while maintaining the ADIM, a still torso, and ideally a ball in the lumbar trough.
  • Scaption (Arm Raise): Have your patient/client slowly perform scaption on one side, and then the other. Pay careful attention to the transition between hands, ensuring they maintain the ADIM, a still torso, and ideally a ball in the lumbar trough.
  • Opposite Arm/Leg Raise: Have your patient/client reach into scaption with one arm and extend the contralateral leg. Note: the cue should be to "reach long" or "get long," not "elevate" or "raise" the limbs. Attempting to "raise" the limbs toward the ceiling often results in lumbar extension. The toes of the extended leg should not be more than a few inches from the floor at terminal extension. Slowly return to the starting position and transition to the opposite limbs, again, while maintaining the ADIM, a still torso, and ideally a ball in the lumbar trough.
  • Just Legs: Have your patient/client perform the quadruped exercise with just extension of one leg, and then the other. It is often assumed that this progression is easier than an opposite/arm leg raise, but without the counterbalance off the contralateral arm, the torque force created by the legs makes maintaining a still torso very challenging.

Gali-Peds (Quadrupeds with Stability Ball)

  1. Instruct your patient/client to start with their elbows under their shoulders and forearms parallel, centered on a stability ball slightly taller than the length of their forearm.
  2. Ensure your client/patient's hips, kneesankles and feet are in alignment, with their knees under their hips.
  3. Have your patient/client dorsiflex their ankles and extend their toes, placing as much of the plantar surface of the toes on the floor as possible. This will enable them to press back into the balls of their feet and better engage their gluteus maximus.
  4. Address any deviations in cervical or thoracic alignment ("head back with chin tucked" and "reaching with the top of the head as if trying to get taller" are often helpful cues).
  5. Have your patient/client perform the abdominal drawing-in maneuver (ADIM) and verbally cue "squeeze the glutes" (press back into the toes).
  6. Inform your patient/client that the goal of the exercise is to prevent any motion of the torso.
  7. Have your patient/client elevate both knees off the floor by using core musculature and pressing back into the ball of the foot (engaging the glute complex). Their goal is knees level with ankles. Note: Do not allow your patient to press their toes "down" into the floor to elevate the knees, essentially using knee extension alone - this will lead to knee pain over time
    • Place a softball or light medicine ball on the back, in the lumbar trough, to aid in awareness of lumbar spine position and create an additional balance challenge.
  8. Attempt to take a small "step" with the feet (progressions below).
    • Note, focus should be placed on using the gluteus maximus of the leg not moving to press into the floor to create the stability needed to lift the other leg.
  9. Switch sides

Progressions:

  • March with Feet: Have your patient/client slowly "march" with their feet; taking a small step forward, planting the foot, and then stepping back, one foot at a time.
  • Knee Taps: Have your patient/client slowly "march" with their feet; lifting a foot, tapping the ball with their knee, and returning the foot to the original position. This is a more challenging progression than the previous progression because the leg is lifted for a longer period of time and moves over a larger range.
  • Leg Raise: Have your patient/client extend one leg at a time. Cuing for gluteus maximus activation may be used to optimize form.
  • Leg Raise to Knee Tap: Various combinations of the above can be used to progress the exercise by extending the time between bilateral support.

Quadruped Crawl (Dynamic Quadruped):

  1. Instruct your patient/client to start with their hands underneath their shoulders and knees underneath their hips in quadruped position.
    • Clinched fists or push up handles may be appropriate for individuals experiencing wrist discomfort or dysfunction.
  2. Ensure your client/patient's hips, knees and ankles are in alignment.
  3. Have your patient/client dorsiflex their ankles and extend their toes, placing as much of the plantar surface of the toes on the floor as possible. This will enable them to press back into the balls of their feet and better engage their gluteus maximus.
  4. Address any deviations in cervical or thoracic alignment ("head back with chin tucked" and "reaching with the top of the head as if trying to get taller" are often helpful cues).
  5. Have your patient/client perform the abdominal drawing-in maneuver (ADIM) and verbally cue "squeeze the glutes" (press back into the toes).
  6. Inform your patient/client that the goal of the exercise is to prevent any motion of the torso.
  7. Have your patient/client elevate both knees off the floor by using core musculature and pressing back into the ball of the foot (engaging the glute complex). Their goal is knees level with ankles. Note: Do not allow your patient to press their toes "down" into the floor to elevate the knees, essentially using knee extension alone - this will lead to knee pain over time
    • Place a softball or light medicine ball on the back, in the lumbar trough, to aid in awareness of lumbar spine position and create an additional balance challenge.
  8. Attempt to take a "step" with the hands or feet (progressions below).
    • Note, focus should be placed on using the gluteus maximus of the leg not moving to press into the floor to create the stability needed to lift the other leg.
  9. Switch sides

