Core Stability Exercise Principles. 인체 모든 힘의 근원, 중심 core. 정리중

[문형철]

정말 중요한 힘의 근원은 코어다. core strengthening

요거 정확히 이해하고 시행할 수 있어야 함. 

Basic exercises - isolate core muscles in different positions

& Transversus abdominus (advance if able to perform 30 reps with 8 s hold)

) Abdominal bracing

) Bracing with heel slides

) Bracing with leg lifts

) Bracing with bridging

) Bracing in standing

) Bracing with standing row

) Bracing with walking

& Paraspinals/multifidi (advance if able to perform 30 reps with 8 s hold)

) Quadruped arm lifts with bracing

) Quadruped leg lifts with bracing

) Quadruped alternate arm and legs lifts with bracing

& Quadratus lumborum and obliques (advance if able to perform 30 reps with 8 s hold)

) Side plank with knees flexed

) Side plank with knees extended

& Trunk curl

Facilitation techniques if necessary (pelvic floor contraction, visualization, palpation, identifying substitution patterns like pelvic tilt, ultrasound)

Progression

& Physioball

& Functional training positions with activation of core

& Build endurance

INTRODUCTION

Core stability (or core strengthening) has become a wellknown fitness trend that has started to transcend into the

sports medicine world. Popular fitness programs, such as Pilates, yoga, and Tai Chi, follow core strengthening

principles. Broad benefits of core stabilization have been touted, from improving athletic performance and preventing

injuries, to alleviating low back pain. 

- 코어 강화운동은 최고의 운동으로 평가되고 있음. 필라테스, 요가, 기공 등은 코어강화운동 원리를 따름.

- 코어 강화운동은 요통의 치료를 위해 손상 방지, 운동선수 수행능력증진으로 최고의 방법으로 인기를 끌고 있음.  

The purpose of this article is to review the available evidence on the benefits of core strengthening, present relevant anatomy, and outline core stabilizing exercise principles. The core can be described as a muscular box with the

abdominals in the front, paraspinals and gluteals in the back, the diaphragm as the roof, and the pelvic floor and hip girdle

musculature as the bottom 

- 이 논문의 목적은 코어강화운동의 이점에 대해서 검증된 증거를 제공하고 코어강화운동의 원리를 설명함. 

- 코어 강화운동은 muscular box로 묘사됨. 전면에서 abdominalis 근육, 등에서 척추기립근, 둔근, 천정에서 횡경막근육, 골반에서 골반저근육 등으로 이루어짐.

Within this box are 29 pairs of muscles that help to stabilize the spine, pelvis, and kinetic chain during functional movements. Without these muscles, the spine would become mechanically unstable with compressive forces as little as 90 N, a load much less than the weight of the upper body 

- 인체가 기능적 움직임을 하는 동안 코어의 muscular box내에 29개의 쌍으로된 근육으 척추, 골반, kinetic chain의 안정화에 도움을 줌. 이러한 근육의 기능없으면 척추는 90N도 안되는 압축력(Compressive force)를 견디지 못하고 불안정해짐. 

When the system works as it should, the result is proper force distribution and maximum force generation with minimal compressive, translational, or shearing forces at the joints of the kinetic chain 

- 이러한 코어 시스템이 작동할때, 적절한 힘의 분산과 최소의 압축력, 전단력이 주어지면서 최대힘을 생산할 수 있음. 

The core is particularly important in sports because it provides ‘‘proximal stability for distal mobility’’ 

- 코어 강화운동은 distal mobility를 위한 체간 안정성(proximal stability)을 제공하기 때문에 특히 스포츠선수에게 중요한 역할을 함 

Ipso facto, core stability exercises appear to be especially important in cases of spinal instability. Gross spinal instability is an obvious radiographic displacement of vertebrae, often with associated neurologic deficit and deformity.

