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The impact of core stability on lower extremity injuries: a systematic review of the literature Cameron, Tara; Honkanen, Sarah; Maunu, Wesley; Stefanson, Nicole; Zboya, Sara; Zhao, Sophia; Supervisor: Roig, Marc 2009-07-31

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Tara CameronSarah HonkanenWesley MaunuNicole StefansonSara ZboyaSophia ZhaoMarc RoigIntroductionMethodsResultsDiscussionLimitationsConclusionClinical ImplicationsRecommendations  for Future ResearchThe word “core” and the idea of training the “core” has become very popular In spite of its popularity, a universally accepted definition of “core stability”,  “core” and the muscles that constitute the “core” has yet to be establishedCore Stability Definition1:Ability to control the position and motion of the trunk over the pelvis and leg to allow optimum production, transfer and control of force and motion to the terminal segment in integrated kinetic chain activities.Number of studies investigating core muscle activation and core stability function either in healthy or injured individuals Results used as rational for use of core stability training for improving spinal stability and postural controlCresswell4Transverse abdominis (TA) first muscle activated during expected and unexpected loading of the trunkAnticipatory functionHodges & Richardson5,6Same activation pattern found prior to upper and lower extremity movementsVan Dieen7, Hodges & Richardson8Patients with low back pain had altered trunk muscle activation patterns compared to healthy controlsCombination of results suggests: Anticipatory core muscle activation of TA, required for movement in healthy adults, is altered in injured patients      reduced spinal stabilityIn addition to providing spinal stability, core stability training may enhance force transmission to the extremitiesMay play a role in lower extremity injury occurrence Role of core stability in force transmission to the extremities, and in particular the effect of core stability on extremity injuries and injury prevention has received little attentionMost of the literature on this topic comes from review articlesCiting the same few authorsWillardson  2007: Core stability training: Applications to sports conditioning programsWilson et al. 2005 : Core stability and its relationship to lower extremity function and injuryMyer et al. 2008: Trunk and hip control neuromuscular training for the prevention of knee joint injuryTo our knowledge no systematic review has been conducted on this topicThe question remains....		Is core stability training effective for reducing lower extremity injuries?		Are there more effective methods of training?To investigate the evidence concerning:Core stability measures predicting lower extremity musculoskeletal injury risk The effectiveness of core stability training as a means of lower extremity injury preventionDatabasesMedline (1950- Present)EMBASE (1980- Present)CINAHL (1982- Present)SportDiscusPubMed (1949- Present)Web of ScienceGrey LiteratureLast Search: January 2009Title ScreenAbstract ScreenFull Text ScreenUsing a standardized screening tool to determine consensusInclusion and Exclusion CriteriaMeasured core stability or provided a core stability training program as a component of the interventionExamined prevention, occurrence, or recurrence of musculoskeletal lower extremity injuriesIncluded participants with a minimum mean age of 18 years who were generally healthy, trained or untrainedWere written in EnglishAbility of the specific core musculature to stabilize the spine and pelvis in order to facilitate force transmission to the extremities3 Core Musculature Subsystems:Inner spinal stabilizers capable of controlling the lumbar segmentsOuter spinal stabilizers concerned with controlling trunk movementsLumbopelvic-extremity muscles which act to maintain lumbopelvic stability on fixed extremities or produce movement of the extremities on a stable trunk and pelvisWere not experimental in designExamined only the prevention of injuries pertaining to the backExamined or included interventions that only measured or targeted muscles of subsystem IIIStudy DesignSackett’s Levels of Evidence as described by Oxford Center for Evidence Medicine12Methodological Quality“Checklist for Measuring Quality” by Downs and Black13Standardized Data Extraction FormStudy Design and PurposeOperational Definition of Core/Core StabilityCharacteristics of ParticipantsMethods of Measuring Core