Progressions:

  1. Just hands: Move a hand forward and then back.
  2. Just feet: Move a foot forward and then back.
  3. One limb at a time: Alternate - move one hand forward and plant it on the floor, followed by moving the contralateral foot and planting it on the floor. Do the same for the opposite limbs.
  4. Reciprocal Motion: Move a hand and contralateral foot forward (at the same time) and plant them on the floor, followed by moving the opposite limbs and planting them on the floor. Pause to ensure stability is achieved before moving each set of reciprocal limbs. This should start to look like a slow crawl.
  5. Backward Reciprocal Motion: Move a hand and contralateral foot backward and plant them on the floor (at the same time), followed by the opposite limbs. Slowly crawling backward.
    • Note: These progressions are similar to a "bear crawl," but with far more attention paid to lumbo-pelvic hip complex stability. The addition of the softball on the lumbar spine makes this a challenge for even the most advanced exerciser.

Additional Quadruped Crawl Progressions:

The directions for this video are identical to the video above; however, additional patterns have been added.

Progressions:

  1. Crawl: Move a hand and contralateral foot forward (at the same time) and plant them on the floor, followed by moving the opposite hand and foot and planting them on the floor. With practice this can be done as a slow crawl, attempting to maintain a ball in the lumbar trough wile crawling for a preset distance.
  2. Reverse crawl: Reversing the direction of the forward crawl is a significant challenge.
  3. Frontal plane crawl: The frontal plane crawl adds a new pattern of reciprocal motion. Contralateral limbs move together; this brings one set of limbs closer together and the other set further apart. For example, if moving to the right, you may start by moving the right hand to just wider than shoulder width, while moving the left foot next to the right foot. Moving the opposite limbs bring the hands close together and the feet further apart.
  4. Transverse plane crawl: The pattern for the limbs is similar to the "frontal plane crawl"; however, the hands will have to more more than the feet, or visa-versa, to perform crawls in a circle.
  5. Gamification:
    • Simon Says: Once a patient, client or group has a repertoire of various dynamic quadruped progressions, adding "Simon Says", or simply randomized coaching cues, can turn quadrupeds into a game in which the person who can balance a ball in their lumbar trough the longest, is the winner.
    • Quadruped Wars: This is an very advanced progression, but can be fun for athletes. Assuming a dynamic quadruped position, pairs of trainees can attempt to knock a foam roll or ball off of their opponents back. Each time a competitor loses the item balanced on their back, their opponent gets a point.

Transverse Abdominis and Deep Cervical Flexor (DCF) Activation:

  1. Instruct your patient/client to start with their hands underneath their shoulders and knees underneath their hips in quadruped position.
    • Clinched fists or push up handles may be appropriate for individuals experiencing wrist discomfort or dysfunction.
  2. Ensure your client/patient's hips, knees and ankles are in alignment.
  3. Have your patient/client dorsiflex their ankles and extend their toes, placing as much of the plantar surface of the toes on the floor as possible. This will enable them to press back into the balls of their feet and better engage their gluteus maximus.
  4. Address any deviations in cervical or thoracic alignment ("head back with chin tucked" and "reaching with the top of the head as if trying to get taller" are often helpful cues).
  5. Have your patient/client perform the abdominal drawing-in maneuver (ADIM) and verbally cue "squeeze the glutes" (press back into the toes).
  6. Inform your patient/client that the goal of the exercise is to prevent any motion of the torso.
  7. The hard part: Find the distance from the wall that is the width of the stability ball when the cervical spine is retracted. The stability ball should rest, just posterior to the crown of the head, but only when the cervical spine is neutral or retracted.
    • Note: As the cervical spine is retracted it gets "longer", it is acceptable for the head to press into the stability ball, assuming that the individual is not bothered by (or symptoms are not exacerbated by) compression forces.
  8. Cue cervical retraction.
  9. Hold cervical retraction and the ADIM, for as long as optimal alignment and comfortable breathing can be maintained.

