Journal of Bodywork & Movement Therapies (2010) 14, 50e54 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt WORKSITE HEALTH PROMOTION Functional fitness improvements after a worksite-based yoga initiative Virginia S. Cowen, Ph.D.* Department of Health, Physical Education and Dance, Queensborough Community College, The City University of New York, 222-05 56th Avenue, Bayside, NY 11364, USA Received 9 September 2008; received in revised form 14 February 2009; accepted 24 February 2009 KEYWORDS Summary This study explored the benefits of yoga on functional fitness, flexibility, and Yoga; perceived stress. A quasi-experimental design was used to measure benefits of yoga in sample Mind-body; of firefighters from a major metropolitan fire department. Yoga classes were conducted Exercise; on-shift, in the fire stations over the period of 6 weeks. The classes included pranayama Worksite health (breathing), asana (postures), and savasana (relaxation); 108 firefighters enrolled in the study, promotion most were physically active but had no prior experience with yoga. Baseline and post-yoga assessments were completed by 77 participants. Paired t-tests revealed significant improvements in the Functional Movement Screen, a seven item test that measures functional fitness. Improvements were also noted in trunk flexibility and perceived stress. Participants also reported favorable perceptions of yoga: feeling more focused and less musculoskeletal pain. These findings e along with the retention of the majority of the participants e indicate that participants benefited from yoga. ª 2009 Elsevier Ltd. All rights reserved. Background firefighters to be able to respond to stressful situations (Blimkie et al., 1977) and traumatic events (Beaton et al., Firefighting operations require superior physical fitness 1999). Within the past few decades, there has been including strength (Gledhill and Jamnik, 1992), endurance growing interest in promoting physical fitness for (Adams et al., 1986), aerobic fitness (Adams et al., 1986), firefighters (Garver et al., 2005). General health promotion and balance (Punakallio, 2003). In addition to ability to (Barnard and Anthony, 1980) and exercise programs (Adams physically perform job-related duties, it is important for et al., 1986; Barnard and Anthony, 1980; Roberts et al., 2002) have noted improvements in physical fitness. * Tel.: þ1 718 631 6322; fax: þ1 718 631 6333. Research has also found correlations between overall E-mail address: [email protected] physical fitness and performance of job-related (func- tional) tests (Punakallio et al., 2004; Rhea et al., 2004). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.02.006
Functional fitness improvements 51 Mindful activities, such as yoga, have not been explored in Total score can range from 0 to 21 with a higher score this population. considered to be optimal. Psychological stress was measured using the Perceived Stress Scale (Cohen et al., Yoga is traditionally a non-competitive and mindful 1983). This 14-item scale considered to provide a reliable activity. Breathing and awareness are integral parts of and valid assessment of stress. Total scores range from 0 to yoga practice (Birkel and Edgren, 2000), and important 56 with a lower score considered to be optimal. Partici- aspects of firefighter job performance. Yoga postures are pants were asked for additional descriptive data including performed in a relaxed manner (Kerr, 2000) and their current physical activity habits, recent musculoskel- sequenced to emphasize balance between strength and etal pain, and previous experience with yoga. At follow-up flexibility (Brust, 1993). Research indicates that yoga yoga participants were invited to express their opinions practice is associated with improvements in overall about yoga and their experience as participants in the physical fitness (Cowen and Adams, 2005; Tran et al., study. 2001), along with increases in muscular strength, endur- ance, and flexibility (Raju et al., 1997; Telles et al., 1993; Yoga class Tran et al., 2001). Research also supports the belief that yoga is beneficial in reducing perceived stress (Berger and The yoga classes included pranayama (breathing), asana Owen, 1988; Cowen and Adams, 2005) and improving (postures), and savasana (relaxation). Yoga classes were physiological measures of stress (Murugesan et al., 2000; conducted in stations, on-shift, at times and in locations Telles et al., 1993). agreed upon by the participants. All firefighters who were on shift in the stations at the time of class were welcome This study was undertaken to evaluate the benefits of to participate, this included firefighters temporarily yoga in a sample of firefighters. The overall hypothesis was assigned to crews (called ‘‘rovers’’). Firefighters who that improvements in functional fitness, flexibility and were not enrolled in the study were informed of the perceived stress would be noted after participation in purpose of the class and the study. If they chose to a series of yoga classes. A secondary hypothesis was that participate, their attendance was recorded by the yoga would be favorably perceived and of interest to the instructor. No other data were recorded for non- firefighters as a worksite-based program. participants. Methods Data were analyzed using SPSS version 11.0. Paired t- tests were used to compare measurements prior to yoga Recruitment and enrollment (baseline) and after 10 yoga sessions (follow-up). The alpha level was set equal to .05. A quasi-experimental design was used for this study. Volunteers were recruited to participate in yoga classes. In Results order to enroll in the study all potential participants were required to be: employed as firefighters, age 18e65, able to One hundred and eight career firefighters were enrolled engage in physical activity, and not regular yoga practi- in the study. Study participants attended an average of tioners. Nineteen fire crews volunteered to participate in four yoga classes during the study. The majority of the the study, 108 firefighters from these crews enrolled as participants. Table 1 Pre- and post-yoga means. The Physical Activity Readiness Questionnaire (PAR-Q) Pre-yoga Post-yoga was used to screen potential study volunteers. Prior to engaging in any of the assessments, all participants were Mean S.D. Mean S.D. required to read and sign an informed consent form detailing the study procedures and their rights as a research Functional Movement 13.25 2.255 16.55 2.131 participant. This study was approved by the Arizona State Screena 17.70 5.168 16.17 5.048 University and the Queensborough Community College 26.46 9.814 28.06 9.577 Institutional Review Boards. Baseline perceived stressb Demographic, behavioral, and physical data were collected for each participant in the study prior to the first Trunk flexibilityc yoga class, and after the last yoga class. Attendance was recorded for all yoga classes. The Functional Movement a The Functional Movement Screen (Cook, 2001) is a seven Screen was used to measure functional fitness (Cook, 2001). item test designed to measure functional fitness by evaluating This seven item test (See Appendix A) was designed to quality of movement. Each item is scored on a scale of 0e3. measure quality of movement. Stability, mobility, and Test scores can range from 0 to 21. Higher score is considered to flexibility are evaluated when the subject performs multi- be optimal. joint movements: squat, hurdle step, lunge, shoulder mobility, leg raise, push-up, and trunk rotation,. Each item b Measured with the Perceived Stress Scale (Cohen et al., is scored on a scale of 0e3. Zero is awarded when subject 1983). Fourteen items are scored on a scale of 0e4. Test scores fails to perform the movement or reports pain, three is can range from 0 to 56. Lower score is considered to be optimal. awarded when subject executes movement without error, one and two are awarded when subject has some degree of c Trunk flexibility was measured in centimeters with a Sit and difficulty but is able to partially execute the movement. Reach Box. Higher score indicates more flexibility of trunk, and posterior leg.