StabilityInterventions for Core StabilizationBaseline and Follow-up Outcome MeasuresResults and ConclusionsLimitations and Suggestions for Future StudiesMeta-analysis not performed due to: Study heterogeneityParticipantsInterventionsOutcome MeasuresMethods of Measuring Core StabilityDuration of Follow-upInability to calculate effect size Qualitative Analysis Study ResultsSackett’s Levels of EvidenceGrades of Recommendation Main Reasons for Exclusion:Review article, not experimental in designFailed to Measure core stability or provide a core stability interventionFailed to examine injury preventionFailed to investigate lower extremity injuriesNo articles of relevance found with Web of Science or Grey Literature SearchDowns and Black ToolRange = 14-20/28Mean = 16/2895.8% agreement between reviewersExternal validity categoryCore Stability as Risk FactorStudies SubjectSample sizeClinical conditionDurationFollow-upStudy focusLeetun et.al 2004Varsity basketball & track athletes140(♀80 ♂60)Back and LE injury2 yrsCore  muscle strength/enduranceZazulak et.al 2007Collegiate athletes277  (♂140♀ 137)Knee injury3 yrsCore neuromuscular controlZazulak et.al 2007Collegiate athletes277  (♂140♀ 137)Knee injury3 yrsCore neuromuscular controlCore Stabilization InterventionStudies SubjectSample sizeClinical conditionDurationFollow-upStudy focusPeate et.al 2007Firefighter433  (♂408 ♀ 25)Back, UE, LE injury1 yrCore  muscle strength/enduranceCusi et.al 2001Rugby player39 Back and groin injury10 wksCore  muscle strength/enduranceSherry et.al 2004Athletes24Hamstring strains 2 wks & 1 yrafter return to sportCore neuromuscular controlagility Injured vs. Uninjured athletes Leetun et al.16:Injured athletes demonstrated lower core stability measures, especially for hip abduction (P=0.02) and external rotation strength(P=0.01)Zazulack et al.18:Injured athletes demonstrated compromised core stability, measured as trunk displacement after sudden force release (P<0.05)Injured vs. Uninjured athletes Zazulack et al.17:Injured female athletes had significantly      decreased core stability , measured as error    in active proprioceptive repositioning (P≤ 0.05);     injured male athletes did notLower Extremity Injury Predictors Leetun  et al.14:Hip external rotation strength was the sole significant predictor of lower extremity injuries in athletes (OR=0.86). Zazulack et al.17,18  :Female athletes: a combination of factors related to core stability (trunk displacements, proprioception, history of low back pain) predicted knee injury risk (84% concordant observation, P<0.0001)Male athletes: history of low back pain was the only significant knee injury risk predictorSummaryStudies used different operational definitions of core and methods of measuring core stabilityStudies provided level 2b evidence suggesting that impaired core stability is a risk factor for lower extremity injuries in athletesInterventionIn all three studies, core stabilization exercises were used in combination with other interventionsPeate et al.15:Multi-disciplinary program with seminars emphasized functional movement, proper body mechanics, core muscles recruitment, worksite analysis, four physiotherapy ball core strengthening exercises Cusi et al.19:Physiotherapy ball for core strengthening in addition to a standard stretching and fitness program performed by the control groupInterventionSherry et al.16:Progressive agility and trunk stabilization exercises , and icingControl group: static stretching and isolated progressive hamstring resistance exercise, and icingOutcome MeasuresInjury and re-injury rate were used as outcome measures in all studiesThere was an absence of direct and specific measurement of core stability and core strengthPeate et al.15Functional movement screenwork-related task performance Cusi et al.19Lower extremity flexibility Back strengthSherry et al.16No measurements of the coreKnee flexion strength, hop and sprintResultsPeate et al.15:Significantly decrease total number of injuries (42%) and lost time injuries (62%) for back injuries and upper extremity injuries, but not for lower extremity injuries (P=0.4624, 0.1292 respectively)Cusi et al.19: No significant difference in lower back and groin injury rate between intervention group and control group (P value was not reported by the study)ResultsSherry et al.16:Intervention was superior to the control in preventing hamstring strain re-injury in athletes (2 weeks post-return to sports P=0.00343, 1 year post-return to sports P=0.0059)No direct