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核心力量

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核心力量 FOCUSED REVIEW C Ve AB Ar tio mo is, aro spi res tiv enh eta ava fra cor Re Re C bil ess aro “co fro roo bo it s the the the the me cor reh and wi pre atu thr stif tac ins Gr tra han the res stif tra we eff up Th bec nal sea glo fun the Ge ord Al few tif...
核心力量
FOCUSED REVIEW C Ve AB Ar tio mo is, aro spi res tiv enh eta ava fra cor Re Re C bil ess aro “co fro roo bo it s the the the the me cor reh and wi pre atu thr stif tac ins Gr tra han the res stif tra we eff up Th bec nal sea glo fun the Ge ord Al few tifi per pu tiv of sho vie Os oss str me ped in art cau car exc po pla tia po the a v pas sta to me F CO of M N supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the authors is/are associated. R PO 0 d S86 Arc Thoracolumbar Fascia The thoracolumbar fascia acts as “nature’s back belt.” It works as a retinacular strap of the muscles of the lumbar spine. eprint requests to Venu Akuthota, MD, Univ of Colorado Health Science Center, Box 6508, Mail Stop F493, Aurora, CO 80045, e-mail: venu.akuthota@uchsc.edu. 003-9993/04/8503-8950$30.00/0 oi:10.1053/j.apmr.2003.12.005 h Phys Med Rehabil Vol 85, Suppl 1, March 2004 ore Strengthening nu Akuthota, MD, Scott F. Nadler, DO STRACT. Akuthota V, Nadler SF. Core strengthening. ch Phys Med Rehabil 2004;85(3 Suppl 1):S86-92. Core strengthening has become a major trend in rehabilita- n. The term has been used to connote lumbar stabilization, tor control training, and other regimens. Core strengthening in essence, a description of the muscular control required und the lumbar spine to maintain functional stability. De- te its widespread use, core strengthening has had meager earch. Core strengthening has been promoted as a preven- e regimen, as a form of rehabilitation, and as a performance- ancing program for various lumbar spine and musculoskel- l injuries. The intent of this review is to describe the ilable literature on core strengthening using a theoretical mework. Overall Article Objective: To understand the concept of e strengthening. Key Words: Athletic injuries; Exercise; Low back pain; habilitation. © 2004 by the American Academy of Physical Medicine and habilitation ORE STRENGTHENING HAS BEEN rediscovered in rehabilitation. The term has come to connote lumbar sta- ization and other therapeutic exercise regimens (table 1). In ence, all terms describe the muscular control required und the lumbar spine to maintain functional stability. The re” has been described as a box with the abdominals in the nt, paraspinals and gluteals in the back, the diaphragm as the f, and the pelvic floor and hip girdle musculature as the ttom.1 Particular attention has been paid to the core because erves as a muscular corset that works as a unit to stabilize body and spine, with and without limb movement. In short, core serves as the center of the functional kinetic chain. In alternative medicine world, the core has been referred to as “powerhouse,” the foundation or engine of all limb move- nt. A comprehensive strengthening or facilitation of these e muscles has been advocated as a way to prevent and abilitate various lumbar spine and musculoskeletal disorders as a way to enhance athletic performance. Despite its despread use, research in core strengthening is meager. The sent review was undertaken to describe the available liter- re using a theoretical framework. Stability of the lumbar spine requires both passive stiffness, ough the osseous and ligamentous structures, and active fness, through muscles. A bare spine, without muscles at- hed, is unable to bear much of a compressive load.2,3 Spinal tability occurs when either of these components is disturbed. rom the Department of Rehabilitation Medicine, University of Colorado, Denver, (Akuthota); and Department of Physical Medicine and Rehabilitation, University edicine and Dentistry of New Jersey, Newark, NJ (Nadler). o commercial party having a direct financial interest in the results of the research oss instability is true displacement of vertebrae, such as with umatic disruption of 2 of 3 vertebral columns. On the other d, functional instability is defined as a relative increase in range of the neutral zone (the range in which internal istance from active muscular control is minimal).4 Active fness or stability can be achieved through muscular cocon- ction, akin to tightening the guy wires of a tent to unload ight on the center pole (fig 1).5 Also described as the “serape ect,”6 cocontraction further connects the stability of the per and lower extremities via the abdominal fascial system. e effect becomes particularly important in overhead athletes ause that stability acts as a torque-countertorque of diago- ly related muscles during throwing.6 The Queensland re- rch group1 has suggested the differentiation of local and bal muscle groups to outline the postural segmental control ction and general multisegmental stabilization function for se muscles groups, respectively (table 2). ANATOMY neral Overview Stability and movement are critically dependent on the co- ination of all the muscles surrounding the lumbar spine. though recent research1,7,8 has advocated the importance of a muscles (in particular, the transversus abdominis and mul- di), all core muscles are needed for optimal stabilization and formance. To acquire this cocontraction, precise neural in- t and output (which has also been referred to as propriocep- e neuromuscular facilitation) are needed.9 Pertinent anatomy the lumbar spine is reviewed below; however, readers uld refer to other texts for an extensive anatomic re- w.1,5,10 seous and Ligamentous Structures Passive stiffness is imparted to the lumbar spine by the eoligamentous structures. Tissue injury to any of these uctures may cause functional instability. The posterior ele- nts of the spine include the zygapophyseal (facet) joints, icle, lamina, and pars interarticularis. These structures are, fact, flexible. However, repetitive loading of the inferior icular facets with excessive lumbar flexion and extension ses failure, typically at the pars. The zygapophyseal joints ry little vertical load except in certain positions such as essive lumbar lordosis.10 The intervertebral disk is com- sed of the annulus fibrosis, nucleus pulposus, and the end- tes. Compressive and shearing loads can cause injury ini- lly to the endplates and ultimately to the annulus such that sterior disk herniations result. Excessive external loads on disk may be caused by weak muscular control, thus causing icious cycle where the disk no longer provides optimal sive stiffness or stability. The spinal ligaments provide little bility in the neutral zone. Their more important role may be provide afferent proprioception of the lumbar spine seg- nts.11 Th mi has abd att lum sup and Th sup a l con act fee Pa spi mu po Th lum mo ing mu a g or com 3 sta are fou Qu sha Th qu and ob are tw qu fle lum iso Ab par fib lik ver abd vat sta del ob nis of ob nal fas Th ina act Fin the do mo mi bal ext des ecc Hi kin Fig sal sup aga Por Table 1: Synonyms and Near-Synonyms for Core Strengthening Lumbar stabilization Table 2: Muscles of the Lumbar Spine Global Muscles (dynamic, phasic, Local Muscles (postural, tonic, S87CORE STRENGTHENING, Akuthota e thoracolumbar fascia consists of 3 layers: the anterior, ddle, and posterior layers. Of these layers, the posterior layer the most important role in supporting the lumbar spine and ominal musculature. The transversus abdominis has large achments to the middle and posterior layers of the thoraco- bar fascia.1 The posterior layer consists of 2 laminae: a erficial lamina with fibers passing downward and medially a deep lamina with fibers passing downward and laterally. e aponeurosis of the latissimus dorsi muscle forms the erficial layer. In essence, the thoracolumbar fascia provides ink between the lower limb and the upper limb.12 With traction of the muscular contents, the thoracolumbar fascia s as an activated proprioceptor, like a back belt providing dback in lifting activities (fig 1). raspinals There are 2 major groups of the lumbar extensors: the erector nae and the so-called local muscles (rotators, intertransversi, ltifidi). The erector spinae in the lumbar region are com- sed of 2 major muscles: the longissimus and iliocostalis. ese are actually primarily thoracic muscles that act on the bar via a long tendon that attaches to the pelvis. This long ment arm is ideal for lumbar spine extension and for creat- posterior shear with lumbar flexion.3 Deep and medial to the erector spinae muscles lay the local scles. The rotators and intertransversi muscles do not have reat moment arm. Likely, they represent length transducers position sensors of a spinal segment by way of their rich position of muscle spindles. The multifidi pass along 2 or spinal levels. They are theorized to work as segmental bilizers. Because of their short moment arms, the multifidi not involved much in gross movement. Multifidi have been nd to atrophy in people with low back pain7 (LBP). adratus Lumborum The quadratus lumborum is large, thin, and quadrangular ped muscle that has direct insertions to the lumbar spine. ere are 3 major components or muscular fascicles to the adratus lumborum: the inferior oblique, superior oblique, longitudinal fascicles. Both the longitudinal and superior lique fibers have no direct action on the lumbar spine. They designed as secondary respiratory muscles to stabilize the 1. Muscular cocontraction via the thoracodor- fascia produces active stability, similar to the port that guy ropes provide to a tent secured inst the wind. Adapted with permission from terfield and DeRosa.5 Dynamic stabilization Motor control (neuromuscular) training Neutral spine control Muscular fusion Trunk stabilization elfth rib during respiration. The inferior oblique fibers of the adratus lumborum are generally thought to be a weak lateral xor of the lumbar vertebrae. McGill13 states the quadratus borum is a major stabilizer of