Joint Bone Spine 73 (2006) 43–50

http://france.elsevier.com/direct/BONSOI/

Review

Spinal muscle evaluation using the Sorensen test:

a critical appraisal of the literature
Christophe Demoulin *, Marc Vanderthommen, Christophe Duysens, Jean-Michel Crielaard
Physical Medicine and Rehabilitation Unit, Liège University, Liège, Belgium
Received 3 May 2004; accepted 4 August 2004

Available online 05 October 2004

Abstract

The first test for evaluating the isometric endurance of trunk extensor muscles was described by Hansen in 1964. In 1984, following a study
by Biering-Sorensen, this test became known as the “Sorensen test” and gained considerable popularity as a tool reported to predict low back
pain within the next year in males. The test consists in measuring the amount of time a person can hold the unsupported upper body in a
horizontal prone position with the lower body fixed to the examining table. This test has been used in many studies, either in its original
version or as variants. Although its discriminative validity, reproducibility, and safety seem good, debate continues to surround its ability to
predict low back pain; in addition, the gender-related difference in position-holding time remains unexplained and the influence of body
weight unclear. A contribution of the hip extensor muscles to position holding has been established, but its magnitude remains unknown. The
influence of personal factors such as motivation complicates the interpretation of the results. Despite these drawbacks, the Sorensen test has
become the tool of reference for evaluating muscle performance in patients with low back pain, most notably before and after rehabilitation
programs.
© 2005 Elsevier SAS. All rights reserved.

Keywords: Muscle endurance; Low back pain; Trunk extensor muscles; Physical evaluation; Spinal muscles

1. Introduction Several studies suggest that patients with chronic nonspe-

Despite growing research efforts, nonspecific low back pain
remains a major public health burden throughout the indus-
trialized world. Epidemiological data indicate an annual
prevalence of about 39–54% [1,2] and a lifetime prevalence
of 60–65% [1–3]. Costs to society stem mainly from chronic
forms, which account for only 5–10% of cases [4,5]. Chronic
nonspecific low back pain results in both physical and psy-
chological deconditioning that traps the patient in a vicious
circle characterized by decreased physical performance, exac-
erbated nociceptive sensations, impaired social functioning,
work disability, and depression. The physical component of
deconditioning involves both stiffness of the lumbar spine-
pelvic-femoral unit, decreased muscle strength and endur-
ance, loss of cardiorespiratory adjustment to physical exer-
tion, and neuromuscular inhibition (kinesiophobia) [6].
* Corresponding author. Département de Médecine Physique et
Kinésithérapie-Réadaptation, ISEPK, B21, Allée des Sports 4,
B-4000 Liege, Sart Tilman, Belgium.
E-mail address: mvanderthommen@ulg.ac.be (C. Demoulin).
1297-319X/$ - see front matter © 2005 Elsevier SAS. All rights reserved.
doi:10.1016/j.jbspin.2004.08.002
cific low back pain may benefit from an active multidisci-
plinary approach involving an individually tailored recondi-
tioning program [6–8]. Tools capable of quantitating
individual deficiencies and of documenting the effects of
reconditioning would be useful. Evaluating the endurance of
trunk extensor muscles seems to have greater discriminative
validity than evaluation of maximal voluntary contractile force
[9–14].
In 1964, Hansen developed the first test for evaluating the
isometric endurance of trunk extensor muscles and validated
it in 168 healthy individuals and 90 patients who had had
surgery for low back pain within the last 3–4 weeks [15]. In
this test, the patient is in the prone position with the lower
body fixed to the examining table and the upper body extend-
ing beyond the edge of the table. The test consists in holding
the upper body horizontal as long as possible. In 1972, Troup
et al. evaluated muscle fatigability by performing surface elec-
tromyography in patients during the test [16]. After a
1984 study by Biering-Sorensen [9] published in Spine, the
test became known as the “Sorensen test”. Biering-Sorensen
44 C. Demoulin et al. / Joint Bone Spine 73 (2006) 43–50
used the test together with several other evaluations in over
900 individuals and concluded that a shorter position-
holding time during the Sorensen test predicted low back pain
within the next year in males.
2. Methods
We conducted a Medline search for articles reporting the
use of the Sorensen test to evaluate the back muscles. The
keywords used for the search were “Sorensen test”, “back
pain”, “muscle endurance”, “static endurance”, “muscle
fatigue”, “function test”, “back extension”, and “trunk exten-
sors”. In addition, the reference list of each article retrieved
by the Medline search was examined for additional related
articles.
3. Description of the Sorensen test
The patient lies on the examining table in the prone posi-
tion with the upper edge of the iliac crests aligned with the
edge of the table. The lower body is fixed to the table by three
straps, located around the pelvis, knees, and ankles, respec-
tively. With the arms folded across the chest, the patient is
asked to isometrically maintain the upper body in a horizon-
tal position (Fig. 1). The time during which the patient keeps
the upper body straight and horizontal is recorded. In patients
who experience no difficulty in holding the position, the test
is stopped after 240 s.
