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Core Stability in Athletes: a Critical Analysis of Current Guidelines

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Core Stability in Athletes: a Critical Analysis of Current Guidelines Sports Med DOI 10.1007/s40279-016-0597-7 REVIEW ARTICLE Core Stability in Athletes: A Critical Analysis of Current Guidelines 1 2 2 Klaus Wirth • Hagen Hartmann • Christoph Mickel • 2 3 4 Elena Szilvas • Michael Keiner • Andre Sander Ó Springer International Publishing Switzerland 2016 Abstract Over the last two decades, exercise of the core muscles has gained major interest in professional sports. Key Points Research has focused on injury prevention and increasing athletic performance. We analyzed the guidelines for so- Most exercise specifications for core stability have called functional strength training for back pain prevention not been tested for effectiveness nor compared with and found that programs were similar to those for back pain the load specifications normally used for strength rehabilitation; even the arguments were identical. Surpris- training. ingly, most exercise specifications have neither been tested for their effectiveness nor compared with the load speci- So far, exercise guidelines have focused on fications normally used for strength training. Analysis of adaptations in the central nervous system (voluntary the scientific literature on core stability exercises shows activation of trunk muscles), whereas adaptations of that adaptations in the central nervous system (voluntary morphological structures have not been adequately activation of trunk muscles) have been used to justify addressed in experimental studies or reviews. exercise guidelines. Adaptations of morphological struc- Guidelines created for back pain rehabilitation are tures, important for the stability of the trunk and therefore insufficient for professional athletes. the athlete’s health, have not been adequately addressed in We recommend the use of classical strength-training experimental studies or in reviews. In this article, we exercises as these provide the necessary stimuli to explain why the guidelines created for back pain rehabili- induce the desired adaptations. tation are insufficient for strength training in professional athletes. We critically analyze common concepts such as ‘selective activation’ and training on unstable surfaces. 1 Introduction & Hagen Hartmann The terms ‘core stability’ and ‘functional training’ have [email protected] been used intensively in fitness, health, and professional sports for the last couple of decades. Exercising the trunk 1 University of Applied Sciences Wiener Neustadt, Wiener Neustadt, Austria muscles is supposed to prevent injuries and improve sports performance. Whereas exercising the trunk prevents injury 2 Department of Human Movement Science and Athletic Training, Institute of Sports Sciences, Goethe-University, via protection of the spinal column, an association between Frankfurt am Main, Germany trunk muscle strength and sports performance has not been 3 Swimming Federation of the State Lower Saxony, Hannover, clearly proved [1–6]. Although only small correlations Germany between running, jumping, and sprinting performance and 4 Bobsleigh and Luge Federation Germany, Berchtesgaden, various strength parameters—such as trunk extension, Germany flexion, rotation, or lateral flexion [2, 3, 7]—have been 123 K. Wirth et al. reported, the importance of the trunk muscles can be log- potential must be retrieved via the central nervous system ically inferred [8–13]. They transfer and develop energy, (CNS). The full potential of the muscle is only revealed if the which is necessary for postural control. Interest in how to muscle or several muscles are activated adequately, in a task- exercise this body part has been increasing, as has the specific way, which is called intra- or inter-muscular coor- number of suggestions for interventions over the last 20 dination. Therefore, stabilization is the result of muscle mass years, particularly because the number of patients with (contractile potential) and its activation through the CNS back pain has also been increasing. Back pain has often (usage of that potential) (see Fig. 1), whereas strengthening been associated with a weakness of the trunk muscles refers to improvements in force production. [14, 15], but this cannot be the only reason behind these The level of force necessary for trunk stabilization symptoms [16] because it has not always been possible to depends on the motor task. Reviewing the literature on core detect a deficit in core muscle strength. Ezechieli et al. [17] stability training, it would appear only muscular activation presented the results of trunk strength testing in trained is important. Unfortunately, high activation but small athletes that gave reason to assume they would require muscle mass still only produces a small level