Progressions: While maintaining cervical retraction and balancing a stability ball just posterior to the crown of the head:

  • March with Hands: Have your patient/client slowly "march" with their hands; slowly lifting each hand a few inches while maintaining the ADIM, a still torso, and ideally a ball in the lumbar trough.
  • Scaption (Arm Raise): Have your patient/client slowly perform scaption on one side, and then the other. Pay careful attention to the transition between hands, ensuring they maintain the ADIM, a still torso, and ideally a ball in the lumbar trough.
  • Opposite Arm/Leg Raise: Have your patient/client reach into scaption with one arm and extend the contralateral leg. Note: the cue should be to "reach long" or "get long," not "elevate" or "raise" the limbs. Attempting to "raise" the limbs toward the ceiling often results in lumbar extension. The toes of the extended leg should not be more than a few inches from the floor at terminal extension. Slowly return to the starting position and transition to the opposite limbs, again, while maintaining the ADIM, a still torso, and ideally a ball in the lumbar trough.
  • Just Legs: Have your patient/client perform the quadruped exercise with just extension of one leg, and then the other. It is often assumed that this progression is easier than an opposite/arm leg raise, but without the counterbalance off the contralateral arm, the torque force created by the legs makes maintaining a still torso very challenging.

Transverse Abdominis and Gluteus Maximus Activation Progression:

  1. Instruct your patient/client to start with their hands underneath their shoulders and knees underneath their hips in quadruped position, and one side of the body as close to a wall as possible.
    • Clinched fists or push up handles may be appropriate for individuals experiencing wrist discomfort or dysfunction.
  2. Place a yoga block, trigger point block, or other solid object (about 4 inches high) underneath the knee closest to the wall.
  3. Ensure your client/patient's hips, knees and ankles are in alignment.
  4. Have your patient/client dorsiflex their ankles and extend their toes, placing as much of the plantar surface of the toes on the floor as possible. This will enable them to press back into the balls of their feet and better engage their gluteus maximus.
  5. Address any deviations in cervical or thoracic alignment ("head back with chin tucked" and "reaching with the top of the head as if trying to get taller" are often helpful cues).
  6. Have your patient/client perform the abdominal drawing-in maneuver (ADIM) and verbally cue "squeeze the glutes" (press back into the toes).
  7. Inform your patient/client that the goal of the exercise is to prevent any motion of the torso.
  8. Have your patient/client elevate the knee furthest from the wall by using core musculature and pressing back into the ball of the foot (engaging the glute complex).
  9. This position should be maintained without touching the wall (roughly a 1/2 inch between the wall, pelvis and shoulders). The wall is used as a check to ensure the patient/client does not weight shift to maintain balance.
  10. Switch sides.
    • Note: Place a softball or light medicine ball on the back, in the lumbar trough, to aid in awareness of lumbar spine position and create an additional balance challenge.

Progressions:

  • Have your patient/client extend the leg furthest from the wall for several repetitions without letting the shoulder or hip closest to the wall touch the wall. The knee of the extending leg should not touch the floor throughout the entirety of the set.
  • Place the yoga block, trigger point block or solid object underneath the knee furthest from the wall. Extend the leg closest to the wall, pressing the side of the foot against the wall to resist abduction. The cues used for extension should mimick the cues used during gluteus maximus activation in quadruped.