52 V.S. Cowen Table 2 Pre- and post-yoga paired sample t-test. Pre-and post-yoga difference 95% confidence interval t p-Value Mean S.D. Lower Upper Functional Movement À3.30 2.317 À3.82 À2.77 À12.491 .000 Screena 1.53 4.596 0.49 2.58 2.926 .005 4.350 À.62 .002 Baseline perceived À1.60 À2.59 À3.235 stressb Trunk flexibilityc a The Functional Movement Screen (Cook, 2001) is a seven item test designed to measure functional fitness by evaluating quality of movement. Each item is scored on a scale of 0e3. Test scores can range from 0 to 21. Higher score is considered to be optimal. b Measured with the Perceived Stress Scale (Cohen et al., 1983). Fourteen items are scored on a scale of 0e4. Test scores can range from 0 to 56. Lower score is considered to be optimal. c Trunk flexibility was measured in centimeters with a Sit and Reach Box. Higher score indicates more flexibility of trunk, and posterior leg. participants (N Z 104, 96%) were male, and four were benefits from yoga if classes were offered more female (4%). Participants ranged in age from 22 to 60 frequently. (mean age 40.6 years, S.D. 9.2). Most (81.8%, N Z 88) had no prior experience with yoga. The participants in Discussion the study were physically active off-the-job. At base- line, 75% of the participants (N Z 63) reported that they Improvements in functional fitness, flexibility, and engaged in moderate or vigorous exercise at least four perceived stress indicated that this study was success- of the seven days prior to the study. Complete follow-up ful. The on-shift delivery of the yoga classes enabled tests were completed by 77 participants. None of the a large number of firefighters to participate. In addition participants formally withdrew from the study, but 31 to the firefighters enrolled in the study, 129 rovers were not available during the follow-up period (due to attended one or more yoga classes. Although it is not alarm calls, transfer to another job or station, or standard practice in research to allow outside partici- scheduled time off.) pants in an intervention, it was acceptable in this project for two reasons. First, goal of the program Paired t-tests revealed significant improvements in presented in this paper was to evaluate how yoga would functional fitness as measured by the overall score on the be perceived by firefighters. Attendance and participa- Functional Movement Screen: pre-yoga mean 13.3 tion by firefighters would provide an additional means (S.D. Z 2.3), post-yoga mean 16.5 (S.D. 2.2), of addressing this question in a general manner. t(76) Z À12.49, p < .0005. The 95% confidence interval for Second, teamwork (Murphy et al., 1994) and social the mean difference was À3.82 to À2.77. Significant support (Regehr et al., 2003) have been identified as improvements in trunk flexibility were noted on the Sit and important aspects of the firefighter’s workplace. Reach test: pre-yoga mean 26.46 cm (S.D. Z 9.814), post- Including, rather than excluding, these individuals yoga mean 28.06 (S.D. Z 9.577), t(76) Z À3.24, p Z .002. seemed both logical and feasible given characteristics The 95% confidence interval for the mean difference was of the setting and the participants. Little is known À2.59 to À.62. Significant reduction in stress was found on about the possible dose response relationship for yoga, the Perceived Stress Scale: pre-yoga mean 17.7 which offers another investigative opportunity. Overall, (S.D. Z 5.2), post-yoga mean 16.2 (S.D. Z 5.0), yoga was favorably received by the firefighters and the t(76) Z 2.93, p Z .005. The 95% confidence interval for the findings of the study indicate that yoga offers physical mean difference was .49e2.58 (Tables 1 and 2). and perceptual benefits for this population. These findings support previous research supporting Appendix A the physical benefits of yoga practice. All participants Functional Movement Screen who completed follow-up assessments stated that they felt that yoga participation had some benefit for them Seven items comprise the Functional Movement Test (See either professionally or personally. Responses were Figure 1aeg) clustered into general topic areas: 56% reported that they felt yoga had a positive impact on their job The test aims to measure functional mobility, stability, performance: 62% of the participants felt more flexible, and flexibility (Cook, 2001). The scores for each item on the 41% calmer/more focused, 17% reported less musculo- test range from 0 (unable to properly execute movement, skeletal pain, 16% improved breathing control, and 15% or pain is present on movement) to 3 (able to execute better balance/core strength. Additionally participants movement without difficulty or compensation.) Possible reported that they found the relaxation techniques composite scores for the overall test range from 0 to 21, helpful and useful outside of class. Several participants with 21 indicating optimal performance. indicated that they anticipated more pronounced
Functional fitness improvements 53 Figure 1 Appendix B techniques may be used including: regulating by lengthening or shortening the breath, retaining the breath, alternating Pranayama is the practice of breathing exercises that aims to the use of the nostrils or mouth, engaging accessory muscles improve mental focus and cleanse the body. A variety of of respiration, and adding vocalizations to the breath. Asana is the physical practice of yoga exercises. Dynamic movements and static postures are performed with the
54 V.S. Cowen body in sitting, standing, supine, and prone positions. The Cowen, V.S., Adams, T.B., 2005. Physical and perceptual benefits dynamic movements warm the joints of the body and the of yoga asana practice: results of a pilot study. Journal of static postures require mental focus. Breathing during the Bodywork and Movement Therapies I9, 211e219. exercises helps to improve mental focus. Practice of asana aims to balance strength and flexibility of the body and Garver, J.N., Jankovitz, K.Z., Danks, J.M., Fittz, A.A., Smith, H.S., mind. Davis, S.C., 2005. Physical fitness of an industrial fire depart- ment vs. a municipal fire department. Journal of Strength and Savasana is relaxation that may be performed before, Condtioning Research 19 (2), 310e317. during, or after yoga practice. The term savasana refers to corpse pose when the body is supine, motionless, yet still Gledhill, N., Jamnik, V., 1992. Characterization of the physical mentally aware. Progressive relaxation of the body and demands of firefighting. Canadian Journal of Sport Sciences 17 regulation of breathing is performed to promote conscious (3), 207e213. relaxation. Savasana aims to refresh the body and mind and promote lifestyle stress reduction. Kerr, K., 2000. Relaxation techniques: a critical review. Physical and Rehabilitation Medicine 12, 51e89. References Murphy, S., Beaton, R., Cain, K., Pike, K., 1994. Gender differences Adams, T., Yanowitz, F., Chandler, S., Specht, P., Lockwood, R., in fire fighter job stressors and symptoms of stress. Women and Yeh, M., 1986. A study to evaluate and promote total fitness Health 22 (2), 55e69. among firefighters. Journal of Sports Medicine 26 (4). Murugesan, R., Govindarajulu, N., Bera, T., 2000. Effect of Barnard, R., Anthony, D., 1980. Effect of health maintenance selected yogic practices on the management of hypertension. programs on Los Angeles City firefighters. Journal of Occupa- Indian Journal of Physiology and Pharmacology 44 (2), 207e210. tional Medicine 22 (10), 667e669. Punakallio, A., 2003. Balance abilities of different-aged workers in Beaton, R., Murphy, S., Johnson, C., Pike, K., Corneil, W., 1999. Coping physically demanding jobs. Journal of Occupational Rehabili- responses and posttraumatic stress symptomatology in urban fire tation 13 (1), 33e43. service personnel. Journal of Traumatic Stress 12 (2), 293e308. Punakallio, A., Lusa, S., Luukkonen, R., 2004. Functional, postural Berger, B.G., Owen, D.R., 1988. Stress reduction and mood and perceived balance for predicting the work ability of fire- enhancement in four exercise modes: swimming, body condi- fighters. International Archives of Occupational and Environ- tioning, Hatha yoga, and fencing. Research Quarterly for Exer- mental Health 77, 482e490. cise and Sport 59 (2), 148e159. Raju, P.S., Prasad, K.V., Venkata, R.Y., Murthy, K.J., Reddy, M.V., Birkel, D.A., Edgren, L., 2000. Hatha yoga: improved vital capacity 1997. Influence of intensive yoga training on physiological of college students. Alternative Therapies in Health and Medi- changes in 6 adult women: a case report. Journal of Alternative cine 6 (6), 55e63. and Complementary Medicine 3 (3), 291e295. Blimkie, C., Rechnitzer, P., Cunningham, D., 1977. Heart rate and Regehr, C., Hill, J., Knott, T., Sault, B., 2003. Social support, self- catecholamine responses of fire fighters to an alarm. Canadian efficacy and trauma in new recruits and experienced fire- Journal of Applied Sport Sciences 2 (3), 153e156. fighters. Stress and Health 19, 189e193. Brust, H.A., 1993. The Yoga of Mindfulness: a Buddhist Path for Rhea, M.R., Alvar, B.A., Gray, R., 2004. Physical fitness and job Body and Mind. Editions Duang Kamol, Bangkok, Thailand. performance of firefighters. Journal of Strength and Condtion- ing Research 18 (2), 348e352. Cohen, S., Kamarck, T., Mermelstein, R., 1983. A global measure of perceived stress. Journal of Health and Social Behavior 24 (4), Roberts, M., O’Dea, J., Boyce, A., Mannix, E., 2002. Fitness levels 385e396. of firefighter recruits before and after a supervised exercise training program. Journal of Strength and Conditioning Cook, G., 2001. Baseline sports-fitness testing. In: Foran, B. (Ed.), Research 16 (2), 271e277. High-Performance Sports Conditioning. Human Kinetics, Cham- paign, IL, pp. 19e48. Telles, S., Nagarathna, R., Nagendra, H.R., Desiraju, T., 1993. Physi- ological changes in sports teachers following 3 months of training in Yoga. Indian Journal of Medical Sciences 47 (10), 235e238. Tran, M.D., Holly, R.G., Lashbrook, J., Amsterdam, E.A., 2001. Effects of hatha yoga practice on the health-related aspects of physical fitness. Preventive Cardiology 4 (4), 165e170.