of force. preventive core muscle training. As the scientific evidence Sometimes, training goals are created using force values for core stability programs seems low [18, 19], this review determined in standing and walking [16]; however, these attempts a critical analysis of common concepts, including are not sufficient for activities of daily living or for sports. the classification into ‘local’ and ‘global’ trunk muscles, The requirements of the neuromuscular system in everyday ‘selective activation’, and training on unstable surfaces. life, e.g., lifting, carrying, and dragging, exceed the demands of standing, walking, and some training exer- cises—which have often been used in training interven- 2 What is Meant by ‘Core Stability’? tions—for the trunk [43]. To estimate the forces with which the trunk muscles must contend, ground reaction force The term ‘core stability’ has no clear definition. Depending (GRF) measurements in sports should be considered— on the author(s), core stability muscles may only include bearing in mind Newton’s third law (for every action, there extensors, flexors, lateral flexors, or rotators of the spinal is an equal and opposite reaction)—which reach values of column. A more complex approach includes all muscles 6- to 17-fold body mass [44–51]. This is one reason why between the shoulders and pelvis. As hip position influ- guidelines extracted from therapy for patients with back ences alignment of the spinal column and therefore mod- pain are inappropriate for professional athletes. Particularly ulates trunk muscle activity [20–22], this article favors the in sports but also in everyday life, stabilizing the trunk latter approach. However, training methods presented here demands forces that far exceed target criteria for thera- are valid for every muscle to be strengthened as the peutic interventions. We emphasize that force production is adaptive mechanisms remain the same [9, 23, 24]. the basic requirement for stabilization of the spinal column. The terms ‘stabilization’, ‘strengthening’, and ‘muscle activation’ are often used side by side as if they are inde- pendent goals in training; however, stabilization is a result of 3 Core Stability: Concepts and Evidence muscle forces [12, 25]. The activation of trunk muscles and their contractile potential (muscle mass) produces those 3.1 ‘Global’ and ‘Local’ Muscle Systems forces and therefore lead to stable and secure positions of the spinal column. Muscle mass is the morphological basis For many investigators studying back pain, the focus of determining how much force can be produced [26–42]. This interest is the deeper-layered muscles of the trunk. In this Fig. 1 Schematic representation of the association Contracle potenal Neural acvaon (CNS) Force producon between force production and (muscle) stability + CNS Learning Strength training to induce Increases in force (coordinaon) morphological adaptaons producon + Task-specific acvaon for Exploing full contracle Improved stability each movement potenal 123 Core Stability in Athletes: A Critical Analysis of Current Guidelines context, trunk muscles have been classified as ‘global’ and abdominal hollowing. In contrast, abdominal hollowing ‘local’, a classification system that can be traced back to does not increase the stability of the spinal column [59, 64]. Bergmark [52]. O’Sullivan [53] nominated the rectus Stanton and Kawchuk [65] reported improved segmental abdominis, the obliquus externus, and the thoracic part of stiffness (measured at thoracic vertebra 4) through co- the lumbar iliocostalis—among others—as part of the contraction of the trunk muscles, with significantly ‘global’ muscle system because they may produce high increased normalized surface electromyography (EMG) torques and affect vertebral orientation without being amplitudes of the rectus abdominis, the obliquus externus directly anatomically connected to them, therefore, sup- and internus, and thoracic and lumbar erector spinae. porting trunk stabilization even without (direct) segmental Moreover, their participants were not able to perform influence. Thus, the ‘global’ muscle system represents the abdominal hollowing without activation of the obliquus prime movers of the trunk, whereas the ‘local’ muscle internus. Vera-Garcia et al. [64] made the same observation system consists of muscles whose insertion and origin are for the obliquus externus and the rectus abdominis. attached to the spinal column and therefore control single Therefore, these findings prove the opposite of that pro- vertebral segments and are responsible for their stabiliza- posed by Hodges and Richardson [66]: abdominal hol- tion [53, 54]. Following this, specific training exercises are lowing does not produce a preparatory stabilization of often recommended that especially emphasize the ability to vertebral segments protecting them from shear forces—
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