However, functional or clinical instability is not as easily defined. Panjabi describes ‘‘clinical instability as the loss of

the spine’s ability to maintain its patterns of displacement under physiologic loads so there is no initial or additional

neurologic deficit, no major deformity, and no incapacitating pain’’ 

- 코어 강화운동은 척추안정성에 중요한 역할을 함. gross spinal 불안정성은 때때로 허리디스크에 의한 신경학적 결손과 deformity와 연관된 척추의 영상의학적 displacement로 나타남. 

- 하지만 기능적, 임상적 불안정성은 쉽게 정의되지 않음. 판자비는 clinical instability를 the loss of the spine’s ability to maintain its patterns of displacement under physiologic loads so there is no initial or additional neurologic deficit, no major deformity, and no incapacitating pain라고 묘사함. 

The spine stability system consists of the following interacting elements:

& Neuromuscular control (neural elements)

& Passive subsystem (osseous and ligamentous elements)

& Active subsystem (muscular elements)

- 척추안정성은 3가지 요소로 구성되어 있음

In other words, stability of the spine is not only dependent on muscular strength, but also proper sensory input that

alerts the central nervous system about interaction between the body and the environment, providing constant feedback

and allowing refinement of movement. 

- 척추의 안정성은 muscular strength에 의존할 뿐 아니라 적절한 sensory input이 작용하여 중추신경계의 작용을 변경시켜 움직임의 강화를 제공하고 지속적인 피드백을 제공하는 것. 

Thus a complete core stabilizing program would consider sensory and motor components related to these systems for optimal spinal stabilization. 

Recently, the Queensland physiotherapy group produced research drawing a great deal of attention to the deep core musculature, specifically the transversus abdominis and multifidi, for core stability.  However, McGill and other biomechanists emphasize larger ‘‘prime mover’’ muscles, such as the abdominal obliques and quadratus lumborum, in providing stability. It appears a coordinated contraction of all deep and superficial core muscles is needed for optimal spinal stabilization.

- Queensland physiotherapy group은 deep core musculacture에 주의를 둠. 특히 코어 강화를 위한 복횡근, 다열근

- 하지만 맥길과 다른 생체역학 연구자들은 큰 prime mover 근육을 강조함. 특히 코아 강화를 위해 내외복사근, 요방형근

- deep and superficial 근육을 cocontraction을 강화하는 적절한 척추안정화가 필요함. 

ANATOMY

The core acts through the thoracolumbar fascia, ‘‘nature’s back belt.’’ The transversus abdominis has large attachments to the middle and posterior layers of the thoracolumbar fascia(9). Additionally, the deep lamina of the posterior layer attaches to the lumbarspinous processes. In essence, the thoracolumbar fascia serves as part of a ‘‘hoop’’ around the trunk (7) that provides a connection between the lower limb and the upper limb (10). With contraction of the muscular contents, the thoracolumbar fascia also functions as a proprioceptor, providing feedback about trunk positioning. 

- 코어는 nature's back belt은 흉요근막을 통해 작용. 

- 복횡근은 흉요근막의 mid, post layer에 크게 부착됨. 흉요근막은 trunk의 덮게의 부분으로 작용하여 상하지의 연결을 제공. 

- 근육의 수축과 함께 흉요근막은 trunk positioning과 관련된 피드백기능을 제공하고, 고유수용감각기로 작용함.

Two types of muscle fibers comprise the core muscles: slow-twitch and fast-twitch. Slow-twitch fibers make up primarily the local muscle system (the deep muscle layer). These muscles are shorter in length and are suited for controlling inter-segmental motion and responding to changes in posture and extrinsic loads. Key local muscles include transversus abdominus, multifidi, internal oblique, deep transversospinalis, and the pelvic floor muscles. Multifidi have been found to atrophy in people with chronic low back pain (LBP) (11). 

근육은 slow-twitch and fast-twitch 두 가지 type로 구분. 