Journal of Bodywork & Movement Therapies (2010) 14, 55e64 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt TRADITIONAL JAPANESE MASSAGE STUDY Effects of Anma therapy (traditional Japanese massage) on body and mind Nozomi Donoyama, MS a,*, Tsunetsugu Munakata, Ph.D. b, Masanao Shibasaki, MD, Ph.D. c a Course of Acupuncture and Moxibustion, Department of Health, Faculty of Health Sciences, Tsukuba University of Technology, 4-12-7 Kasuga, Tsukuba, Ibaraki 305-8521, Japan b Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki 305-8577, Japan c Allergy and Immunology, Department of Health, Faculty of Health Sciences, Tsukuba University of Technology, 4-12-7 Kasuga, Tsukuba, Ibaraki 305-8521, Japan Received 6 September 2007; received in revised form 5 June 2008; accepted 11 June 2008 KEYWORDS Summary Introduction: Anma therapy is a traditional style of Japanese massage, one of Anma therapy; touch and manual therapies, and one of the most popular CAM therapies in Japan. It was Traditional Japanese brought from China in the 6th century and, while based on the theory of Chinese medicine, massage; it developed in Japan according to Japanese preference and has recently come to include Muscle stiffness in the theories of Western medicine. The purpose of this study was to clarify the physical and psycho- neck and shoulder; logical effects of Anma therapy. Visual Analogue Scale Participants and methods: Fifteen healthy female volunteers in their fifth decade, with (VAS); chronic muscle stiffness in the neck and shoulder, received two interventions: 40-min Anma State anxiety; therapy and 40-min rest intervention. The design was cross-over design. Participants were Salivary cortisol; randomly divided into two groups. Group A was started on Anma therapy from the first day fol- Secretory lowed by the rest intervention after a 3-day interval. The order of the Anma therapy and the immunoglobulin rest intervention reversed for Group B. Visual Analogue Scale (VAS) score for muscle stiffness in A (s-IgA) the neck and shoulder, state anxiety score, and salivary cortisol concentration levels and secretory immunoglobulin A (s-IgA) were measured pre- and post-interventions. Results: Anma therapy significantly reduced VAS scores and state anxiety scores. S-IgA concen- tration levels increased significantly across both groups. Conclusion: Anma therapy reduced muscle stiffness in the neck and shoulder and anxiety levels in this pilot study of 50-year-old females. ª 2008 Elsevier Ltd. All rights reserved. * Corresponding author. Tel.: þ81 29 858 9631; fax: þ81 29 855 1745. E-mail address: [email protected] (N. Donoyama). 1360-8592/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.06.007
56 N. Donoyama et al. Background mechanism of the clinical effect of Anma therapy: For example, in anesthetized rats, abdominal pressure stimu- What is Anma therapy? lation inhibited gastrointestinal motility and the excitatory gastric response elicited by pressure stimulation of a hind Anma therapy is a traditional Japanese massage brought paw, which are reflex responses. Moreover, cutaneous from China as ‘‘Do-in and Ankyo’’ in the 6th century at stimulation by brushing produced a reflex inhibition of the approximately the same time as acupuncture, moxibustion, sympathetic nervous system to the adrenal medulla that and Chinese medicine were introduced. ‘‘Do-in and Ankyo’’ resulted in decreased secretion of catecholamines. Thus, were a kind of touch and manual therapy including move- tactile and pressure stimulation affects the autonomic ment and breathing exercises that were designed to stim- nervous system and internal secretion through the brain to ulate the flow of ki, or life energy, throughout the body. act on physical modulation. Tactile and pressure stimula- This therapy is considered to be capable of rebalancing the tion to skin and muscles are important methods in Anma flow of vital energy through the meridians. It originated as therapy, so organ reactions to somatosensory input a way to prevent disease, maintain and promote good (‘‘somato-autonomic reflexes’’) are considered to be the health. The art developed according to Japanese prefer- effective mechanism of Anma therapy. ences, supported by public confidence, and at present, it is called Anma therapy (‘‘an’’ is the Japanese term for Anma therapy has been empirically shown to maintain applying pressure and kneading, and ‘‘ma’’ the term for well-being, promote health, treat illness, and prevent stroking), one of the most popular therapies in Comple- disease. It has often been used to treat symptoms which are mentary and Alternative Medicine (CAM) in Japan. not treated by medical doctors, such as muscle stiffness in the neck and shoulder, lower back pain, musculoskeletal or Recently, Shiatsu (literally, in Japanese, ‘‘pressing with arthritic pain, chronic pain, neuralgia, autonomic nerve the thumb’’) has become famous worldwide, although it is disorders, fatigue and so on (Donoyama and Katahira, 2002; only one technique of many in Anma therapy. In Japan, Oride et al., 2002; Yamashita et al., 2002). a massage practitioner license is given only to those who have passed a national examination, which allows the Introduction practice of all kinds of touch and manual techniques, including Anma therapy, Shiatsu, and other massage ther- Recently, the use of CAM therapies has increased around apies such as Western and other Asian massage styles. In the world, and the prevalence of massage therapy has modern day Japan, the terms ‘‘Anma therapy’’ and rapidly increased, particularly because of its emphasis on ‘‘massage therapy’’ are commonly used synonymously. The stress reduction and increased physical and psychological public call Anma therapy ‘‘massage’’; however, scholasti- relaxation (Lovas et al., 2002). According to the surveys, cally there are differences between Anma therapy, or the rate of persons who have used some form of CAM traditional Japanese massage and Western style massage. therapy in the past 1 year is 42% of the individuals in the Anma therapy is composed of seven techniques (Kimura USA (Eisenberg et al., 1998), 20% in the UK (Ernst and et al., 2003), including stroking, kneading, and pressing, White, 2000), and 76% in Japan (Yamashita et al., 2002). with kneading being used most frequently. These stimuli Among these, individuals who received massage therapy are applied to the deep muscle, usually through clothes, to were 11%, 1%, and 15% in the USA (Eisenberg et al., 1998), achieve tactile and pressure sensation, whereas Western the UK (Ernst and White, 2000), and in Japan (Yamashita style massage is applied directly to the skin using stroking et al., 2002), respectively. Moreover, in Sweden, 17% of technique more frequently with softer superficial tactile respondents (patients) reported having consulted a CAM stimulation and lubrication. provider during the preceding year and 40% reported that the most frequently used CAM therapy was massage In the classical works of traditional Japanese medicine, (Al-Windi, 2004). the stimulation produced by Anma therapy was claimed to affect the functions of not only the body but also of the mind The main goal of Anma therapy in Japan is to treat because it was based on traditional Chinese medicine. In musculoskeletal symptoms (Yamashita et al., 2002), among traditional Chinese medical theory, it is hypothesized that which, muscle stiffness in the neck and shoulder is one of the body and the mind are associated with each other; the most frequent (Donoyama and Katahira, 2002; Oride disorders of the seven emotionsdanger, joy, worry, grief, et al., 2002). In addition, according to national surveys in melancholy, fear, and fright result in injury to physical Japan (Health and Welfare Statistics Association, 1996, organs, and physical and psychological strain were thought to 2001), the most frequent symptoms reported by the public be etiology (Simple Question; Spiritual Axis). According to were muscle stiffness in the neck and shoulder and lower one classical work (Simple Question), Anma therapy is back pain, and the number of people receiving Anma/ effective in the treatment of muscle stiffness when stressful massage therapy increased. Thus, Anma therapy is one of hassles cause the flow of ki in the meridians to stagnate. the most popular CAM therapies in Japan, a therapy from which patients expect much. In spite of its long history and Modern Anma therapy has come to embrace a wider popularity, Anma therapy only has anecdotal evidence for acceptance of aspects of Western medicine, such as in its effectiveness and no evidence resulting from studies anatomy and physiology. Some studies (Sato and Schmidt, employing scientific methodology can be found from Med- 1971; Cao et al., 1992; Sato et al., 1996, 1997, 2002) have line searches. revealed that tactile and pressure stimulation given to the surface of the body in anesthetized rats elicited a somato- As for Western style massage therapy, many scientific visceral reflex, which is currently believed to be the studies aimed at verifying its effectiveness have been