measurements for trunk stabilization was performedNot possible to conclude that results were due to improvements in core stabilitySummaryOverall, studies used different operational definitions of core, different core stabilization interventions and different or absent direct and specific measurement of core stability and core strengthThe studies provided inconclusive level 1b and 2b evidence suggesting the effectiveness of core stabilization interventions in decreasing lower extremity injury or re-injury rateFew quality studies examining the relationship between core stability and lower extremity injuries were foundInconsistent evidence in support of core stability as a risk factor for predicting lower extremity injuriesInconclusive evidence to support core stability training in prevention of lower extremity injuriesReview articles are written based highly on theory due to lack of scientific evidenceWhen research is added to theory misrepresentation can occurExample“Research from the rehabilitation literature has demonstrated the effectiveness of core stability exercises for reducing the likelihood of lower back and lower extremity injuries”9Studies referenced either did not have outcome measures of core strength or stability, or used multiple interventions at once22Muscles Which Constitute the “Core”Leetun16 was referenced in the following statement “A recent prospective study suggests that deficiencies in core muscle capacity may increase the risk of lower extremity injury”10The muscles referred to by Leetun14 are the hip external rotators which can be a component of the “core” but alone are not considered the “core”Three Subsystems3Neural subsystem controls the active lumbopelvic musculatureAlters compressive forces between the passive bony components of the lumbopelvic regionManages stabilityKinetic Chain TheoryHuman movement occurs through a sequencing of body segments from proximal to distal1Proximal base of support necessary for successful distribution of forces20,1 Core muscle activation often preceded lower extremity muscle activity during movement5,6 Deficits in core stability may alter loads tolerable by distal segments and place them at higher risk for injury20, 1No single universal definition of “core” or “core stability”Limited number of studies available on topicMeta-analysis not possibleOnly included articles written in EnglishMajor influence towards developing a standardized and universal definition of “core” and “core stability”More comparable scientific studies to be conductedPromote standardized, valid and reliable methods of assessing core stabilityFacilitate interventions with specific parametersAllow objective and functional outcomes to be measuredWell Controlled, Longitudinal RCTExamine the effectiveness of a core stability intervention in the prevention of lower extremity injuriesMeasure Core StabilityPre- and post- intervention to ensure the results can be attributed to a difference in core stabilityHave a comprehensive definition of core stabilitySuggested RCT Intervention:Pre-season to monitor injuries for entire seasonSpecify which subsystem is targetedExercises that isolate the specific musclesFollow-up minimum of six months for all participantsMethodological qualityPower analysis to ensure sufficient sample sizeWell controlled study to limit confounding factorsAge, level of training, sport, ect.Marc RoigCharlotte BeckDarlene ReidElizabeth DeanKibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Medicine. 2006;36:189-198.Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Disord. 1992; 5(4): 390-397.Panjabi MM. The stabilizing system of the spine. part I. function, dysfunction, adaptation, and enhancement. J Spinal Disord. 1992; 5(4): 383-389. Cresswell AG, Oddsson L, Thorstensoon A. The influence of sudden perturbations of trunk muscle activity and intra-abdominal pressure while standing. Exp Brain Res. 1994;3: 336-341.Hodges PW, Richardson CA. Contraction of the abdominal muscles associated with movement of the lower limb. Phys Ther. 1997;77:132-144.Hodges PW, Richardson CA. Feed-forward contraction of transversus abdominis is not influenced by the direction of arm movement. Exp Brain Res. 1997; 114: 362-370.van Dieen JH, Cholewicki JP. Trunk muscle recruitment patterns in patients with low back pan enhance the stability of the lumbar spine. Spine. 2003; 28(8):834-841.Hodges PW, Richardson CA. Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds. Arch Phys Med Rehab. 