- slow-twitch fiber(지근섬유)은 deep muscle 층인 local muscle system으로 작용. 이 근육은 주로 짧아지고, intersegmental motion을 조절하는데 적합하고, extrinsic load와 자세를 변화시키는데 주요 반응을 함. 

- 복횡근, 다열근, 내복사근, deep transversospinalis, 골반저 근육이 key muscle임. 만성요통 환자에게서 다열근은 흔하게 위축되는 것이 발견됨. 

On the other hand, fast-twitch fibers comprise the global muscle system (the superficial muscle layer). These muscles are long and possess large lever arms, allowing them to produce large amounts of torque and gross movements. Key global muscles include erector spinae, external oblique, rectus abdominis muscles, and quadratus lumborum (which McGill states is a major stabilizer of the spine) (12).

- 반면에 fast-twitch fiber(속근섬유)는 superficial muscle층인 global muscle system으로 작용. 이 근육은 길고(long), large lever arm을 가지고 있어 gross movement와 torque의 많은 양을 생산하는데 도움을 주는 역할. 

- 척추기립근, 외복사근, 복직근, 요방형근이 key muscle임. 

The abdominals serve as a particularly vital component of the core. The transversus abdominis has received attention

for its stabilizing effects. It has fibers that run horizontally (except for the most inferior fibers, which run parallel to the

internal oblique muscle), creating a belt around the abdomen. 

- 복부근육은 core의 가장 핵심적인 역할. 복횡근은 안정화 효과를 위한 핵심역할. 복횡근은 수평으로 주행(inferior fiber를 제외)하고, 내복사근과 수평으로 주행하면서 abdomen주위의 belt를 만들어냄. 

‘‘Hollowing in’’ of the abdomen creates isolated activation of the transversus abdominis. The transversus abdominis and multifidi have been shown to contract 30 ms before movement of the shoulder and 110 ms before movement of the leg in healthy people, theoretically to stabilize the lumbar spine (13,14). However, patients with LBP have delayed contraction of the transversus abdominis and multifidi prior to limb movement (14). 

- 복부의 hollowing in은 복횡근을 독립적으로 활성화시킴. 

- 유튜브 동영상 http://www.youtube.com/watch?v=qPksfqVwAKo

- 건강한 사람에게서 복횡근과 다열근은 어깨의 움직임 30 millisecond(1/1000초)전에 수축을 보이고, 하지의 움직임 110 millisecond전에 수축을 보임. 하지만 요통환자는 복횡근과 다열근의 수축이 지연됨. 

The internal oblique and the transversus abdominis work together to increase the intra-abdominal pressure from the hoop created via the thoracolumbar fascia. Increased intra-abdominal pressure has been shown to impart stiffness to the spine

(7). The external oblique, the largest and most superficial abdominal muscle, acts as a check of anterior pelvic tilt. The

abdominals (and multifidi) need to engage only to 5%~10% of their maximal volitional contraction to stiffen spine segments (15). 

- 내복사근과 복횡근은 흉요근막을 통해 복부내압을 증가시키는데 함께 작용함. 복부내압의 증가는 척추의 안정성을 강화하는데 중요한 역할. 외복사근과 superficial abdominal muscle는 골반의 전방경사을 하게 하는 방향으로 역할. 

- 척추 분절의 강화를 위해서는 maximal volitional contraction의 5-10%가 필요함. 

The hip musculature is vital to all ambulatory activities, and plays a key role in stabilizing the trunk and pelvis in gait(16). Poor endurance and delayed firing of the hip extensor (gluteus maximus) and abductor (gluteus medius) muscles

have previously been noted in people with LBP and other musculoskeletal conditions such as ankle sprains (17).

- 골반근육은 이동하는데 중요한 역할을 하고, 보행시 골반과 trunk 안정화에 중요한 역할

- hip extensor(대둔근)과 외전근(중둔근)의 지연된 firing과 poor endurance는 발목염좌와 요통을 앓는 사람들에게 사전에 나타남. 