Effects of Anma therapy (traditional Japanese massage) on body and mind 57 published recently. Previous studies on massage therapy unpleasant sensation, strain, stiffness, ache, and/or pain in (Field, 1998, 2000; Field et al., 1992, 1997, 1998; Hart et al., the regio axillaris and/or regio scapularis muscles (Hir- 2001; Hernandez-Reif et al., 2000) have indicated that anxiety abayashi, 2002; Ishii and Hirasawa, 2002). scores, salivary stress hormone (cortisol) levels and cate- cholamine levels in blood decrease significantly, and physical All participants gave their informed consent, were symptoms improve, after massage treatment compared to screened for conditions of chronic muscle stiffness in the control groups. In addition, some studies on the effects of neck and shoulder, and the absence of medical disease was massage therapy on immunological function have been pub- confirmed by a doctor. Participants were asked to avoid lished, using secretory immunoglobulin A in saliva (s-IgA) as an strenuous exercise on the days of participation in the study indicator (Green and Green, 1987; Groer et al., 1994). Results and to avoid eating and drinking within 2 hours of partici- show s-IgA concentration increase in massage groups. pation in the study. Thus, a preliminary study on the effect of Anma therapy Interventions was undertaken; Visual Analogue Scale (VAS) of clients’ symptoms, state anxiety, salivary cortisol, and s-IgA were All participants received two interventions on 2 different measured (Donoyama et al., 2005). In the study, three days. One was Anma therapy and the other was a rest female clients participated in five Anma therapy sessions intervention. The 40-min Anma therapy was performed by (two times per week for two and one-half consecutive a female therapist in possession of a national massage weeks) of 40 min’ duration. Immediate changes between practitioner license with greater than 15 years’ treatment pre- and post-therapy, and longer-term changes between experience. On the massage table, Anma therapy was first and last session were observed. According to the performed on the body, except the face, head and results, the degree of all chief complaints and state anxiety abdomen, with a focus on the neck and specific points of scores exhibited both immediate and longer-term shoulder stiffness. Anma therapy techniques were standard decreases across all three women. Another immediate versions composed mainly of kneading and lesser amounts change seen in Anma therapy was an increase in s-IgA levels of stroking and pressing, with intensity of stimulation in saliva. Salivary cortisol concentrations, however, applied within the range of comfort. remained unchanged. These results suggested that Anma therapy may be effective in ameliorating physical symp- Outline of the procedure of the Anma therapy is toms and anxiety, and in enhancing immune function. described briefly in Box 1. Changes of salivary cortisol concentration by Anma therapy were different from those of Western style massage. In the Rest Intervention (controls), participants lie on the However, these statements were premature because massage table and rest for 40 min, without Anma therapy. sample size was small and the conditions were varied. Design and setting In the present study, a larger sample size was prepared, sample conditions were controlled, and the effects of Anma The design of this study was cross-over. Participants were therapy were examined utilizing the VAS of participants’ assigned randomly to two groups: Group A (nine subjects); symptoms, state anxiety, salivary cortisol, and s-IgA, using Anma therapy was performed on the first day, and the rest statistical analyses. intervention was performed 3 days after. Group B (eight subjects); received the rest intervention on the first day, Materials and methods and Anma therapy after a 3 days interval. The participants did not know to which group they had been assigned until Participants the first intervention. Seventeen healthy volunteers were recruited for partici- Two persons in Group B withdrew from participation on pation in this study, by three part-time female workers the first day due to family circumstances. Therefore, the employed at the university. Inclusion criteria for gender, subject number in Group B decreased to six subjects prior age, and physical conditions were as follows: to the beginning of the study. No subjects withdrew from participation during the study. The mean ageÆstandard (i) to be a female in the fifth decade of life; deviation (S.D.) of participants in the study was 55.4Æ2.1 (ii) to feel chronic muscle stiffness around neck and years of age and the mean Body Mass Index (BMI)ÆS.D. was 21.2Æ1.8. In Group A, the mean ageÆS.D. was 55.1Æ2.2 shoulder; years of age and the mean BMIÆS.D. was 21.2Æ2.0, and in (iii) to have no disease requiring medical intervention; Group B, the mean ageÆS.D. and BMIÆS.D. were 55.8Æ2.1 (iv) to desire Anma therapy; years of age and 21.3Æ1.4, respectively. Unpaired (inde- (v) and especially to eliminate the influence from sexual pendent samples, two-tailed) t-test was performed in order to determine the differences in basic physical attributes hormones suggested in the study by Kirschbaum et al. between the two groups, and it was confirmed that there (1999) showing that salivary cortisol levels are affected were no significant differences in age (t (d.f. 13)Z0.6, by menstrual cycle, to be a few years post-menopause; pZ0.54) or BMI (t (d.f. 13)Z0.09, pZ0.93). and (vi) to feel no current symptoms of menopause. Procedure Muscle stiffness in the neck and shoulder is defined as Upon presentation to the laboratory, participants washed symptoms which produce a feeling of annoyance, an their mouths out with water from a disposable paper cup
58 N. Donoyama et al. Box 1. Summary description of Anma procedure I. Lying down on one side for 17 min A. Procedure for the back including the shoulder, the back, and the lower back (1) Stroking starts at the base of the neck along the upper shoulder to the shoulder joint (2) Downward strokes along the full length of the back, starting at the base of the neck down to the waist (3) Thumb kneading by circular or linear (back and forth) movement: the upper shoulder from the side of the 7th cervical vertebra (Cv7) to the acromion along the trapezius (4) Thumb kneading by circular or linear movement: from Cv7 via the superior angle of the scapula and the supraspinous fossa to the acromion, on the levator scapulae, rhomboid, and supraspinatus (5) Thumb kneading by linear movement along the spine: from the side of Cv7 to the side of the 5th lumbar vertebrae (Lv5) on the erector spinae and the quadratus lumborum (6) Thumb or other four-finger kneading by circular or linear movement on the medial and lateral border of scapula (7) Heel of the hand kneading by circular movement on the infraspinous fossa (8) Downward strokes again along the length of the back, starting at the base of the neck down to the waist (9) Stroking again starting at the base of the neck along the upper shoulder to the shoulder joint B. Procedure for the upper limb and the hand (1) Stroking down from the shoulder to the fingertips (2) Palm grasp kneading over the upper limb on the deltoid (3) Palm grasp kneading over the upper front limb on the biceps brachii (4) Palm grasp kneading over the back of the upper limb on the triceps brachii (5) Thumb kneading on the back of the forearm (6) Palm grasp kneading on the front and the side of the forearm (7) Thumb kneading on the hand (8) Knead and squeeze each finger along the full length using the thumb and the index (9) Stroking down from the shoulder to the fingertips C. Procedure for the neck (1) Stroking starting at the superior nuchal line along the neck to the base of the neck (2) Thumb kneading over the back of the neck on the semispinal capitis, the splenius capitis, and the trapezius descending part (3) Thumb, two-finger (thumb and index), or four-finger kneading to the side of the neck, on the sternocleidomastoid (4) Apply four-finger kneading to the front of the neck (5) Thumb kneading and pressure along the superior nuchal line (6) Stroking again starting at the superior nuchal line along the neck to the base of the neck D. The cycle starts again with item A E. Procedure for the lower limb and the foot (1) Stroking from the buttock to the toes (2) Kneading over the buttock with the heel of the hand (3) Palm kneading on the front thigh, on the quadriceps femoris muscle (4) Palm grasp kneading to the back thigh or hamstrings (5) Palm grasp kneading on the patella (6) Thumb kneading on the front lower leg (7) Palm grasp kneading on the calf muscles (8) Palm grasp kneading of the Achilles tendon (9) Finger kneading over the top of the foot (10) Thumb kneading and pressure on the sole (11) Knead and squeeze each toe along the length using thumb and index finger (12) Intermittent palm pressure on the entire leg (13) Stroking again from the buttock to the toes II. Lying down on the opposite side, repeat A B C D E for 17 min III. Conclusion: in the prone position for 6 min (All the techniques in this concluding section are done simultaneously on the left and right side of the subject) (1) Stroking starts at the superior nuchal line along the sides of the neck and the upper shoulders to the shoulder joints (2) Downward strokes along the full length of the back, starting at the base of the neck down to the waist
