Download A modern approach to abdominal training

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Journal of Bodywork and Movement Therapies (2007) 11, 194–198
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Bodywork and
Movement Therapies
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SELF-MANAGEMENT: CLINICIAN SECTION
A modern approach to abdominal training$
Craig Liebenson
L.A. Sports and Spine, 10474 Santa Monica Building, #202 Los Angeles, CA 90025, USA
Received 20 April 2007; accepted 23 April 2007
Self-Management: Clinician Section
Introduction
Active care is a benchmark in the management of
low back conditions. Unfortunately, voluntary exercise often perpetuates faulty movement patterns
or abnormal motor control (AMC). This series of
articles will describe how to train the abdominals
and ensure that patients are performing their
exercises without AMC.
The sit-up is a classic example of an exercise
myth. The sit-up places high compressive load on
the disc (McGill, 2006, 2007). It usually involves a
posterior pelvic tilt which unnecessarily exacerbates disc load (Hickey and Hukins, 1980). Also, it is
frequently performed early in the morning which is
a time of high risk for annular injury (Adams and
Hutton, 1985). Better and safer abdominal exercises exist which will be described in this series of
papers.
Are specific patterns of muscle
co-activation necessary?
Whether the goal is preventive, injury recovery,
rehabilitation, or performance enhancement good
‘‘core’’ fitness is a must. Muscles stabilize joints by
stiffening like rigging on a ship (Fig. 1). According
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to Cholewicki and McGill (1996) spine stability is
greatly enhanced by co-contraction (or co-activation)
of antagonistic trunk muscles. Co-contractions
increase spinal compressive load, as much as
12–18% or 440 N, but they increase spinal stability
even more by 36–64% or 2925 N (Granata and
Marras, 2000). They have been shown to occur
during most daily activities (Marras and Mirka,
1990). This mechanism is present to such an extent
that without co-contractions the spinal column is
unstable even in upright postures! (Gardner-Morse
and Stokes, 1998).
Co-contractions are most obvious during reactions to unexpected or sudden loading (Lavender
et al., 1989). Involuntary coordination of ‘‘core’’
muscles has been found to be correlated to back
pain. Researchers at Yale University have shown
that a specific motor control signature of delayed
agonist-antagonistic muscle activation predicts
which asymptomatic people will later develop low
back pain (LBP) (Cholewicki et al., 2005). In
particular, what was found was longer muscle
response latencies to perturbation in the ‘‘at risk’’
group than those in healthy control subjects.
Marras et al. (2005) have reported that there is a
different pattern of antagonist muscle co-activation
(kinematic ability) in LBP individuals than in
asymptomatics. Patients were found to have greater spine load and greater kinematic compromise
during lifting tasks. Altered kinematics were
strongly related to spine load, being able to predict
87% of the variability in compression, 61% in
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doi:10.1016/j.jbmt.2007.04.007
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A modern approach to abdominal training
195
(Kavcic et al., 2004). They demonstrated that
different muscles played greater or lesser roles
depending on the activity/exercise.
Sufficient stability, according to McGill, is defined
as the amount of muscle stiffness necessary for
stability along with a safety margin (McGill, 2006,
2007). Cholewicki et al. (1997) showed that modest
levels of co-activation are necessary, but if a joint
has lost its stiffness greater amounts of co-activation
are needed.
Figure 1 Mast-rigging stability model.
anteroposterior shear, and 65% in lateral shear. The
kinematic picture for the LBP individual showed
excessive levels of antagonistic muscle co-activation
which reduced trunk motion, but also increased
spine loading.
Ironically, when the spine is under load it is best
stabilized, but when ‘‘surprised’’ by trivial load at a
vulnerable time such as in the morning or after
prolonged sitting the spine stability system is most
dysfunctional (Adams and Dolan, 1995). Inappropriate muscle activation patterns during seemingly
trivial tasks (only 60 N of force) such as bending
over to pick up a pencil can compromise spine
stability and potentiate buckling of the passive
ligamentous restraints (Andersson and Winters,
1990). This motor control skill has also been shown
to be more compromised under challenging aerobic
circumstances (McGill et al., 1995).