The psoas is only a feeble flexor of the lumbar spine (9). However, it does have the potential to exert massive compressive forces on the lumbar disks. In activities that promote maximal psoas contraction, such as full sit-ups, it can exert a compressive load on the L5-S1 disk equal to 100 kg of weight (9). Tightness of the hip flexor (psoas) can cause LBP by increasing compressive loads to the lumbar disks.

- psoas muscle 요근은 요추의 아주 약한 굴곡근 역할을 함. 하지만 lumbar disc에 가해지는 압축력을 엄청나게 높일 수 있는 잠재력을 가지고 있음. full sit-up과 같은 동작은 maximal psoas contraction을 촉진시켜 L5-S1 추간판에 100kg에 육박하는 압축력을 만들어낼 수 있음. 요근의 tightness는 요추간판에 압축력을 증가시킴으로서 요통을 야기할 수 있음. 

The diaphragm serves as the roof of the ‘‘muscular box’’ of the core, and the pelvic floor serves as the floor. Contraction

of the diaphragm increases intra-abdominal pressure, thus adding to spinal stability. Pelvic floor musculature is

coactivated with transversus abdominis contraction (18). Recent studies (19) have indicated that people with sacroiliac pain have impaired recruitment of the diaphragm and pelvic floor. Thus diaphragmatic breathing techniques and pelvic floor activation may be an important part of a core-strengthening program.

- 횡격막 근육은 muscular box의 천정(roof)로서의 역할을 하고, 골반저 근육은 바닥 역할. 

- 횡격막 근육의 수축은 복부내압을 증가시켜, 척추안정성에 도움. 골반저 근육은 복횡근과 동시수축함. 

- 최신연구는 sacroiliac pain을 가진 환자는 횡경막 근육과 골반저 근육 동원의 기능이 떨어져 있다고 보고함. 

- 그래서  diaphragmatic breathing techniques and pelvic floor activation은 코어강화운동에 중요한 역할을 하는 프로그램. 

MEASURING CORE STABILITY

Research on core stability exercises has been hampered by a lack of consensus on how to measure core strength. If core instability and core weakness can be measured, outcomes can be followed and a proper emphasis can be placed upon core strengthening in certain individuals. Delitto and others have proposed that stabilization exercises would work best in individuals who are young, with increased flexibility (postpartum, generalized ligamentous laxity), or with exam

findings suggesting an interspinal segment with increased painful movement (20,21). 

- 코어 안정화운동에 대한 연구는 core strength 측정도구의 부족으로 공격받음. 코어 불안정과 코어 약화가 측정될 수 있다면 각 개인에게 코어 강화운동을 시킬 수 있음. 그래서 델리토는 stabilization exercise를 제안.....

The prone instability test is an example of a physical exam maneuver testing for clinical instability (22) (Fig. 1). Measures can include triplanar, weight-bearing eval‎uation of the global core as well as isolated measures of particular muscles (4) (Fig. 2 Table 1).

table1. measuring core stability

1. Prone instability test

2. Prone extension endurance test (Biering-Sorenson paraspinal endurance strength)

3. Side bridge endurance test (quadratus lumborum endurance strength)

4. Pelvic bridging

5. Leg lowering test (lower abdominal strength)

6. Trunk curl

7. Hip external rotation strength

8. Modified Trendelenburg test (single leg squat with observation infrontal plane)

9. Single leg squat in sagittal plane

10. Single leg squat in transverse plane

DEVELOPING A CORE EXERCISE PROGRAM

Exercise of the core musculature is more than trunk strengthening. Lack of sufficient coordination in core musculature can lead to decreased efficiency of movement and compensatory patterns, causing strain and overuse injuries. Thus motor relearning of inhibited muscles may be more important than strengthening in patients with LBP and other musculoskeletal injuries.