1999; 80(9): 1005-1012.Willardson JM. Core stability training: Applications to sports conditioning programs. Journal of Strength & Conditioning Research. 2007; 21: 979-985. Wilson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its relationship to lower extremity function and injury. J AM Acad Orthop Surg. 2005; 13:316-325. Myer GD, Chu DA, Brent JL, Hewett TE. Trunk and hip control neuromuscular training for the prevention of knee joint injury. Clinical Sports Medicine. 2008;27:425-448.Levels of evidence and grades of recommendation: The Oxford Center for Evidence Medicine. Available at: http:// www.cebm.net/levels_of_evidence.asp.Downs SH and Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health (1998); 52:377-384.Leetun, D. T., Ireland, M. L., Wilson, J. D., Ballantyne, B. T., & McClay Davis, I. (2004). Core stability measures as risk factors for lower extremity injury in athletes. Medicine & Science in Sport & Exercise; 36(6); 926–934.Peate, W. F., Bates, G., Lunda, K., Francis,S., 7 Bellamy, K. (2007). Core strength: A new model for injury prediction and prevention. Journal of Occupational Medicine and Toxicology; 2(3); 1-9.Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. Journal of Orthopaedic & Sports Physical Therapy. 2004;34:116-125.Zazulak BT, Hewett TE, Reeves NP, Goldberg B, Cholewicki J. Deficits in neuromuscular control of the trunk predict knee injury risk: A prospective biomechanical-epidemiologic study. Am J Sports Med. 2007b;35:1123-1130. Zazulak,B. T., Hewett, T. E., Reeves, N. P.,  Goldberg, B., & Cholewicki, J. (2007). Deficits in neuromuscular control of the trunk predict knee injury risk: A prospective biomechanical-epidemiologic study. The American Journal of Sports Medicine; 35(7); 1123-1130.Cusi, M. F., Juska-Butel, C. J., Garlick, D., & Argyrous, G. (2001). Lumbopelvic stability and injury profile in rugby union players. New Zealand Journal of Sports Medicine; 29; 14-19. Brukner P, Khan K. Clinical Sports Medicine. 3rd edition ed. North Rhyde: NSW: McGraw-Hill; 2007.   Tara Cameron Sarah Honkanen Wesley Maunu Nicole Stefanson Sara Zboya Sophia Zhao Marc Roig  o Introduction o Methods o Results o Discussion o Limitations o Conclusion o Clinical  Implications o Recommendations for Future  o  The word “core” and the idea of training the “core” has become very popular  o  In spite of its popularity, a universally accepted definition of “core stability”, “core” and the muscles that constitute the “core” has yet to be established  o  Core Stability Definition1: • Ability to control the position and motion of  the trunk over the pelvis and leg to allow optimum production, transfer and control of force and motion to the terminal segment in integrated kinetic chain activities.   Number  of studies investigating core muscle activation and core stability function either in healthy or injured individuals   Results  used as rational for use of core stability training for improving spinal stability and postural control  o  Cresswell4 • Transverse abdominis (TA) first muscle  activated during expected and unexpected loading of the trunk • Anticipatory function o  Hodges & Richardson5,6 • Same activation pattern found prior to upper  and lower extremity movements  o  Van Dieen7, Hodges & Richardson8 • Patients with low back pain had altered trunk  muscle activation patterns compared to healthy controls • Combination of results suggests: • Anticipatory core muscle activation of TA, required for movement in healthy adults, is altered in injured patients  reduced spinal stability  o  In addition to providing spinal stability, core stability training may enhance force transmission to the extremities • May play a role in lower extremity injury  occurrence  o  Role of core stability in force transmission to the extremities, and in particular the effect of core stability on extremity injuries and injury prevention has received little attention  o  Most of the literature on this topic comes from review articles • Citing the same few authors  o  Willardson 2007: • Core stability training: Applications to sports  conditioning programs  o  Wilson et al. 2005 : • Core stability and its relationship to lower extremity  function and injury  o  Myer et al. 2008: • Trunk and hip control neuromuscular training for the  prevention of knee joint injury  o  To our knowledge no systematic review has been conducted on this topic  o  The question remains.... Is core stability training effective for reducing lower extremity injuries? Are there more effective methods of training?  