Hardest Quadruped Progression Ever:

  1. Instruct your patient/client to start with their hands underneath their shoulders and knees underneath their hips in quadruped position, and one side of the body as close to a wall as possible.
    • Clinched fists or push up handles may be appropriate for individuals experiencing wrist discomfort or dysfunction.
  2. Place a yoga block, trigger point block, or other solid object (about 4 inches high) underneath the knee closest to the wall.
  3. Ensure your client/patient's hips, knees and ankles are in alignment.
  4. Have your patient/client dorsiflex their ankles and extend their toes, placing as much of the plantar surface of the toes on the floor as possible. This will enable them to press back into the balls of their feet and better engage their gluteus maximus.
  5. Address any deviations in cervical or thoracic alignment ("head back with chin tucked" and "reaching with the top of the head as if trying to get taller" are often helpful cues).
  6. Have your patient/client perform the abdominal drawing-in maneuver (ADIM) and verbally cue "squeeze the glutes" (press back into the toes).
  7. Inform your patient/client that the goal of the exercise is to prevent any motion of the torso.
  8. Have your patient/client elevate the knee furthest from the wall by using core musculature and pressing back into the ball of the foot (engaging the glute complex).
  9. This position should be maintained without touching the wall (roughly a 1/2 inch between the wall, pelvis and shoulders). The wall is used as a check to ensure the patient/client does not weight shift to maintain balance.
  10. Have your patient/client raise the hand furthest from the wall several inches from the floor and gently put the hand back down. Repeat for as many repetitions as the ADIM and still torso can be maintained without touching the wall.
    • Note: Place a softball or light medicine ball on the back, in the lumbar trough, to aid in awareness of lumbar spine position and create an additional balance challenge.
  11. Switch sides.

 

Reactive Activation Progression:

  1. Crunch and Catch – Chest Pass on Floor
  2. Crunch and Catch – Soccer Throw on Floor
  3. Crunch and Catch – unilateral “Baseball throw” on Floor
  4. Crunch and Catch – Chest Pass on Bosu
  5. Crunch and Catch – Soccer Throw on Bosu
  6. Crunch and Catch – unilateral “Baseball throw” on Bosu
  7. Crunch and Catch – Chest Pass on Ball
  8. Crunch and Catch – Soccer Throw on Ball
  9. Crunch and Catch – unilateral “Baseball throw on Ball

Crunch and Catch:

  1. Start by having your client/patient sit on a stability ball that is about knee height.
  2. Have them "walk" their feet out and roll down the ball as if they were going to sit on the floor, but stop when the top of the gluteus maximus is still in contact with the ball.
  3. Ensure your client/patient's hips, knees and ankles and feet are in alignment, the patient is maintaining a neutral spine, and the ball is centered on the upper lumbar spine (thoracolumbar junction)
  4. Have your client/patient assume a crunch position. Careful attention should be payed to maintaining the abdominal drawing-in maneuver (ADIM) and "glute squeeze", while performing spinal flexion without additional hip flexion.
  5. Your client/patient should start with the arms extended toward the ceiling.
  6. Throw a stability ball or medicine ball toward the patient/client's hands (above the face) fast enough that the ball travels with a mostly horizontal trajectory.
  7. The client/patient should be cued to receive the ball quietly as if "catching an egg"; decelerating the ball into end range shoulder flexion.
  8. A goal of this exercise is to reduce the time between eccentric and concentric contractions (at the end of shoulder flexion range of motion), also known as the "amortization phase" - there should be no pause at the end of shoulder flexion range of motion (ROM).
  9. The client/patient should be instructed to throw the ball back as fast as can be controlled, ending in the original "crunch positions" while maintaining the ADIM.
    • Note: Throwing smaller stability balls are a wonderful way to introduce upper body power exercise. Do not assume that a weighted medicine ball is a better tool for teaching optimal technique, mechanics and improving power/reactivity.
    • Note: Although it takes some practice and coordination, this exercise can be performed without a partner, by throwing the ball against a very solid wall or column. Note, this should not be done against dry wall.

Crunch and Catch Progressions:

Progressions:

  • Increasing Distance: Increasing the distance between you and your patient/client will generally result in an increase in velocity. This increases the force to be decelerated during the catch phase and requires a faster throw during the concentric phase.
  • Decreasing Distance: If both you and your client/patient are sufficiently coordinated and skilled, throwing harder and decreasing the distance will result in more velocity and reps in a shorter amount of time.
  • Increasing Weight: This progression should only be used when optimal form has been achieved, and velocity/distance cannot be increased further. Note, a heavy medicine ball thrown slowly, is not helping your client/patient increase reactivity, velocity and power.
  • Unilateral/Multi-planer: Using small, softball-sized medicine balls that can be caught and thrown with one hand, allows this exercise to be performed unilaterally. This makes for a wonderful reactive drill, adding the additional options of throwing outside of the mid-sagittal plane and randomizing which hand is thrown to.