The Sorensen test is the most widely used test in pub-
lished studies evaluating the isometric endurance of trunk
extensor muscles. It has been used either as described ini-
tially or with a number of modifications, as listed below.
• Arm position: the test has been used with the arms bent,
the elbows held out, and the hands on the ears [17], fore-
head [18], or nape of the neck [19,20]; in another variant,
the arms are held along the sides [13,21,22]. Because arm
position influences the location of the center of gravity,
these modifications affect the mass moment of the upper
body and, therefore, test performance [23].
• Location of the edge of the table: in several studies, the
anterior–superior iliac spines were placed at the edge of
the table, instead of the upper edge of the iliac crests
[24,25].
Fig. 1. The original Sorensen test.
• Number of straps: two [19,26–28] to five straps [14] have
been used to hold the lower body to the table; in the Roman
chair variant (Fig. 2), the feet are fixed to the device and
no straps are needed [29–34].
• Starting position: in several studies [31,34], the test was
started with the upper body sloping downward toward the
floor so that a concentric contraction of the trunk extensor
muscles was needed initially to reach the horizontal posi-
tion.
• Hip flexion: in theory, the hips remain fully extended
throughout the Sorensen test. However, hip flexion was 6°
in a study by Holmstrom et al. [10] and 40° in a study by
Dedering et al. [29,30] (Fig. 3).
• Method for documenting the horizontal position of the
upper body: whereas many authors (including Biering-
Sorensen) simply trusted a visual evaluation [10,19,21,27,
31,34–36], others used measurement devices (inclinom-
eter [24,37,38], goniometer [18], or photoelectric cell
[10,39]) or asked the patient to maintain contact between
the back and a stadiometer or weight hanging from the
ceiling [18,40,41].
• Criteria for stopping the test: in studies that used measure-
ment devices or contact with an object to define the hori-
zontal position, specific test-stopping criteria were used,
such as trunk downsloping by more than 5–10° [24,37,42]
or loss of contact with the object for more than 10 s [43].
Fig. 2. Roman chair used to evaluate isometric endurance of the trunk exten-
sor muscles.
Fig. 3. Evaluation of the trunk extensor muscles as suggested by Dedering et
al [29].
 C. Demoulin et al. / Joint Bone Spine 73 (2006) 43–50
Table 1
Results of the Sorensen test reported in the literature
Endurance (s)
Healthy
Biering-Sorensen [9] n > 900 198 a
Holmstrom et al. [10] n = 203 171.5 a
Mannion and Dolan [35] n = 229 116 a
Hultman et al. [39] n = 148 150 a
Mannion et al. [44] n = 200
No LBP
Alaranta et al. [21] n = 475 100
Latimer et al. [24] n = 63 132.6 a
Simmonds et al. [22] n = 92 77.8 a
The position-holding times are given in seconds; n is the number of individuals in the study; and LBP means low back pain. * and ** indicate populations of
LBP patients with and without an impact of their disease on their daily activities. Different letters in superscript indicate significant differences (P < 0.05).
• Test duration: some individuals can hold the position for
longer than 240 s [9,15,46], and Jorgenssen and Nico-
laisen suggested that the test should be continued beyond
this time [46].
The populations also varied across studies, from patients
with prior low back pain [10,24] or current chronic low back
pain [20,31,39,42] to patients with no history of low back
pain [10,24,34,35] or 15-year-old students [47,48]. In addi-
tion, several studies failed to separate data from males and
females [22,24].
As expected, these numerous methodological variations
translate into considerable discrepancies in study findings
(Table 1). Biering-Sorensen [9] and Holmstrom et al. [10]
found high mean position-holding times, not only in healthy
individuals (198 and 171.5 seconds, respectively), but also in
patients with low back pain (163 and 137.5 s, respectively).
Most other studies found lower values in healthy individuals
[21,22,24,35,44].
4. Predictive validity of the Sorensen test
Biering-Sorensen [9] reported that a position-holding time
less than 176 s predicted low back pain during the next year
in males, whereas a time greater than 198 s predicted absence
of low back pain. Importantly, the test had no predictive valid-
ity in females. In a study by Luoto et al. [13], separating the
participants into three groups based on position-holding times
showed that a time less than 58 s was associated with a three-
fold increase in the risk of low back pain, as compared to a
time greater than 104 s.
Sjolie and Ljunggren et al. [49] and Adams et al. [50] found
that the Sorensen test predicted low back pain in both males
and females, whereas others found no predictive value
[51–54]. Mannion et al. [44] reported that the risk of low back
pain was independent from the position-holding time but was
correlated with muscle fatigability as measured by surface
electromyography during the test. In miners, Stewart et al.
[55] found no significant differences in position-holding time
between individuals with and without a history of low back
pain.