To investigate the evidence concerning: o  Core stability measures predicting lower extremity musculoskeletal injury risk  o  The effectiveness of core stability training as a means of lower extremity injury prevention  o  Databases • Medline (1950- Present) • EMBASE (1980- Present) • CINAHL (1982- Present) • SportDiscus • PubMed (1949- Present)  o  Web of Science  o  Grey Literature  o  Last Search: January 2009  1. Title Screen 1. Abstract Screen 1. Full Text Screen  • Using a standardized screening tool to determine consensus • Inclusion and Exclusion Criteria  1.  Measured core stability or provided a core stability training program as a component of the intervention  1.  Examined prevention, occurrence, or recurrence of musculoskeletal lower extremity injuries  1.  Included participants with a minimum mean age of 18 years who were generally healthy, trained or untrained  1.  Were written in English  o  Ability of the specific core musculature to stabilize the spine and pelvis in order to facilitate force transmission to the extremities  o  3 Core Musculature Subsystems: 1. Inner spinal stabilizers capable of controlling the lumbar  segments 2. Outer spinal stabilizers concerned with controlling trunk movements 3. Lumbopelvic-extremity muscles which act to maintain lumbopelvic stability on fixed extremities or produce movement of the extremities on a stable trunk and pelvis  1.  Were not experimental in design  1.  Examined only the prevention of injuries pertaining to the back  1.  Examined or included interventions that only measured or targeted muscles of subsystem III  o  Study Design • Sackett’s Levels of Evidence as described by  Oxford Center for Evidence Medicine12 o  Methodological Quality • “Checklist for Measuring Quality” by Downs  and Black13  o  Standardized Data Extraction Form • • • • • • • •  Study Design and Purpose Operational Definition of Core/Core Stability Characteristics of Participants Methods of Measuring Core Stability Interventions for Core Stabilization Baseline and Follow-up Outcome Measures Results and Conclusions Limitations and Suggestions for Future Studies  o  Meta-analysis not performed due to: o Study heterogeneity  o Participants o Interventions o Outcome Measures o Methods of Measuring Core Stability o Duration of Follow-up  o Inability to calculate effect size o  Qualitative Analysis o Study Results o Sackett’s Levels of Evidence o Grades of Recommendation  o  Main Reasons for Exclusion: 1. Review article, not experimental in design 2. Failed to Measure core stability or provide a  core stability intervention 3. Failed to examine injury prevention 4. Failed to investigate lower extremity injuries o  No articles of relevance found with Web of Science or Grey Literature Search  o  Downs and Black Tool • Range = 14-20/28 • Mean = 16/28 • 95.8% agreement between reviewers o External validity category   Core  Stability as Risk Factor  Studies Subject Sample size Leetun Varsity et.al basketball 2004 & track athletes  140 (♀80 ♂60)  Clinical Duration condition Follow-up  Study focus  Back and LE injury  2 yrs  Core muscle strength/endurance  Zazulak Collegiate 277 Knee injury et.al athletes (♂140♀ 137) 2007 Zazulak Collegiate 277 Knee injury et.al athletes (♂140♀ 137) 2007  3 yrs  Core neuromuscular control  3 yrs  Core neuromuscular control   Core  Stabilization Intervention  Studies Subject Sample size  Clinical condition  Duration Follow-up  Study focus  Peate Firefighter 433 Back, UE, LE 1 yr Core muscle et.al (♂408 ♀ 25) injury strength/endurance 2007 Cusi Rugby 39 Back and 10 wks Core muscle et.al player groin injury strength/endurance 2001 Sherry Athletes 24 Hamstring 2 wks & 1 yr Core neuromuscular et.al strains after return to control 2004 sport agility  o  Injured vs. Uninjured athletes    Leetun et al.16:  Injured athletes demonstrated lower core stability  measures, especially for hip abduction (P=0.02) and external rotation strength(P=0.01)    Zazulack et al.18:  Injured athletes demonstrated compromised core  stability, measured as trunk displacement after sudden force release (P<0.05)  o  Injured vs. Uninjured athletes    Zazulack et al.17:  Injured female athletes had significantly  decreased core stability , measured as error in active proprioceptive repositioning (P≤ 0.05); injured male athletes did not  o  Lower Extremity Injury Predictors    Leetun et al.14:  Hip external rotation strength was the sole significant  predictor of lower extremity injuries in athletes (OR=0.86).    