Bibliography

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  2. Hodges, P. W., & Richardson, C. A. (1997). Contraction of the abdominal muscles associated with movement of the lower limb. Physical therapy77(2), 132-142.
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  8. van Wingerden, J. P., Vleeming, A., Buyruk, H. M., & Raissadat, K. (2004). Stabilization of the sacroiliac joint in vivo: verification of muscular contribution to force closure of the pelvis. European Spine Journal13(3), 199-205.
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    • Electromyographic (EMG) Activity
  35. Stevens, V.K., Vleeming, A., Bouche, KG., Mahieu, N.N., Vanderstraeten, G.G., Danneels, L.A. Electromyograhpic activity of trunk and hip muscles during stabilization exercises in four-point kneeling in healthy volunteers. European Spine Journal, 2007. 16: 711-718.
  36. Bae, C. H., Kim, S. H., & Kim, M. K. (2020). Comparison of Muscle Activity of Trunk Muscles According to the Weight Shift Distance in Quadruped Exercise. The Journal of Korean Academy of Orthopedic Manual Physical Therapy, 26(1), 27-36.
  37. Queiroz, B. C., Cagliari, M. F., Amorim, C. F., & Sacco, I. C. (2010). Muscle activation during four Pilates core stability exercises in quadruped position. Archives of physical medicine and rehabilitation91(1), 86-92.
  38. Pirouzi, S., Emami, F., Taghizadeh, S., & Ghanbari, A. (2013). Is Abdominal muscle activity different from lumbar muscle activity during four-point kneeling?. Iranian journal of medical sciences, 38(4), 327.
  39. Lee, J. Y., Park, M. E., Kim, J. S., Hong, J. H., Yu, J. H., & Lee, D. Y. (2015). The Efect of Muscle Activation in Trunk Stabilization Exercise According to the Joint Angle of Normal Adults. Indian Journal of Science and Technology, 8, 19.
  40. Masaki, M., Tateuchi, H., Tsukagoshi, R., Ibuki, S., & Ichihashi, N. (2015). Electromyographic analysis of training to selectively strengthen the lumbar multifidus muscle: effects of different lifting directions and weight loading of the extremities during quadruped upper and lower extremity lifts. Journal of manipulative and physiological therapeutics, 38(2), 138-144.
  41. Kim, H. G., Hwang, B. J., & Kim, J. W. (2019). Comparison of Muscle Activities Serratus Anterior and Upper Trapezius Muscle During Scapular Protraction in Quadruped Position at Legs Difference. The Journal of Korean Academy of Orthopedic Manual Physical Therapy, 25(1), 29-36.
  42. Nam, K., Kim, J., & Park, J. (2020). Comparative Analysis of the Serratus Anterior Muscle Activity When Right and Left Knee Lift during Quadruped Position on Push Up Plus. The Journal of Korean Physical Therapy, 32(1), 58-63.
    • Targeting the Transverse Abdominis
  43. Kang, J. H., Shim, J. H., & Chon, S. C. (2012). The effect of five different trunk stabilization exercise on thickness of abdominal muscle using an ultrasonography imaging in normal people. Physical Therapy Korea, 19(3), 1-10.
  44. Teyhen, D. S., Rieger, J. L., Westrick, R. B., Miller, A. C., Molloy, J. M., & Childs, J. D. (2008). Changes in deep abdominal muscle thickness during common trunk-strengthening exercises using ultrasound imaging. journal of orthopaedic & sports physical therapy, 38(10), 596-605
  45. Horsak, B., Wunsch, R., Bernhart, P., Gorgas, A. M., Bichler, R., & Lampel, K. (2017). Trunk muscle activation levels during eight stabilization exercises used in the functional kinetics concept: A controlled laboratory study. Journal of Back and Musculoskeletal Rehabilitation, 30(3), 497-508.
  46. Ekstrom, R. A., Osborn, R. W., & Hauer, P. L. (2008). Surface electromyographic analysis of the low back muscles during rehabilitation exercises. journal of orthopaedic & sports physical therapy38(12), 736-745.
    • Planks, Crunches and Quadrupeds