- 코어 근육의 적절한 협응수축력의 부족은 움직임의 효율을 감소시키고, 보상성 움직임을 야기하고, strain and overuse 손상을 야기함. inhibited muscle의 motor relearning은 요통환자, 다른 근골격계환자에게 근력강화보다 더 중요할 수 있음. 

A core exercise program should be done in stages with gradual progression. It should start with restoration of normal

muscle length and mobility to correct any existing muscle imbalances. Adequate muscle length and flexibility are

necessary for proper joint function and efficiency of movement. Muscle imbalances can occur where agonist muscles

become dominant and short while antagonists would become inhibited and weak. 

- 코어 운동프로그램은 단계적으로 진행되어야 함. 운동의 출발은 normal muscle length와 mobility의 회복과 함께 시작되어야 muscle imbalance를 바로 잡을 수 있음. 

- Adequate muscle length and flexibility 적절한 근육길이와 신축성은 움직임의 효율과 적절한 관절기능을 위해 꼭 필요함. 

- muscle imbalance는 주동근이 dominant and short되고, 길항근은 inhibited되면서 약화됨으로써 나타남. 

One example of a muscle imbalance pattern includes tightness and over-activity of the primary hip flexor (iliopsoas), which in turn causes reciprocal inhibition of the primary hip extensor (gluteus maximus). Further up the kinetic chain, this particular muscle imbalance leads to increased lumbar extension, with excessive force on the posterior elements of the spine. In addition, postural muscles have a tendency to become tight due to constant activity in order to fight the forces of gravity. Then, activation of the deep core musculature should be taught through lumbo-pelvic stability exercises. When this has been mastered, more advanced lumbo-pelvic stability exercises on the physioball can be added. Finally, there should be transitioning to the standing position, facilitating functional movement exercises that promote balance and coordination of precise movement. The goal of advanced core stabilization is to train functional movements rather than individual muscles (3).

muscle imbalance pattern의 사례 한가지

- hip flexor(iliopsoas)의 과사용과 tightness. 그 결과 primary hip extensor(gluteus maximus)의 reciprocal inhibition을 초래

- 더 나아가 kinetic chain에서 muscle imbalance는 요추 전만을 증가시키고, 척추의 후관절부위에 과도한 부하가 걸리게 함. 게다가 postural muscle은 중력과 싸우느라 constant activity되면서 tight되는 경향을 가지고 있음. 

- 그래서 deep core musculature의 활성화는 lumbo-pelvic stability exercis동안 가르쳐져야 함. 그것이 익숙해질때, 진보된 안정화 운동프로그램으로 나아감. 

BEGINNING A CORE STRENGTHENING PROGRAM

Warm-up can include the ‘‘cat’’ and ‘‘camel’’ stretches and a short aerobic program. A core stability exercise program

begins with recognition of the neutral spine position (midrange between lumbar flexion and extension), touted to be

the position of power and balance for optimal athletic performance in many sports (8).

- warm up은 고양이 낙타 스트레치 기법과 간단한 유산소 프로그램으로

- 고양이 낙타 스트레치 방법 .. 유튜브 동영상 http://www.youtube.com/watch?v=CXRsjICsGnc

The first stage of core stability training begins with learning to activate the abdominal wall musculature. Individuals

who are not adept at volitionally activating motor pathways or individuals with chronic low back pain and fear-avoidance

behavior may require extra time(?) and instruction to learn to recruit muscles in isolation or with motor patterns (23).

- 코어강화 운동의 첫번째 단계는 abdominal wall 근육구조를 활성화시키는 방법을 배우는 것부터 시작. 

- 의지적으로 motor pathway 활성화를 못하거나 만성요통을 가지고 두려움-회피 행동을 보이는 개인은 extra time(?)이 필요할 수있고, motor patters 또는 isolation으로 근육을 동원하는 방법을 배우는 것을 가르쳐야 함. 