the spine, typically working metrically. dominals The abdominals serve as a vital component of the core. In ticular, the transversus abdominis has received attention. Its ers run horizontally around the abdomen, allowing for hoop- e stresses with contraction. Isolated activation of the trans- sus abdominis is achieved through “hollowing in” of the omen. The transversus abdominis has been shown to acti- e before limb movement in healthy people, theoretically to bilize the lumbar spine, whereas patients with LBP have a ayed activation of the transversus abdominis.8 The internal lique has similar fiber orientation to the transversus abdomi- , yet receives much less attention with regard to its creation hoop stresses. Together, the internal oblique, external lique, and transversus abdominis increase the intra-abdomi- pressure from the hoop created via the thoracolumbar cia, thus imparting functional stability of the lumbar spine.3 e external oblique, the largest and most superficial abdom- l muscle, acts as a check of anterior pelvic tilt. As well, it s eccentrically in lumbar extension and lumbar torsion.5 ally, the rectus abdominis is a paired, strap-like muscle of anterior abdominal wall. Contraction of this muscle pre- minantly causes flexion of the lumbar spine. In our opinion, st fitness programs incorrectly overemphasize rectus abdo- nis and internal oblique development, thus creating an im- ance with the relatively weaker external oblique.14 The ernal oblique can be stimulated by some of the exercises cribed later, particularly those that emphasize isometric or entric trunk twists (fig 2).15 p Girdle Musculature The hip musculature plays a significant role within the etic chain, particularly for all ambulatory activities, in sta- torque producing) segmental stabilizers) ectus abdominis Multifidi xternal oblique Psoas major ternal oblique (anterior fibers) Transversus abdominis iocostalis (thoracic portion) Quadratus lumborum Diaphragm Internal oblique (posterior fibers) Iliocostalis and longissimus (lumbar portions) Arch Phys Med Rehabil Vol 85, Suppl 1, March 2004 R E In Il bil the and abd in people with lower-extremity instability or LBP.17,18 Nadler et al19 showed a significant asymmetry in hip extensor strength in female athletes with reported LBP. In a prospective study, Na str the fem to ext kin act the cha bee of dis do exc me com Di im and ind cru lat dy spi im the abd Ex eni mo ath po adv wo mu the ma bac ma spi inc are spi no str on inj (2) mu int to po po Pa Ho Fig obl S88 CORE STRENGTHENING, Akuthota Arc ization of the trunk and pelvis, and in transferring force from lower extremities to the pelvis and spine.16 Poor endurance delayed firing of the hip extensor (gluteus maximus) and uctor (gluteus medius) muscles have previously been noted 2. Example of a movement awareness exercise: here, external ique muscles are activated with a controlled trunk twist. h Phys Med Rehabil Vol 85, Suppl 1, March 2004 dler et al20 showed a significant association between hip ength and imbalance of the hip extensors measured during preparticipation physical and the occurrence of LBP in ale athletes over the ensuing year. Overall, the hip appears play a significant role in transferring forces from the lower remities to the pelvis and spine, acting as 1 link within the etic chain. The psoas major is a long, thick muscle whose primary ion is flexion of the hip. However, its attachment sites into lumbar spine give it the potential to aid in spinal biome- nics. During anatomic dissections, the psoas muscle has n found to have 3 proximal attachment sites: the medial half the transverse processes from T12 to L5, the intervertebral k, and the vertebral body adjacent to the disk.10 The psoas es not likely provide much stability to the lumbar spine ept in increased lumbar flexion.3 Increased stability require- nts or a tight psoas will concomitantly cause increased, pressive, injurious loads to the lumbar disks. aphragm and Pelvic Floor The diaphragm serves as the roof of the core. Stability is parted on the lumbar spine by contraction of the diaphragm increasing intra-abdominal pressure. Recent studies21 have icated that people with sacroiliac pain have impaired re- itment of the diaphragm and pelvic floor. Likewise, venti- ory challenges on the body may cause further diaphragm sfunction and lead to more compressive loads on the lumbar ne.22 Thus, diaphragmatic breathing techniques may be an portant part of a core-strengthening program. Furthermore, pelvic floor musculature is coactivated with transversus ominis contraction.23 ercise of the Core Musculature Exercise of the core musculature is more than trunk strength- ng. In fact, motor relearning of inhibited muscles may be re important than strengthening in patients with LBP. In letic endeavors, muscle endurance appears to be more im- rtant than pure muscle strength.24 The overload principle ocated in sports medicine is a nemesis in the back. In other rds, the progressive resistance strengthening of some core scles, particularly