Australian researchers have demonstrated that a
delayed activation of the transverse abdominus
muscle during arm or leg movements has been
found to distinguish LBP patients from asymptomatic individuals (Hodges and Richardson, 1998,
1999). However, according to Canadian scientists
focusing on a single muscle is like focusing on a
single guy wire (Kavcic et al., 2004). Research from
the University of Waterloo in Canada has found that
while certain muscles such as multifidus and
transverse abdominus may have special relevance
in distinguishing LBP subjects from asymptomatic
individuals that these muscles are part of a much
bigger orchestra responsible for spinal stability
Specific spinal stabilization exercises have been
shown to reduce future recurrences following an
acute LBP episode (Hides et al., 2001). Specific
spine stabilization exercises achieved superior
outcomes to isotonic exercises in chronic patients
with spondylolysthesis (O’Sullivan et al., 1997).
One study that compared McGill’s ‘‘general’’
stabilization exercise approach to the Australian
‘‘deep’’ local stabilization training demonstrated that the ‘‘general’’ approach was superior
(Koumantakis et al., 2005).
Stuge et al. (2004) found that stabilizing exercises
were superior to traditional physical therapy for
pelvic girdle pain after pregnancy. The stabilization
group had lower pain intensity, disability, higher
quality of life, and less impairments. The results
persisted at 1-year check post-partum.
Yilmaz et al. (2003) administered an 8-week
stabilization program to post-operative lumbar
microdiscectomy patients. It was compared to
home exercise and to no exercise. At the 12th
week superior results were achieved in pain,
function, mobility, and lifting ability for the
stabilization group. Supervised stabilization training was superior to home exercises which was
superior to no exercise.
Assessment of motor control during
abdominal training
There are a few fundamental components necessary to optimize motor control during abdominal
stabilization training. They are the abdominal
brace (AB), neutral spine posture, normal respiration, and the sternal crunch. Avoiding AMC during
abdominal stabilization training is crucial to maintaining ‘‘sufficient stability’’.
The abdominal brace
In assessing AMC the first criteria is achieving
stiffness via pre-contraction or performing an AB.
Self-Management: Clinician Section
How effective is abdominal training?
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196
C. Liebenson
end-range loading in flexion. The ‘‘neutral zone is
the inner region of a joint’s range of motion (ROM)
where minimal resistance to motion is encountered
(Panjabi, 1992).
Disc herniation has been shown to be related to
repeated flexion motion, especially (Callaghan and
McGill, 2001) if coupled with lateral bending and
twisting (Adams and Hutton, 1985). This was
supported by the work of Hickey and Hukins
(1980) who demonstrated the protective function
of lumbar lordosis on the disc. According to McGill
(2006) ‘‘Because ligaments are not recruited
when lordosis is preserved, nor is the disc bent, it
appears that the annulus is at low risk for failure.’’
Normal respiration
Self-Management: Clinician Section
Figure 2 The abdominal brace.
Co-contractions have been shown to occur automatically in response to unexpected or sudden
loading (Lavender et al., 1989; Marras et al., 1987).
Stokes et al. (2000) has described how there are
basically two mechanisms by which this co-activation occurs. One is a voluntary pre-contraction to
stiffen and thus dampen the spinal column when
faced with unexpected perturbations. The second
is an involuntary, reflex contraction of the muscles
quick enough to prevent excessive motion that
would lead to buckling following either expected or
unexpected perturbations (Cresswell et al., 1994;
Lavender et al., 1989; Marras et al., 1987; Stokes
et al., 2000; Wilder et al., 1996).