45
Males Females
Prior LBP LBP Healthy Prior LBP Current
LBP
176 b 163 197 210 177
166.7 a 137.5 b
142 b
136 a 85 b
141.7 a 123 a
Males and females
Prior LBP Current LBP
85 85*–99**
107.7 b 94.6 b
39.5 b
5. Discriminative validity of the Sorensen test
In many studies, the position-holding time was signifi-
cantly decreased in patients with chronic low back pain
[9,11,15,22,24,39,56,57]. This finding suggests that chronic
low back pain may be associated with decreased isometric
endurance of the trunk extensor muscles.
6. Biometric characteristics
In several studies, neither body weight [42,58] nor mass
moment of the trunk [10] influenced the position-holding time.
Other studies, however, found a negative correlation between
body weight and position-holding time [9,19,21,
27,40]. The potential influence of age and stature remains
debated [9,10,21,27]. In contrast, there is general agreement
that differences exist between males and females. With a few
exceptions [21,42,59], studies found significantly longer
position-holding times in females [9,35,40,44,60]. Similarly,
spectral analysis of electromyography signals recorded dur-
ing the test indicated greater muscle fatigability in males
[14,29,40,44,58]. Several hypotheses have been put forward
to explain this gender-related difference. In females, the
weight of the upper body is less and the center of gravity of
the trunk lowers, as compared to males [9,11]. However, the
position-holding time remained longer in females wearing
weights attached to the upper body [61] or performing iso-
metric trunk muscle endurance tests in the standing position
[11]. The greater degree of lumbar lordosis in females may
afford a mechanical advantage by lengthening the lever arm
of the spinal erector muscles [62,63]. An influence of sex hor-
mones has been suggested also [11,35]. Nevertheless, the most
compelling hypothesis involves differences in muscle com-
position. Mannion et al. [64] suggested that the spinal muscles
may show better adaptation to aerobic exercise in females as
a result of a larger proportion of slow Type I fibers in the
cross-sectional muscle area.
46 C. Demoulin et al. / Joint Bone Spine 73 (2006) 43–50
7. Reproducibility
The reproducibility of the Sorensen test has been evalu-
ated, but the studies either included small numbers of indi-
viduals [10,11,30,35,60] or used the correlation coefficient r,
which is not optimal for assessing test reproducibility
[10,21,34,36,38,57]. Investigations that relied on the intrac-
lass coefficient of correlation (ICC) usually found that repro-
ducibility was satisfactory (ICC > 0.75) [65] both in healthy
individuals and in patients with low back pain. Simmonds et
al. [22] reported that ICC values were 0.73, 0.68, and 0.99 for
within-session, session-to-session, and intraobserver repro-
ducibility, respectively, in healthy individuals; correspond-
ing values in patients with low back pain were 0.91, 0.88,
and 0.99. In a study of interobserver reproducibility, Latimer
et al. found ICC values of 0.77, 0.83, and 0.88 in individuals
with prior low back pain, no symptoms, and current low back
pain, respectively [24].
Reproducibility was poorer when a Roman chair was used
for the test. In a study of 12 healthy individuals conducted by
Mayer et al. [34], the correlation coefficient was 0.2. Keller
et al. [31] reported that the coefficient of variation was
20–21% in 31 patients with low back pain and 31 healthy
individuals.
8. Validity
Although Hansen [15] described the test as a tool for evalu-
ating back strength, studies subsequently established that it
assesses isometric muscle endurance. Furthermore, the muscle
contractions elicited by the test were found to be no greater
than 40–52% of the maximal voluntary contractile force
[10,25,35,45,66,67]. Similarly, the electromyographic activ-
ity of the spinal erector muscles rarely exceeded 40% of its
maximal value [67,68].
The Sorensen test has been misinterpreted as a specific
tool for evaluating the back muscles [13]. Published studies
demonstrate that the test assesses the endurance of all the
muscles involved in extension of the trunk, which include
not only the paraspinal muscles, most notably the multifidus
muscle [25,69], but also the hip extensor muscles. The con-
tribution of the gluteus maximus and hamstring muscles
remains controversial [42,70,71]. Sparto et al. [72] and Aro-
kosky et al. [69] stated that these muscles played a minor
role, whereas others reported a correlation between the
position-holding time and the time-course of hip extensor fati-
gability as assessed by surface electromyography, suggesting
a significant role for the hip extensor muscles [40,42].
Another challenge to the validity of the Sorensen test comes
from evidence that the position-holding time is unrelated to
the cross-sectional area of the paraspinal muscles [39,73]. An
influence of individual factors such as motivation, pain toler-
ance, and competitiveness has been suggested [66,74]. In indi-
viduals who stop the test because of pain or breathing prob-
lems [9,24,27,28,35], the result may not reflect muscle
performance. In this situation, a submaximal Sorensen test
coupled with electromyography or a Borg scale evaluation
might be sufficient for documenting muscle fatigability while
limiting the role for individual factors such as motivation
[29,35].
9. Sensitivity to change
The position-holding time has been reported to increase
significantly after active rehabilitation therapy [38,75]. A
training program involving dynamic exercises performed on
a Roman chair regularly over several weeks was followed by
a significant increase in the position-holding time [71],
although measurements obtained using a dedicated dynamom-
eter showed no increase in back extensor muscle strength
[32,71].
