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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

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Tara CameronSarah HonkanenWesley MaunuNicole StefansonSara ZboyaSophia ZhaoMarc Roigo Introductiono Methodso Resultso Discussiono Limitationso Conclusiono Clinical Implicationso Recommendations  for Future Researcho 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 establishedo 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 controlo Cresswell4• Transverse abdominis (TA) first muscle activated during expected and unexpected loading of the trunk• Anticipatory functiono Hodges & Richardson5,6• Same activation pattern found prior to upper and lower extremity movementso 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   à reduced spinal stabilityo 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 attentiono Most of the literature on this topic comes from review articles• Citing the same few authorso Willardson  2007: • Core stability training: Applications to sports conditioning programso Wilson et al. 2005 : • Core stability and its relationship to lower extremity function and injuryo Myer et al. 2008: • Trunk and hip control neuromuscular training for the prevention of knee joint injuryo To our knowledge no systematic review has been conducted on this topico 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 preventiono Databases• Medline (1950- Present)• EMBASE (1980- Present)• CINAHL (1982- Present)• SportDiscus• PubMed (1949- Present)o Web of Scienceo Grey Literatureo Last Search: January 20091. Title Screen2. Abstract Screen3. Full Text Screen• Using a standardized screening tool to determine consensus• Inclusion and Exclusion Criteria1. Measured core stability or provided a core stability training program as a component of the intervention2. Examined prevention, occurrence, or recurrence of musculoskeletal lower extremity injuries3. Included participants with a minimum mean age of 18 years who were generally healthy, trained or untrained4. Were written in Englisho Ability of the specific core musculature to stabilize the spine and pelvis in order to facilitate force transmission to the extremitieso 3 Core Musculature Subsystems:1. Inner spinal stabilizers capable of controlling the lumbar segments2. Outer spinal stabilizers concerned with controlling trunk movements3. Lumbopelvic-extremity muscles which act to maintain lumbopelvic stability on fixed extremities or produce movement of the extremities on a stable trunk and pelvis1. Were not experimental in design2. Examined only the prevention of injuries pertaining to the back3. Examined or included interventions that only measured or targeted muscles of subsystem IIIo Study Design• Sackett’s Levels of Evidence as described by Oxford Center for Evidence Medicine12o Methodological Quality• “Checklist for Measuring Quality” by Downs and Black13o 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 Studieso Meta-analysis not performed due to:o Study heterogeneityo Participantso Interventionso Outcome Measureso Methods of Measuring Core Stabilityo Duration of Follow-upo Inability to calculate effect size o Qualitative Analysiso Study Resultso Sackett’s Levels of Evidenceo Grades of Recommendation o Main Reasons for Exclusion:1. Review article, not experimental in design2. Failed to Measure core stability or provide a core stability intervention3. Failed to examine injury prevention4. Failed to investigate lower extremity injurieso No articles of relevance found with Web of Science or Grey Literature Searcho Downs and Black Tool• Range = 14-20/28• Mean = 16/28• 95.8% agreement between reviewersoExternal validity category¡ Core Stability as Risk FactorStudies Subject Sample size Clinical conditionDurationFollow-upStudy focusLeetun et.al 2004Varsity basketball & track athletes140(♀80 ♂60)Back and LE injury2 yrs Core  muscle strength/enduranceZazulak et.al 2007Collegiate athletes277  (♂140♀ 137)Knee injury 3 yrs Core neuromuscular controlZazulaket.al 2007Collegiate athletes277  (♂140♀ 137)Knee injury 3 yrs Core neuromuscular control¡ Core Stabilization InterventionStudies Subject Sample size Clinical conditionDurationFollow-upStudy focusPeate et.al 2007Firefighter 433  (♂408 ♀ 25)Back, UE, LE injury1 yr Core  muscle strength/enduranceCusiet.al 2001Rugby player39 Back and groin injury10 wks Core  muscle strength/enduranceSherry et.al 2004Athletes 24 Hamstring strains 2 wks & 1 yrafter return to sportCore neuromuscular controlagility o Injured vs. Uninjured athletes Ø Leetun et al.16:Ø Injured athletes demonstrated lower core stability measures, especially for hip abduction (P=0.02) and external rotation strength(P=0.01)Ø Zazulack et al.18:Ø Injured athletes demonstrated compromised core stability, measured as trunk displacement after sudden force release (P<0.05)o Injured vs. Uninjured athletes Ø Zazulack et al.17:Ø Injured female athletes had significantly decreased core stability , measured as errorin active proprioceptive repositioning (P≤ 