Zazulack et al.17,18 :  Female athletes: a combination of factors related to core  stability (trunk displacements, proprioception, history of low back pain) predicted knee injury risk (84% concordant observation, P<0.0001)   Male athletes: history of low back pain was the only  significant knee injury risk predictor  o  Summary • Studies used different operational definitions of  core and methods of measuring core stability • Studies provided level 2b evidence suggesting  that impaired core stability is a risk factor for lower extremity injuries in athletes  o  Intervention • In all three studies, core stabilization exercises were  used in combination with other interventions    Peate et al.15:  Multi-disciplinary program with seminars emphasized  functional movement, proper body mechanics, core muscles recruitment, worksite analysis, four physiotherapy ball core strengthening exercises    Cusi et al.19:  Physiotherapy ball for core strengthening in addition to  a standard stretching and fitness program performed by the control group  o  Intervention    Sherry et al.16:  Progressive agility and trunk stabilization exercises ,  and icing   Control group: static stretching and isolated progressive  hamstring resistance exercise, and icing  o  Outcome Measures • Injury and re-injury rate were used as outcome  measures in all studies • There was an absence of direct and specific measurement of core stability and core strength Peate et al.15  Functional movement screen work-related task performance  Cusi et al.19  Lower extremity flexibility Back strength  Sherry et al.16  No measurements of the core Knee flexion strength, hop and sprint   Results   Peate et al.15:  Significantly decrease total number of injuries (42%) and  lost time injuries (62%) for back injuries and upper extremity injuries, but not for lower extremity injuries (P=0.4624, 0.1292 respectively)    Cusi et al.19:  No significant difference in lower back and groin injury  rate between intervention group and control group (P value was not reported by the study)   Results   Sherry et al.16:  Intervention was superior to the control in preventing hamstring strain re-injury in athletes (2 weeks post-return to sports P=0.00343, 1 year post-return to sports P=0.0059)  No direct measurements for trunk stabilization was performed Not possible to conclude that results were due to improvements in core stability  o  Summary • Overall, studies used different operational  definitions of core, different core stabilization interventions and different or absent direct and specific measurement of core stability and core strength • The studies provided inconclusive level 1b and 2b  evidence suggesting the effectiveness of core stabilization interventions in decreasing lower extremity injury or re-injury rate  o  Few quality studies examining the relationship between core stability and lower extremity injuries were found  o  Inconsistent evidence in support of core stability as a risk factor for predicting lower extremity injuries  o  Inconclusive evidence to support core stability training in prevention of lower extremity injuries  o  Review articles are written based highly on theory due to lack of scientific evidence • When research is added to theory  misrepresentation can occur  o  Example • “Research from the rehabilitation literature  has demonstrated the effectiveness of core stability exercises for reducing the likelihood of lower back and lower extremity injuries”9 • Studies referenced either did not have  outcome measures of core strength or stability, or used multiple interventions at once22  o  Muscles Which Constitute the “Core” • Leetun16 was referenced in the following  statement “A recent prospective study suggests that deficiencies in core muscle capacity may increase the risk of lower extremity injury”10 • The muscles referred to by Leetun14 are the  hip external rotators which can be a component of the “core” but alone are not considered the “core”  o  Three Subsystems3 • Neural subsystem controls the active  lumbopelvic musculature • Alters compressive forces between the passive bony components of the lumbopelvic region • Manages stability  o  Kinetic Chain Theory • Human movement occurs through a  sequencing of body segments from proximal to distal1 • Proximal base of support necessary for successful distribution of forces20,1 • Core muscle activation often preceded lower extremity muscle activity during movement5,6 • Deficits in core stability may alter loads tolerable by distal segments and place