10. Spinal loads induced by the Sorensen test
Callaghan et al. [76] estimated that the compression load
imposed on the spine during the brief Sorensen test was
4000 N, which is slightly above the value recommended by
the National Institute of Occupational Security and Health in
1981 [77].
Pain, including spinal pain, may cause the patient to dis-
continue the test [9,24,27,28,35]. However, no persistent
adverse effects such as pain exacerbation have been reported.
Simmonds et al. [22] found high within-session reproducibil-
ity and recorded no instances of lasting pain induced by the
test. Measurements of the lumbar curvature with the trunk in
a horizontal position showed no increase in the normal lum-
bar lordosis [76]. Nevertheless, the suggestion by Tsuboi et
al. [14] that the test be performed with the trunk extended 5°
above the horizontal seems inappropriate.
11. Variants of the Sorensen test
11.1. Dynamometric measurements
Tests for evaluating isometric spinal muscle endurance
using a dynamometer have been developed [11,44,78]. Jor-
genssen et al. [11] reported that dynamometric measure-
ments obtained at a fixed percentage of the voluntary maxi-
mal force (usually 50–60%) were superior over the Sorensen
test with a 4-min maximum in several ways: the influence of
anthropometric factors was smaller, reproducibility was bet-
ter (with a correlation coefficient of 0.89 as compared to 0.82),
discriminative validity was greater, and the time needed for
the test was shorter, resulting in a smaller influence of moti-
vation. However, whereas the Sorensen test requires only sub-
maximal muscle contraction, dynamometric tests require
determination of the maximal voluntary force, which may be
inappropriate in some patients. Furthermore, pain may result
 C. Demoulin et al. / Joint Bone Spine 73 (2006) 43–50
in underestimation of the maximal voluntary force and there-
fore in spurious endurance test results.
11.2. The Ito test (Fig. 4)
Ito et al. [79] developed a test for evaluating isometric
endurance of the trunk extensor muscles. The patient lies in
the prone position with a pad under the abdomen and the arms
along the sides. When a signal is given, the individual lifts
the upper body while flexing the neck as much as possible
and contracting the gluteus maximus muscles to stabilize the
pelvis. The test consists in holding this position as long as
possible (without exceeding 5 min) while breathing nor-
mally. This simple test was described by Ito et al. as inducing
less lumbar lordosis than the Sorensen test. Shirado et al. [80]
reported that maximum neck flexion together with pelvic sta-
bilization resulted in maximum activity of the erector spinae
muscles. In a study of 190 individuals, Ito et al. [79] found
that their test discriminated between healthy controls and
patients with low back pain. Evaluation of session-to-session
reproducibility showed that the ICC was 0.97 in healthy con-
trols and 0.93 in low-back-pain patients [79].
The Ito test does not seem to induce pain and may result in
less spinal loading than the Sorensen test. Furthermore, as
the lower body is not fixed, the contribution of the hip exten-
sor muscles may be smaller [68]. Factors that limit interna-
tional recognition of the Ito test include the absence of stud-
ies, the absence of a standardized test procedure (type of pad,
extent of upper-body lifting, etc.), and the theoretical risk of
exaggerating the degree of lumbar lordosis.
11.3. McIntosh tests
Moreau et al. [81] noted that two other tests have been
described in the literature, for evaluating the isometric endur-
ance of the upper and lower spinal extensor muscles, respec-
tively. However, the only published study of these tests [82]
fails to provide information on validity, safety, and potential
use in low-back-pain patients.
11.4. Dynamic evaluations
Repetitive arch-up tests provide a dynamic evaluation of
the trunk extensor muscles without requiring the use of a dyna-
mometer [21,59,83–86]. The position is derived from the
Sorensen test. The test consists in flexing the trunk at 45°
then returning to the horizontal position as many times as
possible, at a rate of one arch-up every 2–3 s.
Moreland et al. [28] used a test in which the lower limbs
were fixed to a triangular pad and the patient was asked to
Fig. 4. The Ito test [79].
47
Fig. 5. Moreland et al.’s [28] dynamic test for evaluating the trunk extensor
muscles.
flex the trunk so as to touch the table with the nose then to
return to the horizontal position at a rate of 25 arch-ups per
minute (Fig. 5). In a study by Uderman et al. [87], the test
was done on a Roman chair and the patients asked to arch up
repeatedly over a 90° angle.
Whereas the static version of the Sorensen test has been
widely used in published studies, the dynamic variant has
received less attention. Available data suggest that results may
be similar in males and females [61] and that the discrimina-
tive validity may be decreased as compared to the static test
[21,59]. As with the static test, the occurrence of pain or
cramps may limit the validity of the test [28,83]. In addition,
the contribution of the hip extensor muscles increases gradu-
ally from one repetition to the next, further limiting the valid-
ity of the test [88,89]. Thus, in-depth studies are needed to
evaluate the usefulness and limitations of these dynamic tests.