  47. Emami, F., Pirouzi, S., & Taghizadeh, S. (2015). Comparison of abdominal and lumbar muscles electromyography activity during two types of stabilization exercises. Zahedan Journal of Research in Medical Sciences17(4).
  48. Kang, J. H., Suh, H. R., Kim, C. Y., Kim, H. D., & Kim, H. (2016). Influence of difficulty variation of the core stabilization exercise on thickness changes of abdominal muscles in healthy subjects: a pilot study. The Journal of Korean Physical Therapy28(2), 112-118.
  49. Willardson, J. M., Behm, D. G., Huang, S. Y., Rehg, M. D., Kattenbraker, M. S., & Fontana, F. E. (2010). A comparison of trunk muscle activation: Ab Circle vs. traditional modalities. The Journal of Strength & Conditioning Research, 24(12), 3415-3421.
  50. Okubo, Y., Kaneoka, K., Imai, A., Shiina, I., Tatsumura, M., Izumi, S., & Miyakawa, S. (2010). Electromyographic analysis of transversus abdominis and lumbar multifidus using wire electrodes during lumbar stabilization exercises. journal of orthopaedic & sports physical therapy40(11), 743-750.
    • Extension Exercises (and 47)
  51. Kelly, M., Jacobs, D., Wooten, M. E., & Edeer, A. O. (2016). Comparison of electromyographic activities of lumbar iliocostalis and lumbar multifidus muscles during stabilization exercises in prone, quadruped, and sitting positions. Journal of physical therapy science, 28(10), 2950-2954.
  52. Saranya, S., Poonguzhali, S., Baala, N. M., & Karunakaran, S. (2020). EMG Analysis of Lumbar Muscle Activations During Resisted and Unresisted Core Strength Exercises. International Journal of Biomedical and Clinical Engineering (IJBCE), 9(2), 12-24.
  53. Ekstrom, R. A., Donatelli, R. A., & Carp, K. C. (2007). Electromyographic analysis of core trunk, hip, and thigh muscles during 9 rehabilitation exercises. Journal of orthopaedic & sports physical therapy37(12), 754-762.
    • Shoulder
  54. Park, D. J., & Lee, H. O. (2013). The intramuscular activation of scapular stabilizing muscles during push-up plus and PNF exercises in a quadruped position. Journal of Physical Therapy Science, 25(4), 371-374.
  55. Tsuruike, M., & Ellenbecker, T. S. (2015). Serratus anterior and lower trapezius muscle activities during multi-joint isotonic scapular exercises and isometric contractions. Journal of athletic training, 50(2), 199-210.
  56. Ju, S. K., & Yoo, W. G. (2015). Electromyography activity of the deltoid muscle of the weight-bearing side during shoulder flexion in various weight-bearing positions. Journal of physical therapy science, 27(10), 3285-3286.
  57. Kang, J. I., Park, J. S., Jeong, D. K., Choi, H. H., & Moon, Y. J. (2018). Effects on muscle activities according to the type of bodyblade exercise in quadruped position. Journal of physical therapy science, 30(6), 862-865.
    • Additional Resistance (and 57)
  58. Yoon, T. L., Cynn, H. S., Choi, S. A., Choi, W. J., Lee, J. H., & Choi, B. S. (2015). Visual feedback using a smart-phone mirroring system influences trunk muscle activity and kinematics of the trunk and pelvis in healthy and chronic low-back pain groups during arm and leg lift in quadruped position. Isokinetics and Exercise Science, 23(2), 117-125.
  59. Kim, J. H., So, K. H., Bae, Y. R., & Lee, B. H. (2014). A comparison of flexi-bar and general lumbar stabilizing exercise effects on muscle activity and fatigue. Journal of physical therapy science26(2), 229-233.
    • Comparing Exercise Outcomes:
  60. Kim, D. H., & Kim, T. H. (2019). Effects of abdominal drawing-in maneuver with pressure biofeedback, foam-roller and quadruped on lumbopelvic stability and muscle activities in lumbar rotation syndrome. Journal of exercise rehabilitation15(2), 287.
  61. Lee, J. S., Kim, T. H., Kim, D. Y., Shim, J. H., & Lim, J. Y. (2015). Effects of selective exercise for the deep abdominal muscles and lumbar stabilization exercise on the thickness of the transversus abdominis and postural maintenance. Journal of physical therapy science, 27(2), 367-370.