This can be achieved by having a patient perform
a dead bug or bird dog and then ‘‘brace’’. While the
patient performs an AB the clinician offers slow and
then quick perturbations in different planes while
asking the patient to maintain their posture. The
patient can pretend they are about to be pushed or
hit and they will ‘‘automatically’ brace (see Fig. 2).
Neutral spine posture
The second criteria for spine stability is maintainance of a ‘‘neutral spine’’ or normal lumbar
lordosis. Many patients perform posterior pelvic
tilts which actually places the lumbo-sacral spine in
flexion and thus can potentially harm the disc via
When performing the AB with neutral spine posture
(e.g. slight lumbar lordosis) it is important that the
normal respiration is maintained. The tendency
when performing an AB and resisting perturbations
is to hold the breath or chest breathe. Simple
cueing to continue breathing normally is usually all
that is required. The best cue is to say ‘‘breathe
and brace’’.
Practice-based problem
Won’t abdominal bracing encourage chest
breathing?
Yes, it can. However, the patient is encouraged to breathe horizontally in 3601 around
the abdomen and rib cage rather than vertically by lifting the chest to breathe in.
A valuable cue is to open the ribs laterally
like an accordion.
McGill et al. (1995) recommends that patients AB
during both phases of respiration rather than only
during exhalation. Typical gym training advice to
exhale with exertion does not make sense in sports
or work demands since stability must be ensured as
endurance challenges are faced.
Sternal crunch
A novel approach to achieving stronger co-activation of all abdominal wall muscles is to observe the
position of the anterior chest wall (Kolar, 2007).
A cephalad position which can be thought of as an
‘‘inhalation’’ position is inhibitory of the normal
diaghragmatic function. It is noted that the
thoraco–lumbar (T/L) junction is hyperlordotic
and the diaphragm is oblique in this position (see
Fig. 3). Ideally, a caudal anterior chest position is
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A modern approach to abdominal training
Figure 3 Inhalation position of the sternum and anterior–inferior chest wall which inhibits diaphragmatic
function.
197
Figure 5 Incorrect sternal crunch with a posterior pelvic
tilt.
Figure 4 The ideal, neutral spine, sternal crunch.
Practice-based problem
Won’t the sternal crunch remove the lumbar
lordosis?
Yes it can. However, it should not since the
key is to mobilize the rib cage inferiorly and
posteriorly WITHOUT altering the lumbo-sacral
posture (e.g. lordosis). If the patient combines
the sternal crunch with a posterior pelvic tilt
this should be discouraged (see Fig. 5).
The overhead arm reach on a foam roll is an
excellent training exercise for the abdominal wall.
The patient should be able to maintain a sternal
crunch while moving the arms overhead (see
Fig. 6). This should be performed without T/L
hyperlordosis and without a posterior pelvic tilt.
The clinician would initially cue the patient for
spinal stiffness, and thus an AB, by offering light
perturbations of the torso in a transverse plane
twisting direction. Last but not least, the patient
Figure 6 The overhead arm reach on a foam roll—(a)
incorrect inhalation position and (b) correct exhalation
position.
should be reminded to maintain normal respiration
throughout the duration of the exercise.
Conclusion
In a nutshell, abdominal exercises are commonly
prescribed to prevent and treat lower back pain as
well as to build overall fitness. Certain myths
should be dispelled about this subject regarding
sit-ups, morning exercise, the posterior pelvic tilt,
the transverse abdominis, exhaling with exertion,
etc. The role of maintaining a ‘‘neutral spine’’ and
performing an AB should be understood. The next
Self-Management: Clinician Section
facilitated which is the ‘‘exhalation’’ position. In
this case, the T/L junction is more neutral and the
diaphragm is ‘‘centrated’’ in a horizontal position
(see Fig. 4). The ‘‘exhalation’’ position is believed
to be facilitory of the abdominal wall since active
exhalation is produced by the abdominal muscles.
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198
two articles in this series will review more detail
about the basics of assessment and training of the
abdominal wall.
Self-Management: Clinician Section
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