12. Conclusions
The Sorensen test allows for a rapid, simple, and repro-
ducible evaluation of the isometric endurance of the trunk
extensor muscles. It discriminates between healthy individu-
als and patients with low back pain and may predict the occur-
rence of low back pain in the near future. Although the
Sorensen test has been extensively studied, the better perfor-
mance among females remains partly unexplained and the
contribution of the hip extensor muscles is unknown. The
absence of a single standardized test procedure is an impedi-
ment to comparative studies. The role for motivation, the fact
that pain can lead patients to stop the test, and the impossi-
bility of quantifying the relative muscle strength developed
by the individual constitute the major shortcomings of the
Sorensen test. Nevertheless, data in the literature argue in favor
of the Sorensen test for evaluating the isometric endurance of
the trunk extensor muscles. The Ito test and the dynamic vari-
ants of the Sorensen test need to be investigated further.
48 C. Demoulin et al. / Joint Bone Spine 73 (2006) 43–50
References
[1] Hillman M, Wright A, Rajaratnam G, Tennant A, Chamberlain MA.
Prevalence of low back pain in the community: implications for
service provision in Bradford, UK. J Epidemiol Community Health
1996;50:347–52.
[2] Leboeuf-Yde C, Klougart N, Lauritzen T. How common is low back
pain in the Nordic population? Data from a recent study on a middle-
aged general Danish population and four surveys previously con-
ducted in the Nordic countries. Spine 1996;21:1518–26.
[3] Papageorgiou AC, Croft PR, Ferry S, Jayson MI, Silman AJ. Estimat-
ing the prevalence of low back pain in the general population. Evi-
dence from the South Manchester Back Pain Survey. Spine 1995;20:
1889–94.
[4] Andersson GB, Svensson HO, Oden A. The intensity of work recov-
ery in low back pain. Spine 1983;8:880–4.
[5] Frank JW, Brooker AS, DeMaio SE, Kerr MS, Maetzel A, Shan-
non HS, et al. Disability resulting from occupational low back pain.
Part II: What do we know about secondary prevention? A review of the
scientific evidence on prevention after disability begins. Spine 1996;
21:2918–29.
[6] Mayer TG, Gatchel RJ, Kishino N, Keeley J, Capra PN, Mayer H,
et al. Objective assessment of spine function following industrial
injury. A prospective study with comparison group and one-year
follow-up. Spine 1985;10:482–93.
[7] Bendix AE, Bendix T, Haestrup C, Busch E. A prospective, random-
ized 5-year follow-up study of functional restoration in chronic low
back pain patients. Eur Spine J 1998;7:111–9.
[8] Van Tulder M, Malmivaara A, Esmail R, Koes B. Exercise therapy for
low back pain: a systematic review within the framework of the
Cochrane collaboration back review group. Spine 2000;25:2784–96.
[9] Biering-Sorensen F. Physical measurements as risk indicators for
low-back trouble over a one-year period. Spine 1984;9:106–19.
[10] Hölmstrom E, Moritz U, Andersson M. Trunk muscle strength and
back muscle endurance in construction workers with and without low
back disorders. Scand J Rehabil Med 1992;24:3–10.
[11] Jorgensen K. Human trunk extensor muscles physiology and ergo-
nomics. Acta Physiol Scand Suppl 1997;637:1–58.
[12] Kujala UM, Taimela S, Viljanen T, Jutila H, Viitasalo JT, Videman T,
et al. Physical loading and performance as predictors of back pain in
healthy adults. A 5-year prospective study. Eur J Appl Physiol Occup
Physiol 1996;73:452–8.
[13] Luoto S, Heliovaara M, Hurri H, Alaranta H. Static back endurance
and the risk of low-back pain. Clin Biomech (Bristol, Avon) 1995;10:
323–4.
[14] Tsuboi T, Satou T, Egawa K, Izumi Y, Miyazaki M. Spectral analysis
of electromyogram in lumbar muscles: fatigue induced endurance
contraction. Eur J Appl Physiol Occup Physiol 1994;69:361–6.
[15] Hansen JW. Postoperative management in lumbar disc protrusions. I.
Indications, method and results. II. Follow-up on a trained and an
untrained group of patients. Acta Orthop Scand 1964;17(Suppl 71):1–
47.
[16] Troup JD, Chapman AE. Changes in the waveform of the electromyo-
gram during fatiguing activity in the muscles of the spine and hips: the
analysis of postural stress. Electromyogr Clin Neurophysiol 1972;12:
347–65.
[17] Mannion AF, Dumas GA, Stevenson JM, Cooper RG. The influence of
muscle fiber size and type distribution on electromyographic mea-
sures of back muscle fatigability. Spine 1998;23:576–84.
[18] Ng JK, Richardson CA. Reliability of electromyographic power spec-
tral analysis of back muscle endurance in healthy subjects. Arch Phys
Med Rehabil 1996;77:259–64.
[19] Gibbons LE, Videman T, Battie MC. Determinants of isokinetic and
psychophysical lifting strength and static back muscle endurance: a
study of male monozygotic twins. Spine 1997;22:2983–90.