  62. Kim, Y., Son, J., & Yoon, B. (2013). Intensive unilateral neuromuscular training on non-dominant side of low back improves balanced muscle response and spinal stability. European journal of applied physiology, 113(4), 997-1004.
  63. Bagherian, S., Ghasempoor, K., Rahnama, N., & Wikstrom, E. A. (2019). The Effect of Core Stability Training on Functional Movement Patterns in College Athletes. Journal of sport rehabilitation, 28(5).
  64. Imai, A., Kaneoka, K., Okubo, Y., & Shiraki, H. (2014). Effects of two types of trunk exercises on balance and athletic performance in youth soccer players. International journal of sports physical therapy, 9(1), 47.
  65. Lust, K. R., Sandrey, M. A., Bulger, S. M., & Wilder, N. (2009). The effects of 6-week training programs on throwing accuracy, proprioception, and core endurance in baseball. Journal of sport rehabilitation, 18(3), 407-426.
    • Low Back Pain and Recruitment during Quadrupeds
  66. Masaki, M., Tateuchi, H., Koyama, Y., Sakuma, K., Otsuka, N., & Ichihashi, N. (2018). Back muscle activity and sagittal spinal alignment during quadruped upper and lower extremity lift in young men with low back pain history. Gait & posture, 66, 221-227.
  67. Shah, Jayshree, Tarushi Tanwar, Iram Iram, Mosab Aldabbas, and Zubia Veqar. "Effect of Increased Lumbar Lordosis on Lumbar Multifidus and Longissimus Thoracis Activation During Quadruped Exercise in Patients With Chronic Low Back Pain: An EMG Study." Journal of Applied Biomechanics 36, no. 6 (2020): 436-443.
  68. Marshall, P. W., Desai, I., & Robbins, D. W. (2011). Core stability exercises in individuals with and without chronic nonspecific low back pain. The Journal of Strength & Conditioning Research, 25(12), 3404-3411.
  69. Yoon, T. L., Cynn, H. S., Choi, S. A., Choi, W. J., Jeong, H. J., Lee, J. H., & Choi, B. S. (2015). Trunk muscle activation during different quadruped stabilization exercises in individuals with chronic low back pain. Physiotherapy Research International20(2), 126-132.
    • Targeting the TVA and Normalizing Recruitment
  70. Gorbet, N., Selkow, N. M., Hart, J. M., & Saliba, S. (2010). No difference in transverse abdominis activation ratio between healthy and asymptomatic low back pain patients during therapeutic exercise. Rehabilitation research and practice2010.
  71. Desai, I., & Marshall, P. W. (2010). Acute effect of labile surfaces during core stability exercises in people with and without low back pain. Journal of Electromyography and Kinesiology20(6), 1155-1162.
  72. Selkow, N. M., Eck, M. R., & Rivas, S. (2017). Transversus abdominis activation and timing improves following core stability training: a randomized trialInternational journal of sports physical therapy12(7), 1048.
    • Low Back Pain Outcomes
  73. Nelson-Wong, E., & Callaghan, J. P. (2010). Changes in muscle activation patterns and subjective low back pain ratings during prolonged standing in response to an exercise intervention. Journal of Electromyography and Kinesiology, 20(6), 1125-1133.
  74. Marshall, P., & Murphy, B. (2006). Changes in the flexion relaxation response following an exercise intervention. Spine, 31(23), E877-E883.
  75. Sung, P. S. (2013). Disability and back muscle fatigability changes following two therapeutic exercise interventions in participants with recurrent low back pain. Medical science monitor: international medical journal of experimental and clinical research, 19, 40.
  76. Akodu, A. K., Tella, B. A., & Olujobi, O. D. (2015). Effect of stabilization exercise on pain and quality of life of patients with non-specific chronic low back pain. African Journal of Physiotherapy and Rehabilitation Sciences, 7(1-2), 7-11.
  77. Akodu, A. K., & Akindutire, O. M. (2018). The effect of stabilization exercise on pain-related disability, sleep disturbance, and psychological status of patients with non-specific chronic low back pain. The Korean journal of pain, 31(3), 199.