0.05); injured male athletes did noto Lower Extremity Injury Predictors Ø Leetun  et al.14:ØHip external rotation strength was the sole significant predictor of lower extremity injuries in athletes (OR=0.86). Ø Zazulack et al.17,18 :Ø 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)ØMale athletes: history of low back pain was the only significant knee injury risk predictoro 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 athleteso Intervention• In all three studies, core stabilization exercises were used in combination with other interventionsØ Peate et al.15:ØMulti-disciplinary program with seminars emphasized functional movement, proper body mechanics, core muscles recruitment, worksite analysis, four physiotherapy ball core strengthening exercises Ø Cusi et al.19:ØPhysiotherapy ball for core strengthening in addition to a standard stretching and fitness program performed by the control groupo InterventionØ Sherry et al.16:ØProgressive agility and trunk stabilization exercises , and icingØControl group: static stretching and isolated progressive hamstring resistance exercise, and icingo 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 strengthPeate et al.15 Functional movement screenwork-related task performance Cusi et al.19 Lower extremity flexibility Back strengthSherry et al.16 No measurements of the coreKnee flexion strength, hop and sprint¡ ResultsØ Peate et al.15:Ø 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)Ø Cusi et al.19:ØNo significant difference in lower back and groin injury rate between intervention group and control group (P value was not reported by the study)¡ ResultsØ Sherry et al.16:ØIntervention 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)ØNo direct measurements for trunk stabilization was performedØNot possible to conclude that results were due to improvements in core stabilityo 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 rateo Few quality studies examining the relationship between core stability and lower extremity injuries were foundo Inconsistent evidence in support of core stability as a risk factor for predicting lower extremity injurieso Inconclusive evidence to support core stability training in prevention of lower extremity injurieso Review articles are written based highly on theory due to lack of scientific evidence• When research is added to theory misrepresentation can occuro 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 once22o 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 stabilityo 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 for injury20, 1o No single universal definition of “core” or “core stability”o Limited number of studies available on topico Meta-analysis not possibleo Only included articles written in Englisho 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 measuredo 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• Have a comprehensive definition of core stabilityo 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 Roigo Charlotte Becko Darlene Reido Elizabeth Dean1. Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Medicine. 2006;36:189-198.2. Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Disord. 1992; 5(4): 390-397.3. Panjabi MM. The stabilizing system of the spine. part I. function, dysfunction, adaptation, and enhancement. J Spinal Disord. 1992; 5(4): 383-389. 4. 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: 336-341.5. Hodges PW, Richardson CA. Contraction of the abdominal muscles associated with movement of the lower limb. Phys Ther. 1997;77:132-144.6. Hodges PW, Richardson CA. Feed-forward contraction of transversus abdominis is not influenced by the direction of arm movement. Exp Brain Res. 1997; 114: 362-370.7. 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):834-841.8. 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): 1005-1012.9. Willardson JM. Core stability training: Applications to sports conditioning programs. Journal of Strength & Conditioning Research. 2007; 21: 979-985. 10. Wilson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its relationship to lower extremity function and injury. J AM Acad OrthopSurg. 2005; 13:316-325.11. 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;27:425-448.12. Levels of evidence and grades of recommendation: The Oxford Center for Evidence Medicine. Available at: http:// www.cebm.net/levels_of_evidence.asp.13. 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); 52:377-384.14. 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); 926–934.15. 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); 1-9.16. Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. Journal of Orthopaedic & Sports Physical Therapy. 2004;34:116-125.17. 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. 18. 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); 1123-1130.19. 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. 20. Brukner P, Khan K. Clinical Sports Medicine. 3rd edition ed. North Rhyde: NSW: McGraw-Hill; 2007. 

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