[20] Suter E, Lindsay D. Back muscle fatigability is associated with knee
extensor inhibition in subjects with low back pain. Spine 2001;26:
E361–E366.
[21] Alaranta H, Hurri H, Heliovaara M, Soukka A, Harju R. Non-
dynamometric trunk performance tests: reliability and normative data.
Scand J Rehabil Med 1994;26:211–5.
[22] Simmonds MJ, Olson SL, Jones S, Hussein T, Lee CE, Novy D, et al.
Psychometric characteristics and clinical usefulness of physical per-
formance tests in patients with low back pain. Spine 1998;23:2412–
21.
[23] Mayer JM, Graves JE, Robertson VL, Pierra EA, Verna JL, Ploutz-
Snyder LL. Electromyographic activity of the lumbar extensor
muscles: effect of angle and hand position during Roman chair exer-
cise. Arch Phys Med Rehabil 1999;80:751–5.
[24] Latimer J, Maher CG, Refshauge K, Colaco I. The reliability and
validity of the Biering-Sorensen test in asymptomatic subjects and
subjects reporting current or previous nonspecific low back pain.
Spine 1999;24:2085–90.
[25] Ng JK, Richardson CA, Jull GA. Electromyographic amplitude and
frequency changes in the iliocostalis lumborum and multifidus
muscles during a trunk holding test. Phys Ther 1997;77:954–61.
[26] Cooper RG, Stokes MJ, Sweet C, Taylor RJ, Jayson MI. Increased
central drive during fatiguing contractions of the paraspinal muscles
in patients with chronic low back pain. Spine 1993;18:610–6.
[27] Latikka P, Battie MC, Videman T, Gibbons LE. Correlations of isoki-
netic and psychophysical back lift and static back extensor endurance
tests in men. Clin Biomech (Bristol, Avon) 1995;10:325–30.
[28] Moreland J, Finch E, Stratford P, Balsor B, Gill C. Interrater reliability
of six tests of trunk muscle function and endurance. J Orthop Sports
Phys Ther 1997;26:200–8.
[29] Dedering A, Nemeth G, Harms-Ringdahl K. Correlation between
electromyographic spectral changes and subjective assessment of
lumbar muscle fatigue in subjects without pain from the lower back.
Clin Biomech (Bristol, Avon) 1999;14:103–11.
[30] Dedering A. Roos af Hjelmsater M, Elfving B, Harms-Ringdahl K,
Nemeth G. Between-days reliability of subjective and objective
assessments of back extensor muscle fatigue in subjects without
lower-back pain. J Electromyogr Kinesiol 2000;10:151–8.
[31] Keller A, Hellesnes J, Brox JI. Reliability of the isokinetic trunk
extensor test, Biering-Sorensen test, and Astrand bicycle test: assess-
ment of intraclass correlation coefficient and critical difference in
patients with chronic low back pain and healthy individuals. Spine
2001;26:771–7.
[32] Mayer JM, Udermann BE, Graves JE, Ploutz-Snyder LL. Effect of
Roman chair exercise training on the development of lumbar exten-
sion strength. J Strength Cond Res 2003;17:356–61.
[33] Mayer JM, Verna JL, Manini TM, Mooney V, Graves JE. Electromyo-
graphic activity of the trunk extensor muscles: effect of varying hip
position and lumbar posture during Roman chair exercise. Arch Phys
Med Rehabil 2002;83:1543–6.
[34] Mayer T, Gatchel R, Betancur J, Bovasso E. Trunk muscle endurance
measurement. Isometric contrasted to isokinetic testing in normal
subjects. Spine 1995;20:920–7.
[35] Mannion AF, Dolan P. Electromyographic median frequency changes
during isometric contraction of the back extensors to fatigue. Spine
1994;19:1223–9.
[36] Hyytiainen K, Salminen JJ, Suvitie T, Wickstrom G, Pentti J. Repro-
ducibility of nine tests to measure spinal mobility and trunk muscle
strength. Scand J Rehabil Med 1991;23:3–10.
[37] Chok B, Lee R, Latimer J, Tan SB. Endurance training of the trunk
extensor muscles in people with subacute low back pain. Phys Ther
1999;79:1032–42.
[38] Moffroid MT, Haugh LD, Haig AJ, Henry SM, Pope MH. Endurance
training of trunk extensor muscles. Phys Ther 1993;73:10–7.
[39] Hultman G, Nordin M, Saraste H, Ohlsen H. Body composition,
endurance, strength, cross-sectional area, and density of MM erector
spinae in men with and without low back pain. J Spinal Disord
1993;6:114–23.
 C. Demoulin et al. / Joint Bone Spine 73 (2006) 43–50
[40] Kankaanpaa M, Laaksonen D, Taimela S, Kokko SM, Airaksinen O,
Hanninen O. Age, sex, and body mass index as determinants of back
and hip extensor fatigue in the isometric Sorensen back endurance
test. Arch Phys Med Rehabil 1998;79:1069–75.
[41] Koumantakis GA, Arnall F, Cooper RG, Oldham JA. Paraspinal
muscle EMG fatigue testing with two methods in healthy volunteers.