the lumbar extensors, may be unsafe to back. In fact, many traditional back strengthening exercises y also be unsafe. For example, roman chair exercises or k extensor strengthening machines require at least torso ss as resistance, which is a load often injurious to the lumbar ne.3 Traditional sit-ups are also unsafe because they cause reased compression loads on the lumbar spine.15 Pelvic tilts used less often than in the past because they may increase nal loading. In addition, all these traditional exercises are nfunctional.3 In individuals suspected to have instability, etching exercises should be used with caution, particularly es encouraging end range lumbar flexion. The risk of lumbar ury is greatly increased (1) when the spine is fully flexed and when it undergoes excessive repetitive torsion.25 Exercise st progress from training isolated muscles to training as an egrated unit to facilitate functional activity. The neutral spine has been advocated by some as a safe place begin exercise.26 The neutral spine position is a pain-free sition that should not be confused with assuming a flat back sture nor the biomechanic term “neutral zone” described by njabi.4,27 It is touted as the position of power and balance. wever, functional activities move through the neutral posi- tio tio De aw dis tra pel cis pat ma app wa Gr to not adept at volitionally activating motor pathways require facilitation in learning to recruit muscles in isolation or with motor patterns. As well, some individuals with back injury will do kn ph ma exe Fu cor act pro and lar tot Fig sist S89CORE STRENGTHENING, Akuthota n, thus exercises should be progressed to nonneutral posi- ns. creasing Spinal and Pelvic Viscosity Spinal exercises should not be done in the first hour after akening because of the increased hydrostatic pressures in the k during that time.28 The “cat and camel” and the pelvic nslation exercises are ways to achieve spinal segment and vic accessory motion before starting more aggressive exer- es. As well, improving hip range of motion can help dissi- e forces from the lumbar spine. A short aerobic program y also be implemented to serve as a warmup. Fast walking ears to cause less torque on the lower back than slow lking.29 ooving Motor Patterns The initial core-strengthening protocol should enable people become aware of motor patterns. Some individuals who are l to activate core muscles because of fear-avoidance behav- .30 More time will need to be spent with these people at this ge. Prone and supine exercises have been described to train transversus abdominis and multifidi. Biofeedback devices re used by the Queensland group and others to help facilitate activation of the multifidi and transversus abdominis.1 rbal cues may also be useful to facilitate muscle activation. r example, abdominal hollowing is performed by transversus ominis activation; abdominal bracing is performed by co- traction of many muscles including the transversus abdo- nis, external obliques, and internal obliques. However, most these isolation exercises of the transversus abdominis are in nfunctional positions. When the trained muscle is “awak- d,” exercise training should quickly shift to functional po- ons and activities. bilization Exercises Stabilization exercises can be progressed from a beginner el to more advanced levels. The most accepted program ludes components from the Saal and Saal31 seminal dynamic bar stabilization efficacy study (table 3). The beginner level rcises incorporate the “big 3” (figs 3A–C) as described by Gill.3 These include the curl-up, side bridge, and the “bird g.” The bird dog exercise (fig 3C) can progress from 4-point eeling to 3-point to 2-point kneeling. Advancement to a ysioball (fig 4) can be done at this stage (table 4). Sahr- nn14 also describes a series of lower abdominal muscle rcise progression (table 5). nctional Progression Functional progression is the most important stage in the e-strengthening program. A thorough history of functional ivities should be taken to individualize this part of the gram. Patients should be given exercises in sitting, standing, walking. Sitting is often a problematic position, particu- ly with lumbar disk injury. Sitting with lumbar lordosis ally flattened shifts the center of gravity anteriorly, relative 3. The basic exercise triad for most stabilization programs con- s of the (A) curl-up, (B) side bridge, and (C) bird dog exercises. Arch Phys Med Rehabil Vol 85, Suppl 1, March 2004 fai ior sta the we the Ve Fo abd con mi of no ene siti Sta lev inc lum exe Mc to fle cau Ed wi bee for tiv sta mu mo mu tiv Co Co pla mu or me (lu bee the tes pla sio als too em str pro pro of req era bal lab fer str in Ef no con gra wh edu exi pro Co Pe of eni up cle LB sta inc neg exe B B M D S B S Lu Fi Table 5: Sahrmann’s Lower Abdominal Exercise Progression Base position Supine with knees bent and feet on floor; Da S90 CORE STRENGTHENING, Akuthota Arc the standing position. This shift, in
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