Effects of Anma therapy (traditional Japanese massage) on body and mind 59 (3) Grasp hand kneading, thumb kneading, and pressure over the back of the neck (4) Four-finger kneading and pressure on the sides of the neck (5) Grasp hand kneading, thumb kneading, and pressure on the upper shoulder (6) Thumb kneading and pressure along the spine (7) Palm grasp hand kneading over the sides of the back, from the waist to the shoulder jointsdlatissimus dorsi (8) Downward strokes again along the full length of the back (9) Stroking again from the superior nuchal line along the sides of the neck and the upper shoulders to the shoulder joints Note: It is recommended that the guide book by Kimura et al. (2003) should be referred to for more detailed infor- mation on the basic techniques of Anma therapy. and took a 15-min rest. Then, a saliva sample was obtained, intervention was conducted. On the next morning, and participants answered self-assessments of the neck and they were delivered to the assay company (SRL Inc., shoulder stiffness condition and feeling of anxiety. A 40-min Tsukuba, Japan). Assays were conducted for concen- intervention was then performed. After the session, tration levels of salivary cortisol and s-IgA in samples assessments were performed again. Each time, the exper- by g-cortisol and Enzyme Immunoassay (EIA) s-IgA test, iments began at 5 p.m. in consideration of the circadian respectively. rhythms of cortisol and s-IgA in saliva (Walker et al., 1984; Dimitriou et al., 2002). Statistical analysis This study was approved by Human Ethics Committee of To assess the immediate effects of Anma therapy the Institute of Health and Sport Sciences, University of comparing to those of rest without Anma therapy, VAS, Tsukuba and performed according to the ethical standards state anxiety, salivary cortisol concentration level, and set forth in the Helsinki Declaration in its revised version of s-IgA concentration level were analyzed by repeated 1975 and its amendments of 1983, 1989, and 1996. measures analyses of variance (ANOVA). To assess the longer-term effects of Anma therapy, repeated measures Measurements ANOVA were performed again. Moreover, to clarify differ- ences between Anma therapy and the rest intervention (i) The VAS was used to assess the severity of the effects on each item of the state anxiety, significant subjective symptom, muscle stiffness in the neck and differences between pre- and post-intervention scores for shoulder. A sheet of paper (width 100 mmÂheight each of the 20 State Anxiety items were determined by 40 mm) was given to the subject and it was explained paired (two-tailed) t-test. All statistical analyses were that the left edge of the paper represented no symp- performed by SPSS 15.0. Alpha was set equal to 0.05, toms and the right edge represented the most serious thereby implying that any statistical outcome that had symptoms that the subject could imagine. The subject a p<0.05 would indeed be statistically significant. was then asked to indicate how serious the degree of their neck and shoulder stiffness was at that time and Results to record it as a tick on the paper. Length from the left edge to the tick on the paper was measured and To assess immediate changes of Anma therapy, differences treated as the VAS score. of intervention order by the cross-over design, i.e., differences between group A (Anma therapy was performed (ii) The state anxiety score was measured by the Japanese on the first day) and Group B (the rest intervention was version of the State Trait Anxiety Inventory by Spiel- performed on the first day) were not effective (VAS FZ0.2, berger, Gorsuch, and Leshene (Mizuguchi et al., 1991), pZ0.652; state anxiety FZ1.2, pZ0.277; cortisol FZ0.5, a self-report Likert scale, to assess the degree of pZ0.479; s-IgA FZ0.012, pZ0.913) (Table 1). Post-inter- anxiety being felt by participants at that time. The vention VAS scores were significantly lower than those State Anxiety scale consists of 20 items that assess how obtained pre-intervention (FZ42.4, pZ0.0005); there was the individual feels at that very moment, on a scale of significant difference between Anma therapy and the rest severity including, 1 ‘‘not at all’’; 2 ‘‘somewhat’’; 3 intervention (FZ20, pZ0.0005). Further, post-intervention ‘‘moderately so’’; and 4 ‘‘very much so’’; and the state anxiety scores were significantly lower than those scores of items are added. The range of obtained obtained pre-intervention (FZ15.0, pZ0.001); difference scores is from 20 to 80. The higher the score obtained, between Anma therapy and the rest intervention was the stronger the state anxiety. The reliability and FZ4.1, pZ0.053. For concentration levels of salivary validity of this scale has been repeatedly demon- cortisol, no significant differences between Anma therapy strated (Mizuguchi et al., 1991). Cronbach’s alpha and the rest intervention (FZ0.8, pZ0.383) and within pre- coefficients of this scale in the present study were intervention and post-intervention (FZ1.1, pZ0.301). 0.94, 0.91, 0.77, and 0.82 for pre-AI, post-AI, pre-RI, Concentration levels of s-IgA post-intervention were and post-RI, respectively. (iii) Two milliliter unstimulated saliva was collected at pre- and post-interventions, into serum-tubes, sealed and frozen immediately in a freezer on the night when the
60 N. Donoyama et al. Table 1 Immediate intervention comparison (repeated measures analyses of variance ANOVA) nZ15. Pre-/post-intervention measures Effect Values Pre Post Pre vs post Pre/post Pre/post Anma/rest Groups A/B MeansÆS.E. (95% CI) MeansÆS.E. (95% CI) Fp Fp Fp Visual Analogue Scale 42.4 0.0005*** 20 0.0005*** 0.2 0.652 Anma therapy 59.6Æ4.3 (50.4e68.8) 25.8Æ5.8 (13.1e38.6) Rest intervention 52.9Æ5.0 (42.2e63.7) 46.7Æ5.2 (35.4e57.9) State anxiety 15.0 0.001** 4.1 0.053 1.2 0.277 Anma therapy 35.6Æ1.9 (31.9e39.4) 28.3Æ1.7 (24.8e31.7) Rest intervention 35.0Æ1.9 (31.1e38.8) 32.7Æ1.7 (29.3e36.1) Cortisol (mg/dL) 1.1 0.301 0.8 0.383 0.5 0.479 Anma therapy 0.229Æ0.022 (0.183e0.275) 0.210Æ0.020 (0.169e0.251) Rest intervention 0.196Æ0.022 (0.149e0.242) 0.194Æ0.020 (0.153e0.235) s-IgA (mg/mL) 63.9 0.0005*** 0.3 0.605 0.012 0.913 Anma therapy 582.9Æ69.5 (439.9e725.4) 1082.8Æ131.4 (812.8e1352.9) Rest intervention 586.0Æ69.5 (443.3e728.8) 1156.3Æ131.4 (886.3e1426.4) Group A: nZ9, first interventionZAnma therapy, second interventionZrest. Group B: nZ6, first interventionZrest, second inter- ventionZAnma therapy. ** p<0.01. *** p<0.001. increased significantly compared with those obtained pre- the score for the item ‘‘I am tense’’ improved significantly. intervention (FZ6.39, pZ0.0005); however, there was no There were no items that revealed significant differences difference between Anma therapy and the rest intervention between pre-Anma therapy and pre-rest intervention (FZ0.1, pZ0.756) (Table 1). start lines. To assess the longer-term effects of Anma therapy, pre- Discussion first intervention values and pre-second intervention values were compared between Group A and the B (Table 2). In The immediate change in the post-Anma therapy VAS scores Group A, pre-second intervention VAS scores, 47.2Æ5.7 verified that Anma therapy, distinguished from rest lying on were lower than those obtained pre-first intervention, the massage table, can improve subjective symptoms of 60.7Æ6.0, but not statistically significantly different muscle stiffness in the neck and shoulder. The effectiveness (FZ3.4, pZ0.087); whereas in Group B, those obtained of Chinese and Western massage therapies for similar pre-second intervention, 58.5Æ7.0 was not almost changed symptoms was discussed in previous studies: Can et al. as those obtained pre-first intervention, 58.7Æ7.3; there (2003) suggested that traditional Chinese massage was was no significant difference between Groups A and the B effective for neck pain. In some studies on fibromyalgia (FZ3.3, pZ0.094). Pre-second intervention state anxiety (Sunshine et al., 1996; Field et al., 2002, 2003), improve- scores were significantly lower than those obtained pre-first ment of muscle pain and stiffness were demonstrated by intervention (FZ4.8, pZ0.048); however, there was no Western style massage. On the therapeutic effective significant difference between Groups A and the B (FZ0.1, mechanism of massage therapy, Field (2002a, b) hypothe- pZ0.740). For concentration levels of salivary cortisol, sized that massage therapy may reduce muscle tension, there were no significant differences within pre-first facilitate the