  78. Rydeard, R., Leger, A., & Smith, D. (2006). Pilates-based therapeutic exercise: effect on subjects with nonspecific chronic low back pain and functional disability: a randomized controlled trial. Journal of orthopaedic & sports physical therapy, 36(7), 472-484.
  79. Kumar, S. P. (2011). Efficacy of segmental stabilization exercise for lumbar segmental instability in patients with mechanical low back pain: A randomized placebo controlled crossover study. North American journal of medical sciences, 3(10), 456.
  80. Hicks, G. E., Fritz, J. M., Delitto, A., & McGill, S. M. (2005). Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Archives of physical medicine and rehabilitation, 86(9), 1753-1762.
  81. Salavati, M., Akhbari, B., Takamjani, I. E., Bagheri, H., Ezzati, K., & Kahlaee, A. H. (2016). Effect of spinal stabilization exercise on dynamic postural control and visual dependency in subjects with chronic non-specific low back pain. Journal of bodywork and movement therapies, 20(2), 441-448.
  82. Sung, P. S. (2003). Multifidi muscles median frequency before and after spinal stabilization exercises. Archives of physical medicine and rehabilitation84(9), 1313-1318.
  83. Sundaram, M. S. (2017). Comparing the Effects of Pilates and Conventional core Stabilization Exercise with moist Hot Pack in Females with Low Back Pain.
  84. Rohini, K., Gaurav, T., & Singh, S. J. (2007). Comparison of effects of specific stabilization exercises and conventional back extension exercises in management of chronic disc prolapse. Indian J Physiother Occup Ther, 1, 2007-9.
  85. Ko, K. J., Ha, G. C., Yook, Y. S., & 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. Journal of physical therapy science, 30(1), 18-22.
  86. Pillastrini, P., Mugnai, R., Bertozzi, L., Costi, S., Curti, S., Mattioli, S., & Violante, F. S. (2009). Effectiveness of an at-work exercise program in the prevention and management of neck and low back complaints in nursery school teachers. Industrial health, 47(4), 349-354.
    • Addition of Stabilization Exercise
  87. Jeong, U. C., Sim, J. H., Kim, C. Y., Hwang-Bo, G., & Nam, C. W. (2015). The effects of gluteus muscle strengthening exercise and lumbar stabilization exercise on lumbar muscle strength and balance in chronic low back pain patients. Journal of physical therapy science, 27(12), 3813-3816.
  88. Javadian, Y., Akbari, M., Talebi, G., Taghipour-Darzi, M., & Janmohammadi, N. (2015). Influence of core stability exercise on lumbar vertebral instability in patients presented with chronic low back pain: A randomized clinical trial. Caspian journal of internal medicine, 6(2), 98.
  89. Kumar, S., & Narkeesh, A. (2017). Effect of Integrated Exercise Protocol in Lumbar Spinal Stenosis as Compare with Conventional Physiotherapy-A Randomized Control Trial. Int J Neurorehabilitation, 4(301), 2376-0281.
    • Quadrupeds for Other Pathologies
  90. Im, B., Kim, Y., Chung, Y., & Hwang, S. (2015). Effects of scapular stabilization exercise on neck posture and muscle activation in individuals with neck pain and forward head posture. Journal of physical therapy science, 28(3), 951-955.
  91. Aoyama, M., Ohnishi, Y., Utsunomiya, H., Kanezaki, S., Takeuchi, H., Watanuki, M., ... & Uchida, S. (2019). A prospective, randomized, controlled trial comparing conservative treatment with trunk stabilization exercise to standard hip muscle exercise for treating femoroacetabular impingement: a pilot study. Clinical Journal of Sport Medicine, 29(4), 267.
  92. Ehsani, F., Sahebi, N., Shanbehzadeh, S., Arab, A. M., & ShahAli, S. (2020). Stabilization exercise affects function of transverse abdominis and pelvic floor muscles in women with postpartum lumbo-pelvic pain: a double-blinded randomized clinical trial study. International Urogynecology Journal, 31(1), 197-204.

  © 2016, 2020 Brent Brookbush Questions, comments, and criticisms are welcomed and encouraged –