Cueing individuals on abdominal hollowing, which may activate the transversus abdominis, as well as abdominal 

bracing, which activates many muscles including the transversus abdomin is, external obliques, and internal obliques, is

an important beginning step. One study showed that performing abdominal hollowing and bracing prior to performing abdominal curls facilitated activation of the transversus abdominis and internal obliques throughout the abdominal curling activity (22,24).

- http://www.youtube.com/watch?v=qPksfqVwAKo

- http://www.youtube.com/watch?v=SZPMhtcdyDM 

- abdominal hollowing은 복횡근을 활성화 시킬 수 있고, abdominal bracing은 내외복사근, 복횡근 등 많은 근육을 활성화. 

- one study에서 abdominal hollowing and bracing을 시행하기 전에 abdominal curl을 시행하여 복횡근과 내복사근 활성을 촉진시키는 방법을 제시. 

Grenier and McGill, however, found little utility of the abdominal hollowing to cue the transversus abdominis into

improving core stability and place more emphasis on abdominal bracing (25).

- 그러나 Grenier and McGill은 abdominal hollowing의 적은 사용이 코어 안정성 강화를 통해 복횡근 활성화의 신호가 된다고 하였고, abdominal bracing의 강조가 좀더 중요하다고 ...

PROGRESSING A CORE STRENGTHENING PROGRAM

Once these activation techniques are mastered and the transversus abdominisis ‘‘awakened,’’ training should be progressed. The beginner can then incorporate the ‘‘big 3’’ exercises as described by McGill. These include the curl-up, side bridge (side plank), and quadruped position with alternate arm/leg raises (‘‘bird dog’’). The prone plank and bridging also can be added at this stage (3). Pelvic bridging is particularly effective for activating the lumbar paraspinals(26).

- 이러한 근육활성화 테크닉이 완성되면 복횡근 awakened training이 프로그램 되어야 함. 초보자는 맥길의 big 3로 시작할 수 있음. 맥길의 big3는 curl-up, side bridge (side plank), and quadruped position with alternate arm/leg raises (‘‘bird dog’’)

Initial exercises are done in supine, hook-lying, or quadruped positions. It should be reiterated that the pelvis should not be tilted and the spine should not be flattened, but should maintain a neutral posture. Normal rhythmic diaphragmatic breathing also is emphasized. Once good control is demonstrated with the static core exercises, the individual can advance to exercises using a physioball. 

- 초기 운동자세는 앙와로 무릎을 구부린 자세나 네발자세로 시작함. 

- pelvis는 tilt되지 말아야하고, 척추는 flattened되지 않아야 하고, 어깨는 neutral posture를 유지해야 한다고 반복해서 인지시켜야 함. 

- Normal rhythmic diaphragmatic breathing이 강조되어야 함. 

- 바닥에 누운 정적인 코어운동이 잘 조절되면, 짐볼을 사용하여 advance할 수 있음. 

Notably, non-weight-bearing core exercises, such as ones performed on a physioball, may not translate to improved

athletic performance (27). Thus, athletes should quickly advance to more functional exercises in sitting, standing, and

walking positions.

- 명백하게 체중부하가 없는 코어운동(짐볼에서 시행하는) 운동선수 수행능력의 증진으로 진행할 수는 없음. 그래서 운동선수는 빠르게 sitting, standing, and walking positions에서 기능적 운동으로 진행해야 함. 

ADVANCED CORE STRENGTHENING: CHALLENGING BALANCE AND MOTOR CONTOL

As progression is made through the initial stages of a core strengthening program, emphasis should be placed on

developing balance and coordination while performing a variety of movement patterns in the three cardinal planes of

movement: sagittal, frontal, and transverse. Exercises should be performed in a standing position and should mirror

functional movements. Functional training typically requires acceleration, deceleration, and dynamic stabilization. An

advanced core stabilizing program should train reflexive control and postural regulation (3).