Reliability in the context of clinical applications. Clin Biomech (Bris-
tol, Avon) 2001;16:263–6.
[42] Moffroid M, Reid S, Henry SM, Haugh LD, Ricamato A. Some
endurance measures in persons with chronic low back pain. J Orthop
Sports Phys Ther 1994;20:81–7.
[43] Rashiq S, Koller M, Haykowsky M, Jamieson K. The effect of opioid
analgesia on exercise test performance in chronic low back pain. Pain
2003;106:119–25.
[44] Mannion AF, Connolly B, Wood K, Dolan P. The use of surface EMG
power spectral analysis in the evaluation of back muscle function. J
Rehabil Res Dev 1997;34:427–39.
[45] Smidt GL, Blanpied PR. Analysis of strength tests and resistive
exercises commonly used for low-back disorders. Spine 1987;12:
1025–34.
[46] Jorgensen K, Nicolaisen T. Two methods for determining trunk exten-
sor endurance. A comparative study. Eur J Appl Physiol Occup
Physiol 1986;55:639–44.
[47] Salminen JJ, Erkintalo-Tertti MO, Paajanen HE. Magnetic resonance
imaging findings of lumbar spine in the young: correlation with
leisure time physical activity, spinal mobility, and trunk muscle
strength in 15-year-old pupils with or without low-back pain. J Spinal
Disord 1993;6:386–91.
[48] Salminen JJ, Oksanen A, Maki P, Pentti J, Kujala UM. Leisure time
physical activity in the young. Correlation with low-back pain, spinal
mobility and trunk muscle strength in 15-year-old school children. Int
J Sports Med 1993;14:406–10.
[49] Sjolie AN, Ljunggren AE. The significance of high lumbar mobility
and low lumbar strength for current and future low back pain in
adolescents. Spine 2001;26:2629–36.
[50] Adams MA, Mannion AF, Dolan P. Personal risk factors for first-time
low back pain. Spine 1999;24:2497–505.
[51] Gibbons LE, Videman T, Battie MC. Isokinetic and psychophysical
lifting strength, static back muscle endurance, and magnetic reso-
nance imaging of the paraspinal muscles as predictors of low back
pain in men. Scand J Rehabil Med 1997;29:187–91.
[52] Klaber Moffett JA, Hughes GI, Griffiths P. A longitudinal study of low
back pain in student nurses. Int J Nurs Stud 1993;30:197–12.
[53] Salminen JJ, Erkintalo M, Laine M, Pentti J. Low back pain in the
young. A prospective three-year follow-up study of subjects with and
without low back pain. Spine 1995;20:2101–7 [discussion 2108].
[54] Takala EP, Viikari-Juntura E. Do functional tests predict low back
pain? Spine 2000;25:2126–32.
[55] Stewart M, Latimer J, Jamieson M. Back extensor muscle endurance
test scores in coal miners in Australia. J Occup Rehabil 2003;13:79–
89.
[56] Novy DM, Simmonds MJ, Olson SL, Lee CE, Jones SC. Physical
performance: differences in men and women with and without low
back pain. Arch Phys Med Rehabil 1999;80:195–8.
[57] Salminen JJ, Maki P, Oksanen A, Pentti J. Spinal mobility and trunk
muscle strength in 15-year-old schoolchildren with and without low-
back pain. Spine 1992;17:405–11.
[58] Umezu Y, Kawazu T, Tajima F, Ogata H. Spectral electromyographic
fatigue analysis of back muscles in healthy adult women compared
with men. Arch Phys Med Rehabil 1998;79:536–8.
[59] Gronblad M, Hurri H, Kouri JP. Relationships between spinal mobil-
ity, physical performance tests, pain intensity and disability assess-
ments in chronic low back pain patients. Scand J Rehabil Med 1997;
29:17–24.
[60] McGill SM, Childs A, Liebenson C. Endurance times for low back
stabilization exercises: clinical targets for testing and training from a
normal database. Arch Phys Med Rehabil 1999;80:941–4.
49
[61] Clark BC, Manini TM. The DJ, Doldo NA, Ploutz-Snyder LL. Gender
differences in skeletal muscle fatigability are related to contraction
type and EMG spectral compression. J Appl Physiol 2003;94:2263–
72.
[62] Macintosh JE, Bogduk N, Pearcy MJ. The effects of flexion on the
geometry and actions of the lumbar erector spinae. Spine 1993;18:
884–93.
[63] Tveit P, Daggfeldt K, Hetland S, Thorstensson A. Erector spinae lever
arm length variations with changes in spinal curvature. Spine 1994;
19:199–204.
[64] Mannion AF, Dumas GA, Cooper RG, Espinosa FJ, Faris MW,
Stevenson JM. Muscle fibre size and type distribution in thoracic and
lumbar regions of erector spinae in healthy subjects without low back
pain: normal values and sex differences. J Anat 1997;190:505–13.
[65] Lee D, Koh D, Ong CN. Statistical evaluation of agreement between
two methods for measuring a quantitative variable. Comput Biol Med
1989;19:61–70.