removal of toxic metabolites and waste intervention and pre-second intervention (FZ1.8, products, and allow oxygen and nutrients to reach the cells pZ0.198) and between Groups A and the B (FZ2.5, and tissues. In a study by Mori et al. (2004), it was revealed pZ0.135). Moreover, for concentration levels of s-IgA, that massage increased the blood flow although it was there were no significant differences within pre-first performed on the lower back. In the present study, it is intervention and pre-second intervention (FZ0.1, suggested that manual mechanical stimuli by Anma therapy pZ0.756) and between Groups A and the B (FZ0.004, also increase blood flow, remove metabolites and waste pZ0.951) (Table 2). products that may in turn, result in the alleviation of the subjective symptoms in the neck and shoulder. Table 3 shows the results of an examination of the significant differences between pre- and post-interventions Gregory and Mars (2004) showed that mean external on each of the 20 items of state anxiety. After Anma cross-sectional diameter increased on microscopic exami- therapy, the scores improved significantly in 10 items: ‘‘I nation by 8% immediately after compressed air massage of feel at ease’’; ‘‘I feel rested’’; ‘‘I feel anxious’’; ‘‘I feel muscle and suggested that compressed air massage of comfortable’’; ‘‘I feel self-confident’’; ‘‘I am relaxed’’; ‘‘I muscle caused vasodilation of skeletal muscle capillaries feel content’’; ‘‘I am worried’’; ‘‘I feel joyful’’; and ‘‘I feel pleasant’’; on the other hand, after the rest intervention,
Effects of Anma therapy (traditional Japanese massage) on body and mind 61 Table 2 Longer-term intervention comparison (repeated measures analyses of variance ANOVA). Pre-/post-intervention measures Effect Values Pre-first Pre-second Pre-first/ Pre-first/ pre-second pre-second Groups A/B MeansÆS.E. (95% CI) MeansÆS.E. (95% CI) Fp Fp Visual Analogue Scale 60.7Æ6.0 (47.7e73.6) 47.2Æ5.7 (34.8e59.6) 3.4 0.087 3.3 0.094 Group A 58.7Æ7.3 (42.8e74.5) 58.5Æ7.0 (43.3e73.7) 4.8 0.048* 0.1 0.740 Group B 1.8 0.198 2.5 0.135 41.8Æ2.3 (36.7e46.9) 37.4Æ2.4 (32.2e42.7) 0.1 0.756 0.004 0.951 State anxiety 32.5Æ2.9 (26.3e38.7) 29.3Æ3.0 (22.9e35.7) Group A Group B 0.263Æ0.035 (0.187e0.339) 0.201Æ0.020 (0.159e0.243) 0.190Æ0.043 (0.097e0.283) 0.195Æ0.024 (0.143e0.247) Cortisol (mg/dL) Group A 528.9Æ81.5 (352.9e704.9) 515.5Æ93.8 (312.8e718.2) Group B 656.6Æ99.8 (441.0e872.1) 636.5Æ114.9 (388.2e884.7) s-IgA (mg/mL) Group A Group B Group B: nZ6, first interventionZrest, second interventionZAnma therapy. Group A: nZ9, first interventionZAnma therapy, second interventionZrest. * p<0.05. that persisted for a minimum of 24 h after treatment. VAS was not changed. A close relationship between the client score reduction in the present study was also found 3 days and the therapist is created in the usual clinical setting for after Anma therapy, though there was no statistically Anma therapy. A client usually chooses a person as thera- significant difference. It is implied that Anma therapy pist whom they can trust based on the personality and reduces muscle tension, causes vasodilation of skeletal technique. In this study, however, participants did not muscle capillaries, and boosts circulation, resulting in the know the personality of the therapist or what techniques alleviation of symptoms of annoyance, unpleasant sensa- the practitioner could perform, because they were tion, strain, stiffness, ache, and pain in muscles, and that recruited only for the study. On the other hand, rest is not the effectiveness of this may continue for a minimum of 3 necessarily associated with a given individual. It is days. Further studies are needed to verify these points. It presumed that this is the reason why rest could alleviate was thought that sample size in the present study was too the feeling of tension more than Anma therapy could in the small to analyze two factor repeated measures ANOVA; the study. This implies that it is important for Anma therapists number of the participants who had been given Anma to develop a good relationship with clients for more therapy on the first day was nine, and that of those who had effective treatment. been given the rest intervention on the first day was six. Cortisol is a major steroid hormone secreted by the In the immediate change in the post-Anma therapy state adrenal cortex via reactions in the hypothalamus-pituitary- anxiety scores, it was verified that Anma therapy can adrenal axis and autonomic nervous system, and is used reduce state anxiety, however significant probability commonly as an index of stress (Fukuda and Morimoto, differed from rest lying on the massage table was 0.053. 2001). In this study, salivary cortisol concentration was This result was the same as results obtained in previous reduced only marginally after Anma therapy. This is in studies on Western style massage therapy (Field et al., contrast to results obtained in previous studies on Western 1992, 1997, 1998, 2002, 2003; Hart et al., 2001; Hernandez- massage therapy (Field, 1998, 2000; Field et al., 1992, Reif et al., 2000, 2001, 2003, 2005, 2007). However, it is not 1997, 1998; Hart et al., 2001; Hernandez-Reif et al., 2000), meaningful to compare state anxiety scores 3 days after in which salivary cortisol levels decreased significantly after Anma therapy with scores obtained pre-Anma therapy, massage sessions. We can consider two reasons for these because the State Anxiety scale assesses the degree of results at present. One is an equation on a method to anxiety being felt at that moment. Further studies, using an collect saliva. In this study, 2 mL unstimulated saliva was appropriate measurement (i.e., the Trait Anxiety Inven- collected directly from the mouth into the serum-tube by tory, designed to assess susceptibility to long-term feelings the participants, themselves. The difficulty of saliva of anxiety), are needed to clarify consecutive effect on collection may have varied among participants, requiring anxiety by Anma therapy. more time for some participants to perform and causing some to feel a psychological burden. It is possible that From the results of analysis on the 20 items for state these circumstances prevented the reduction of cortisol. anxiety, it is thought that Anma therapy can eliminate Further studies, using easier means of collect saliva, are emotional discomfort, induce psychological relaxation and needed to verify these points. Another possibility is that enjoyment, and improve the anxious condition. On the there was a baseline effect with cortisol levels being so low other hand, the score for the item ‘‘I am tense’’ improved that any intervention, no matter how effective would cause significantly after rest, while the score after Anma therapy
62 N. Donoyama et al. Table 3 MeanÆstandard deviation for pre-/post-intervention measures for immediate intervention comparison for each of the 20 state anxiety items nZ15.
Effects of Anma therapy (traditional Japanese massage) on body and mind 63 these levels to become significantly lower. Further studies Japan Society of Acupuncture and Moxibustion 52, 296 are necessary to clarify these points on salivary cortisol. (in Japanese). Donoyama, N., Shoji, S., Munakata, T., 2005. Effect of traditional In immediate changes by both of Anma therapy and rest, Japanese massage, Anma therapy on body and mind: a prelimi- in the present study, s-IgA concentration levels were nary study. The Journal of the Japanese Society of Balneology, significantly increased. Several studies demonstrate that Climatology and Physical medicine 68 (4), 241e247. relaxation by the watching of a humorous movie (Dillon Eisenberg, D.M., Davis, R.B., Ettner, S.L., Appel, S., Wikey, S., Van et al., 1985), imagery (Jasnoski and Kugler, 1987), and Rompay, M., Kessler, R.C., 1998. Trends in alternative medicine massage (Green and Green, 1987) lead to highly significant use in the United States, 1990e1997: results of a follow-up increases in s-IgA concentrations. Dillon et al. (1985) national survey. The Journal of the American Medical Associa- showed that a humorous movie led to increases in s-IgA, tion 280, 1569e1575. suggesting that increases in well-being are accompanied by Ernst, E., White, A., 2000. The BBC survey of complementary medicine increases in s-IgA. Groer et al. (1994) also demonstrated an use in the UK. Complementary Therapies in Medicine 8 (1), 32e36. elevation in s-IgA concentration after a 10-min back rub and Field, T., 1998. Massage therapy effects. The American Psycholo- provided the rationale for the holistic benefits. On the gist 53, 1270e1281. other hand, during overtraining, athletes are susceptible to Field, T., 2000. Touch Therapy. Churchill Livingstone, Edinburgh. upper respiratory tract infection (URTI) because of Field, T., 2002. Massage therapy. The Medical Clinics of North decreases in s-IgA (Mackinnon et al., 1993; Mackinnon and America 86 (1), 163e171. Hooper, 1994). S-IgA, the predominant immunoglobulin Field, T., 2002. Massage