- 초기 코어강화운동으로부터 시작하여 운동이 진보해감에 따라 balance, coordination으로 진행되어야 

- An advanced core stabilizing program should train reflexive control and postural regulation.

Various unstable surfaces can be used to further challenge balance and coordination and assist with training movement patterns. These include the balance board (a whole sphere underneath the board, which creates multiplanar instability), the rocker board (a curved surface underneath the board, which allows single-plane motion), the Bosu Balance Trainer, and the Dyna Disk (the latter two, both of which are air-filled plastic discs, can be used interchangeably) (3).

- unstable surface는 movement pattern 트레이닝을 도와 평형성과 협응성을 좀더 증진시키기 위해 사용될 수 있음. 

The abdominal bracing technique should be initiated before performing any of the standing exercises. Initial gait training is important, emphasizing control of heel strike in the supinated position on the lateral edge of the foot, moving to pronation onto the medial foot with flexion of the first metatarsal head and toes. From there, exercises can be progressed to a controlled falling lunge onto an unstable surface, emphasizing control and spinal alignment. Multidirectional lunges can be done on the floor in multiple planes of movement. Progress can be made to jumps on one or two legs, which stimulates cerebellar activity and helps create automatic postural control (3). An example of an evidencebased core stability program is provided in Table 2 (28,29).

- abdominal bracing 테크닉은 선자세 운동이 시행되기 전 초기에 시행되어야 함. 

- 초기 걷기 트레이닝은 중요함. 

- emphasizing control of heel strike in the supinated position on the lateral edge of the foot, moving to pronation onto the medial foot with flexion of the first metatarsal head and toes

- 다방면의 런지가 시행될 수 있음.

Basic exercises - isolate core muscles in different positions

& Transversus abdominus (advance if able to perform 30 reps with 8 s hold)

) Abdominal bracing

) Bracing with heel slides

) Bracing with leg lifts

) Bracing with bridging

) Bracing in standing

) Bracing with standing row

) Bracing with walking

& Paraspinals/multifidi (advance if able to perform 30 reps with 8 s hold)

) Quadruped arm lifts with bracing

) Quadruped leg lifts with bracing

) Quadruped alternate arm and legs lifts with bracing

& Quadratus lumborum and obliques (advance if able to perform 30 reps with 8 s hold)

) Side plank with knees flexed

) Side plank with knees extended

& Trunk curl

Facilitation techniques if necessary (pelvic floor contraction, visualization, palpation, identifying substitution patterns like pelvic tilt, ultrasound)

Progression

& Physioball

& Functional training positions with activation of core

& Build endurance

Compliance with home exercise

CREATING MORE HARM THAN GOOD: PRACTICES TO AVOID

Some traditional progressive resistance strengthening of the core muscles may be unsafe to the back. Specifically,

heavy resistance training of the lumbar extensors is not recommended. Roman chair exercises or back extensor

strengthening machines require at least torso mass for resistance, which is a load that is often injurious to the

lumbar spine (8). 

Traditional sit-ups also may be unsafe because they create excessive compressive forces in the lumbar spine (9,30). Caution should be used with full spinal flexion or repetitive torsion, as risk of lumbar injury is greatest with these positions (31). In addition, spinal exercise should not be done in the first hour after rising in the morning. This is due to the fact that hydrostatic pressure in the disk is increased during that time (32).

WHO SHOULD HAVE CORE STABILITY PRESCRIBED?