[66] Moffroid MT. Endurance of trunk muscles in persons with chronic
low back pain: assessment, performance, training. J Rehabil Res Dev
1997;34:440–7.
[67] Plamondon A, Marceau C, Stainton S, Desjardins P. Toward a better
prescription of the prone back extension exercise to strengthen the
back muscles. Scand J Med Sci Sports 1999;9:226–32.
[68] Plamondon A, Serresse O, Boyd K, Ladouceur D, Desjardins P.
Estimated moments at L5/S1 level and muscular activation of back
extensors for six prone back extension exercises in healthy individu-
als. Scand J Med Sci Sports 2002;12:81–9.
[69] Arokoski JP, Kankaapaa M, Valta T, Juvonen I, Partanen J, Taimela S,
et al. Back and hip extensor muscle function during therapeutic
exercises. Arch Phys Med Rehabil 1999;80:842–50.
[70] Plamondon A, Trimble K, Larivière C, Desjardins P. Back muscle
fatigue during intermittent prone back extension exercise. Scand J
Med Sci Sports 2004;14:1–0.
[71] Verna JL, Mayer JM, Mooney V, Pierra EA, Robertson VL, Graves JE.
Back extension endurance and strength: the effect of variable-angle
roman chair exercise training. Spine 2002;27:1772–7.
[72] Sparto PJ, Parnianpour M, Reinsel TE, Simon S. Spectral and tempo-
ral responses of trunk extensor electromyography to an isometric
endurance test. Spine 1997;22:418–26.
[73] Gibbons LE, Latikka P, Videman T, Manninen H, Battie MC. The
association of trunk muscle cross-sectional area and magnetic reso-
nance image parameters with isokinetic and psychophysical lifting
strength and static back muscle endurance in men. J Spinal Disord
1997;10:398–403.
[74] Mannion AF, Dolan P, Adams MA. Psychological questionnaires: do
“abnormal” scores precede or follow first-time low back pain? Spine
1996;21:2603–11.
[75] Mannion AF, Taimela S, Muntener M, Dvorak J. Active therapy for
chronic low back pain part 1. Effects on back muscle activation,
fatigability, and strength. Spine 2001;26:897–908.
[76] Callaghan JP, Gunning JL, McGill SM. The relationship between
lumbar spine load and muscle activity during extensor exercises. Phys
Ther 1998;78:8–18.
[77] NIOSH. National Institute for Occupational Safety and Health (USA).
Guidelines for lifting. 1981.
[78] Nicolaisen T, Jorgensen K. Trunk strength, back muscle endurance
and low-back trouble. Scand J Rehabil Med 1985;17:121–7.
[79] Ito T, Shirado O, Suzuki H, Takahashi M, Kaneda K, Strax TE.
Lumbar trunk muscle endurance testing: an inexpensive alternative to
a machine for evaluation. Arch Phys Med Rehabil 1996;77:75–9.
[80] Shirado O, Ito T, Kaneda K, Strax TE. Electromyographic analysis of
four techniques for isometric trunk muscle exercises. Arch Phys Med
Rehabil 1995;76:225–9.
[81] Moreau CE, Green BN, Johnson CD, Moreau SR. Isometric back
extension endurance tests: a review of the literature. J Manipulative
Physiol Ther 2001;24:110–22.
50 C. Demoulin et al. / Joint Bone Spine 73 (2006) 43–50
[82] McIntosh G, Wilson L, Affieck M, Hall H. Trunk and lower extremity
muscle endurance: normative data for adults. J Rehabil Outcome
Meas 1998;2:20–39.
[83] Kuukkanen T, Malkia E. Muscular performance after a 3 month
progressive physical exercise program and 9 month follow-up in
subjects with low back pain. A controlled study. Scand J Med Sci
Sports 1996;6:112–21.
[84] Leino P, Aro S, Hasan J. Trunk muscle function and low back
disorders: a ten-year follow-up study. J Chronic Dis 1987;40:289–96.
[85] Rissanen A, Alaranta H, Sainio P, Harkonen H. Isokinetic and non-
dynamometric tests in low back pain patients related to pain and
disability index. Spine 1994;19:1963–7.
[86] Rissanen A, Heliovaara M, Alaranta H, Taimela S, Malkia E, Knekt P,
et al. Does good trunk extensor performance protect against back-
related work disability? J Rehabil Med 2002;34:62–6.
[87] Udermann BE, Mayer JM, Graves JE, Murray SR. Quantitative
assessment of lumbar paraspinal muscle endurance. J Athl Train
2003;38:259–62.
[88] Clark BC, Manini TM, Mayer JM, Ploutz-Snyder LL, Graves JE.
Electromyographic activity of the lumbar and hip extensors during
dynamic trunk extension exercise. Arch Phys Med Rehabil 2002;83:
1547–52.
[89] Clark BC, Manini TM, Ploutz-Snyder LL. Derecruitment of the lum-
bar musculature with fatiguing trunk extension exercise. Spine
2003;28:282–7.