therapy research methods. In: Lewith, G., type in mucosal secretion is a major effector of resistance Jones, W. (Eds.), Clinical Research in Complementary Thera- against pathogenic microorganisms causing URTI (Mack- pies. Harcourt Publishers Limited, Edinburgh. innon et al., 1993; Mackinnon and Hooper, 1994). These Field, T., Morrow, C., Valdeon, C., Larson, S., Kuhn, C., results, therefore, indicate that Anma therapy as a holistic Schanberg, S., 1992. Massage reduces depression and anxiety in treatment may increase s-IgA by increasing well-being, child and adolescent psychiatric patients. Journal of the Amer- enhance immunological function, and contribute to the ican Academy of Child and Adolescent Psychiatry 31, 125e130. prevention of illness, although the immediate changes by Field, T., Hernandez-Reif, M., Seligman, S., Krasnegor, J., therapy are no more effective than the control and other Sunshine, W., 1997. Juvenile rheumatoid arthritis: benefits from previous interventions in increasing s-IgA levels. In addi- massage therapy. Journal of Pediatric Psychology 22, 607e617. tion, s-IgA concentration changes could not be demon- Field, T., Schanberg, S., Kuhn, C., Field, T., Fierro, K., strated for long-term periods. Further studies measuring s- Henteleff, T., Mueller, C., Yando, R., Shaw, S., Burman, I., IgA concentration levels over time are needed to clarify this 1998. Bulimic adolescents benefit from massage therapy. point. Adolescence 33, 555e563. Field, T., Diego, M., Cullen, C., Hernandez-Reif, M., Sunshine, W., In conclusion, it is found that Anma therapy by which Douglas, S., 2002. Fibromyalgia pain and substance P decrease stimulation is applied to the surface of the body can reduce and sleep improves after massage therapy. Journal of Clinical muscle stiffness in the neck and shoulder and anxiety. Rheumatology 8 (2), 72e76. Field, T., Delage, J., Hemandez-Reif, M., 2003. Movement and Acknowledgments massage therapy reduce fibromyalgia pain. Journal of Bodywork and Movement Therapies 7, 49e52. The present study, No. 17653125, was supported by Fukuda, S., Morimoto, K., 2001. Lifestyle, stress and cortisol a science study program grant from the Education and response: review 1. Environmental Health and Preventive Science Ministry of Japan, 2005. Principal Investigator was Medicine 6, 9e14. Nozomi Donoyama. Green, R.G., Green, M.L., 1987. Relaxation increases salivary immunoglobulin A. Psychological Reports 61, 623e629. References Gregory, M.A., Mars, M., 2004. Compressed air massage causes capillary dilation in untraumatised skeletal muscle: a morpho- Al-Windi, A., 2004. Determinants of complementary alternative medi- metric and ultrastructural study. Society of Physiotherapy 91 cine (CAM) use. Complementary Therapies in Medicine 12, 99e111. (3), 131e137. Groer, M., Mozingo, J., Droppleman, P., Davis, M., Jolly, M.L., Can, S.Y., Loy, S.F., Sletten, E.G., Mclaine, A., 2003. The effect of Boynton, M., Davis, K., Kay, S., 1994. Measures of salivary traditional Chinese therapeutic massage on individuals with neck secretory immunologlobulin A and state anxiety after a nursing pain. Clinical Acupuncture and Oriental Medicine 4, 88e93. back rub. Applied Nursing Research 7, 2e6. Hart, S., Field, T., Hernandez-Reif, M., Nearing, G., Shaw, S., Cao, W.H., Sato, A., Sato, Y., Zhou, W., 1992. Somatosensory Schanberg, S., Kuhn, C., 2001. Anorexia nervosa symptoms are regulation of regional hippocampal blood flow in anesthetized reduced by massage therapy. Eating Disorders 9, 289e299. rats. The Japanese Journal of Physiology 42 (5), 731e740. Health and Welfare Statistics Association, 1996. Movement of the Public Health, Tokyo (in Japanese). Dillon, K.M., Minchoff, B., Baker, K.H., 1985. Positive emotional Health and Welfare Statistics Association, 2001. Movement of the states and enhancement of the immune system. International Public Health, Tokyo (in Japanese). Journal of Psychiatry in Medicine 15, 13e18. Hernandez-Reif, M., Field, T., Krasnegor, J., Theakston, H., 2000. High blood pressure and associated symptoms were reduced by massage Dimitriou, L., Sharp, N.C.C., Doherty, M., 2002. Circadian effects on therapy. Journal of Bodywork and Movement Therapies 4, 31e38. the acute responses of salivary cortisol and IgA in well trained Hernandez-Reif, M., Field, T., Krasnegor, J., Theakston, H., 2001. swimmers. British Journal of Sports Medicine 36, 260e264. Lower back pain is reduced and range of motion increased after massage therapy. The International Journal of Neuroscience Donoyama, N., Katahira, A., 2002. The situation of use of 106, 131e145. acupuncture, moxibustion and Anma/massage therapy: the Hernandez-Reif, M., Ironson, G., Field, T., Katz, G., Diego, M., results from a questionnaire survey for clients. Journal of the Weiss, S., Fletcher, M., Schanberg, S., Kuhn, C., 2003. Breast
64 N. Donoyama et al. cancer patients have improved immune functions following in elite kayakers. European Journal of Applied Physiology and massage therapy. Journal of Psychosomatic Research 57, 45e52. Occupational Physiology 67, 180e184. Hernandez-Reif, M., Field, T., Ironson, G., Beutler, J., Vera, Y., Mizuguchi, K., Shimonaka, Y., Nakazato, K., 1991. The Japanese Hurley, J., Fletcher, M., Schanberg, S., Kuhn, C., Fraser, M., Translation Version of STAI. Sankyobo, Kyoto (in Japanese). 2005. Natural killer cells and lymphocytes increase in women Mori, H., Ohsawa, H., Tanaka, T.H., Taniwaki, E., Leisman, G., with breast cancer following massage therapy. The Interna- Nishijo, K., 2004. Effect of massage on blood flow and muscle tional Journal of Neuroscience 115, 495e510. fatigue following isometric lumbar exercise. Medical Science Hernandez-Reif, M., Field, T., Diego, M., Fraser, M., 2007. Lower Monitor 10 (5), CR173eCR178. back pain and sleep disturbance are reduced following massage Oride, T., Kimura, K., Saito, S., Sakai, T., 2002. The role of therapy. Journal of Bodywork and Movement Therapies 11 (2), Anma/massage therapy in the company: the first report. The 141e145. Journal of Japanese Association of Manual Therapy 13, 14e18 Hirabayashi, S., 2002. Cervico-omo-brachial syndrome (including (in Japanese). muscle stiffness of shoulder). In: Ogata, E. (Ed.), Today’s Sato, A., Schmidt, R.F., 1971. Spinal and supraspinal conponents of Therapy. Igakushoin, Tokyo (in Japanese). the reflex discharges into lumber and thoracic white rami. The Ishii, S., Hirasawa, Y. (Eds.), 2002. Standard Textbook Orthopedics Journal of physiology 212 (3), 839e850. and Traumatology: Locomotive Quality of Life. Igakushoin, Sato, A., Sato, Y., Suzuki, A., Uchida, S., 1996. Reflex modulation Tokyo (in Japanese). of catecholamine secretion and adrenal sympathetic nerve Jasnoski, M.L., Kugler, J., 1987. Relaxation, imagery, and neuro- activity by acupuncture-like stimulation in anesthetized rat. immunomodulation. Annals of the New York Academy of The Japanese Journal of Physiology 46 (5), 411e421. Sciences 496, 722e730. Sato, A., Sato, Y., Schmidt, R.F., 1997. The impact of somatosen- Kimura, A., Yokoyama, E., Takahashi, F., 2003. Japanese Anma: A sory input on autonomic functions. Reviews of Physiology Step-by-Step Guide of Japanese Traditional Massage. Ounkai Biochemistry and Pharmacology 130, 1e328. Social Welfare for the Blind, Tokyo. Sato, A., Sato, Y., Uchida, S., 2002. Reflex modulation of visceral Kirschbaum, C., Kudielka, B.M., Gaab, J., Schommer, N.C., functions by acupuncture-like stimulation in anesthetized rats. Hellhammer, D.H., 1999. Impact of gender, menstrual cycle International Congress Series 1238, 111e123. phase, and oral contraceptives on the activity of the hypo- Simple Question. Yellow Emperor’s Inner Classic (in Japanese). thalamus-pituitary-adrenal axis. Psychosomatic Medicine 61 (2), Spiritual Axis. Yellow Emperor’s Inner Classic (in Japanese). 154e162. Sunshine, W., Field, T.M., Quintino, O., Fierro, K., Kuhn, C., Lovas, J.M., Graig, A.R., Raison, R.L., Weston, K.M., Segal, Y.D., Burman, I., Schanberg, S., 1996. Fibromyalgia benefits from Markus, M.R., 2002. The effects of massage therapy on the massage therapy and transcutaneous electrical stimulation. human immune response in healthy adults. Journal of Bodywork Journal of Clinical Rheumatology 2, 18e22. and Movement Therapies 6 (3), 143e150. Walker, R.F., Joyce, B.G., Dyas, J., 1984. Salivary cortisol: 1. Mackinnon, L.T., Hooper, S., 1994. Mucosal (secretory) immune Monitoring changes in normal adrenal activity. In: Read, G.F., system responses to exercise of varying intensity and during Riad-Fahmy, D., Walker, R.F., Griffiths, K. (Eds.), Immunoassays overtraining. International Journal of Sports Medicine 15, of Steroids in Saliva. Alpha Omega, Cardiff. 179e183. Yamashita, H., Tsukayama, H., Sugishita, C., 2002. Popularity of Mackinnon, L.T., Ginn, E., Seymour, G.J., 1993. Decreased salivary complementary and alternative medicine in Japan: a telephone immunoglobulin A secretion rate after intense interval exercise survey. Complementary Therapies in Medicine 10 (2), 84e93.