Certain predictors can be used to determine which patients will be more likely to benefit from lumbar stabilization

programs. One study (28) found the following factors could be used to assess which patients would be likely to

respond favorably to core stabilization:

& Younger age (40세 이하)

& Greater general flexibility (hamstring length greater than 90도, postpartum)

& Positive prone instability test

& Presence of aberrant movement during spinal range of motion (painful arc of motion, abnormal lumbopelvic

rhythm, and using arms on thighs for support) 

Stuge et al. also proposed the following physical maneuvers as predicting a good response from stabilization exercise in postpartum women (33):

& Positive posterior pelvic pain provocation (P4) test (also called thigh thrust test)

& Positive active straight leg raise

& Positive pain provocation (persists greater than 5 s after palpation) with palpation of PSIS region (long dorsal

sacroiliac ligament)

& Positive pain provocation (persists greater than 5 s after palpation) with palpation of pubic symphysis

& Positive Trendelenburg sign

EFFICACY OF CORE-STRENGTHENING EXERCISE FOR TREATMENT OF BACK PAIN

There is ample evidence that individuals with chronic LBP and sacroiliac pain lack proper recruitment of core

muscles and exhibit core weakness (6,11,14,26,34,35). There also is evidence of increased fatigability, decreased cross

section, and fatty infiltration of paraspinal muscles in patients with chronic LBP (6). Even high-level athletes show signs of core instability, and this may set them up for more musculoskeletal injuries (4,36Y39). Female athletes may be particularly susceptible to injury to the anterior cruciate ligament if core weakness is found (36Y38). In addition, these patients seem to have increased difficulty with balance and decreased ability to compensate for unexpected trunk perturbation. Patients with back pain also seem to over-activate superficial global muscles whereas control and activation of the deep spinal muscles is impaired.

Thus core stability exercises have strong theoretical basis for prevention of different musculoskeletal conditions and the

treatment of spinal disorders. Level 1 evidence for stabilization exercises is mixed and mainly comes from studies on LBP. To our knowledge, there have been five randomized trials that have supported stabilization exercises for LBP (33,40Y43). However, there are some methodological flaws in some of these studies, including lack of true controls, significant attrition rate, and statistical vagaries (21,44). Two other randomized trials further question the superiority of stabilization exercises (29,45). The control groups in both of these studies included generalized strengthening components in addition to other features (21). Systemic reviews also have come to the conclusion that stabilization is helpful for spinal disorders but may not be superior to other therapeutic exercise regimens (46Y48).

CORE STRENGTHENING AND INJURY PREVENTION

Some evidence in the literature supports the notion that core stabilization programs may be used to help prevent

injury in athletics. Leeton and colleagues (36) performed a prospective study looking at 140 male and female intercollegiate basketball and track athletes. They found that injured athletes [injuries included anterior cruciate ligament (ACL) rupture, iliotibial band syndrome, patellofemoral pain, and stress fracture in the lower extremity] had significantly

decreased strength in hip abduction and external rotation compared with non-injured athletes. Hip external rotation strength was most useful in predicting injury (36).

Some literature supports using neuromuscular training to prevent ACL injuries in athletes. These programs include

muscle co-contraction to provide joint stability, balance and perturbation training, and plyometric exercises. Hewitt and

colleagues conducted a prospective study comparing injuries in female high school athletes with preseason neuromuscular training, including single-leg functional core stability training, with a control group of female and male athletes without preseason neuromuscular training (37). Non-contact ACL injury risk was significantly less in the group of female athletes with neuromuscular training. In a similar study, Heidt and colleagues found that preseason neuromuscular

training in female high school soccer players led to significantly fewer injuries overall, but no difference in ACL injuries between groups (39). 

Specific core stability programs in prevention of athletic injuries have not been well studied. Additionally, core programs have not been proven to enhance athletic performance. Despite these facts, many of these programs have been promoted in lay literature for use in performance enhancement.

CONCLUSIONS

Core strengthening has a strong theoretical basis in treatment and prevention of LBP, as well as other musculoskeletal

afflictions, as is evidenced by its widespread clinical use. Studies have shown that these programs may help decrease pain and improve function in patients with LBP. However studies are limited, and some show conflicting results. Future studies are needed to elucidate precise core strengthening programs and their effects on treatment and prevention of LBP, in comparison with other exercise training programs.

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