them at higher risk  o  No single universal definition of “core” or “core stability”  o  Limited number of studies available on topic  o  Meta-analysis not possible  o  Only included articles written in English  o  Major influence towards developing a standardized and universal definition of “core” and “core stability” • More comparable scientific studies to be  conducted • Promote standardized, valid and reliable  methods of assessing core stability • Facilitate interventions with specific parameters • Allow objective and functional outcomes to be  measured  o  Well Controlled, Longitudinal RCT • Examine the effectiveness of a core stability  intervention in the prevention of lower extremity injuries  • Measure Core Stability  • Pre- and post- intervention to ensure the results can be attributed to a difference in core stability  o  Suggested RCT • Intervention: • Pre-season to monitor injuries for entire season • Specify which subsystem is targeted • Exercises that isolate the specific muscles • Follow-up minimum of six months for all  participants • Methodological quality • Power analysis to ensure sufficient sample size • Well controlled study to limit confounding factors • Age, level of training, sport, ect.  o  Marc Roig  o  Charlotte Beck  o  Darlene Reid  o  Elizabeth Dean  1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.  19. 20.  Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Medicine. 2006;36:189-198. Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Disord. 1992; 5(4): 390-397. Panjabi MM. The stabilizing system of the spine. part I. function, dysfunction, adaptation, and enhancement. J Spinal Disord. 1992; 5(4): 383-389. Cresswell AG, Oddsson L, Thorstensoon A. The influence of sudden perturbations of trunk muscle activity and intra-abdominal pressure while standing. Exp Brain Res. 1994;3: 336-341. Hodges PW, Richardson CA. Contraction of the abdominal muscles associated with movement of the lower limb. Phys Ther. 1997;77:132-144. Hodges PW, Richardson CA. Feed-forward contraction of transversus abdominis is not influenced by the direction of arm movement. Exp Brain Res. 1997; 114: 362-370. van Dieen JH, Cholewicki JP. Trunk muscle recruitment patterns in patients with low back pan enhance the stability of the lumbar spine. Spine. 2003; 28(8):834-841. Hodges PW, Richardson CA. Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds. Arch Phys Med Rehab. 1999; 80(9): 1005-1012. Willardson JM. Core stability training: Applications to sports conditioning programs. Journal of Strength & Conditioning Research. 2007; 21: 979-985. Wilson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its relationship to lower extremity function and injury. J AM Acad Orthop Surg. 2005; 13:316-325. Myer GD, Chu DA, Brent JL, Hewett TE. Trunk and hip control neuromuscular training for the prevention of knee joint injury. Clinical Sports Medicine. 2008;27:425-448. Levels of evidence and grades of recommendation: The Oxford Center for Evidence Medicine. Available at: http:// www.cebm.net/levels_of_evidence.asp. Downs SH and Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health (1998); 52:377-384. Leetun, D. T., Ireland, M. L., Wilson, J. D., Ballantyne, B. T., & McClay Davis, I. (2004). Core stability measures as risk factors for lower extremity injury in athletes. Medicine & Science in Sport & Exercise; 36(6); 926–934. Peate, W. F., Bates, G., Lunda, K., Francis,S., 7 Bellamy, K. (2007). Core strength: A new model for injury prediction and prevention. Journal of Occupational Medicine and Toxicology; 2(3); 1-9. Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. Journal of Orthopaedic & Sports Physical Therapy. 2004;34:116-125. Zazulak BT, Hewett TE, Reeves NP, Goldberg B, Cholewicki J. Deficits in neuromuscular control of the trunk predict knee injury risk: A prospective biomechanical-epidemiologic study. Am J Sports Med. 2007b;35:1123-1130. Zazulak,B. T., Hewett, T. E., Reeves, N. P., Goldberg, B., & Cholewicki, J. (2007). Deficits in neuromuscular control of the trunk predict knee injury risk: A prospective biomechanical-epidemiologic study. The American Journal of Sports Medicine; 35(7); 11231130. Cusi, M. F., Juska-Butel, C. J., Garlick, D., & Argyrous, G. (2001). Lumbopelvic stability and injury profile in rugby union players. New Zealand Journal of Sports Medicine; 29; 14-19. Brukner P, Khan K. Clinical Sports Medicine. 3rd edition ed. North Rhyde: NSW: McGraw-Hill; 2007.  

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