Journal of Bodywork & Movement Therapies (2010) 14, 65e72 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt PERFORMING ARTS MEDICINE Performing arts medicine e Instrumentalist musicians, Part II e Examination Jan Dommerholt, PT, DPT, MPS* Bethesda Physiocare, Inc./Myopain Seminars, LLC, 7830 Old Georgetown Road, Suite C-15, Bethesda, MD 20814-2440, USA Received 24 November 2008; received in revised form 11 February 2009; accepted 12 February 2009 KEYWORDS Summary Part I of this article’s series included background information on performing arts Musicians; medicine with a special focus on musicians. It covered in detail what questions need to be Performing arts included in the history, when healthcare providers first examine musicians. In part II of the medicine; series, the emphasis is on the physical examination, including posture, range of motion and Posture; hypermobility, ergonomics, and instrument-specific examination procedures. The final article Range of motion in the series will describe three case histories of musicians with hand pain. ª 2009 Elsevier Ltd. All rights reserved. Introduction Examination This article is the second installment of a series of three Each musician needs to be approached on the basis of articles on performing arts medicine with an emphasis on professional and personal demands and not every musician musicians. Part I covered general background information requires a full examination, including an assessment of and outlined the components of the history-taking process pain, posture, strength, and range of motion. (Brand- indicated when examining musicians. In this article the fonbrener, 1990; De Smet et al., 1998). The predominant emphasis is on the examination of musicians. During the symptom of musicians is pain, which usually involves history, clinicians will start formulating clinical hypotheses, muscles (Fry, 1984; Lambert, 1992; Moulton and Spence, which subsequently are confirmed or denied by the physical 1992). There is little evidence that musicians suffer examination. A unique aspect of the examination of musi- frequently from tendonitis or tenosynovitis, although these cians is the evaluation with the musical instrument diagnoses are often made (Amadio and Russoti, 1990; Bengtson et al., 1993; Bejjani et al., 1996). Most musicians * Tel.: þ1 301 656 5613; fax: þ1 301 654 0333. have developed inefficient movement patterns not only E-mail address: [email protected] when they play their instruments, but also during other activities or functions (Williamson et al., 2007). Based on 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.02.004
66 J. Dommerholt empirical evidence, many musicians develop overuse syndromes with clinically relevant myofascial trigger points, even after brief periods of playing (Bryant, 1989; Meador, 1989; Chen et al., 2000; Davies, 2002). The examination for the presence of relevant myofascial trigger points will be included in part III of the series. Posture The influence of posture on musical performance is well Figure 2 Same French horn player with winging of the right recognized (Dommerholt and Norris, 1997; Brandfonbrener, scapula, elevation of the left shoulder, and scoliosis of the 1998; Dommerholt, 2000). Musicians’ postures may not be spine (ª 2008 e Jan Dommerholt). all that different from others, but the combination of deficient posture and playing an instrument may become problematic (Cailliet, 1990; Eijsden-Besseling et al., 1993; Dommerholt, 2000; Kapandji, 2000), which is why musicians’ postures should be evaluated with and without the musical instrument. In this context, it is important to realize that frequently the musical instrument has become an extension of professional musicians (Ostwald, 1992). Wind instrumentalists with forward head posture may experience difficulty with their embouchure and breathing, and may suffer from frequent headaches (see Figures 1 and 2) (Samama, 1981; Brouw, 1983; Balfoort, 1985; Ferna´ndez Figure 1 French horn player with forward head posture, who de las Pen˜as et al., 2006; Ferna´ndez de las Pen˜as et al., complained of episodic tension-type headaches, neck and 2007). shoulder pain, low back pain, decreased air volume, and difficulty with his embouchure (ª 2008 e Jan Dommerholt). Postural asymmetries as a result of instrument design are common for example, with the violin, guitar, flute, or double bass (Norris and Dommerholt, 1996). Violinists with forward head posture and poor axial extension may have difficulty with prolonged bowing and with positioning the fingers of the left hand in the strings, due to excessive internal rotation of the left arm. Violinists often play with their head tilted to the left and left rotation of the cervical spine, elevation of the left shoulder, and a scoliotic curve of the thoracic spine, combined with a preference to carry the weight of the body on the right foot, which in turn induces a downward shift of the left pelvis, and a scoliotic curvature of the lumbar spine (see Figures 3 and 4) (Kapandji, 2000). The question remains when asymmetry becomes problematic. Not all musicians have musculo- skeletal problems and clinicians need to assess ease of movement, constraints, and coordination. The combination of awkward postures and repetitive motions has been shown to be particularly stressful and may contribute to muscle damage, tendonitis, or nerve damage (Larsson et al., 1988; Feuerstein and Hickey, 1992; Kuorinka and Forcier, 1995). The more a clinician is familiar with the characteristics and demands of musical instru- ments, the more accurate the assessment will be (Blanken et al., 1991; Ackermann and Adams, 2004a). Interestingly, many musicians consult with posture and movement specialists before consulting with a physician or physical therapist (Williamson, 1998). Physical therapists tend to have a predominant biomechanical orientation, which may not always be adequate in the treatment of musicians (Hullegie, 1995). Biomechanical approaches
Performing arts medicine e Instrumentalist musicians 67 Figure 3 Common incorrect posture of a violinist (ª 2008 e Figure 4 Correct posture of a violinist (ª 2008 e Jan Jan Dommerholt). Dommerholt). employ hypothetico-deductive methods and focus mainly at times be indicated, such as measuring limb lengths in on the external aspects of human movement (Hullegie, relation to the musical instrument to identify those musi- 1995), whereas somatic approaches, such as the Alexander cians at greater risk for injury. Violinists with relatively technique or Feldenkrais, recognize the unique context in short arms were found to be at greater risk unless they which musicians work and move (Dommerholt, 2000). The modified their head position or the way they hold the Alexander technique is not really a form of movement instrument (Ackermann and Adams, 2003). Some musicians education, but aims to help musicians and others to may need to be examined for localized or systemic hyper- become aware of habitual movement patterns, which are mobility, which can be problematic for some, while corrected by increasing self-awareness and thought advantageous to others (Brandfonbrener, 1990; Larsson through processes referred to as inhibition and direction et al., 1993; Brandfonbrener, 2002). The Beighton Scale of (Williamson, 2003). Through inhibition, musicians may Hypermobility is useful as an initial screening. The test learn to restrain the habitual patterns, while direction assesses hypermobility at the fingers, elbows, spine, knees, refers to the actual learning of new patterns (Mayers and and thumb for a total of nine joints. A score of 4 out of 9 Babits, 1987; Knebelman et al., 1994). Posture should be may indicate systemic hypermobility (Russek, 1999, 2000). seen as relational and intentional movements through The Modified Beighton Scale provides more detailed infor- which musicians can express their musical dialogue mation. It is important to understand that not all persons (Batson, 1996, 1997). with hypermobility have systemic hypermobility (Keer and Grahame, 2003). Sometimes, hypermobility is seen only in Range of motion the upper extremities. For example, an 11-year-old cellist experienced much difficulty when playing vibrato, because Musicians may present with characteristic differences in of hypermobility of her finger joints. During the evaluation, range of motion. For example, experienced violinists may she was asked to play the cello and demonstrate how she display greater range of motion of their left hand when would play with vibrato. It was evident that she could not compared to the right, which most likely can be attributed stabilize her fingers adequately and she was not able to functional adaptation (Ackermann and Adams, 2003). to avoid hyper-extending her interphalangeal joints Special tests to identify involved structures or tissues may (see Figure 5).
68 J. Dommerholt Figure 5 Eleven-year-old cellist with hyperextension of the Figure 7 Correction of thumb hypermobility with a custom- distal interphalangeal joints of the left fingers. The musician made splint* enabling the violinist to return to playing the was referred to physical therapy by her music teacher to instrument without any discomfort (ª 2008 e Jan Dommer- determine whether there were any physical reason why she holt). *Silver Ring Splint Company, Charlotteville, VA, USA. was not able to play vibrato (ª 2008 e Jan Dommerholt). the young player’s smaller hand size, but for other instru- An eighteen-year-old violinist with hypermobility of the ments such as the flute, clarinet, or oboe one size is left thumb was not able to play the instrument until she supposed to fit all (Kopfstein-Penk, 1994). Kopfstein-Penk started using a custom-made splint (see Figures 6 and 7). developed a measurement system to match players’ hands to the appropriate size guitar (Kopfstein-Penk, 1994). She Ergonomics relates the size of the hand to the size of the instrument. Norris designed a pediatric flute with an angled head joint Musical instruments were designed without incorporating and modified keys, which would allow young players to play any ergonomic principles and in spite of some efforts to the instrument without intrinsic hand strain (Norris and improve the design, playing a musical instrument may Dommerholt, 1996). One of the world’s leading authorities physically be challenging (Wagner, 1995; Norris and Dom- on adapting musical instruments is Maarten Visser, who out merholt, 1996; Markison, 1998). The design of an instru- of his Amsterdam-based studio (www.flutelab.com) has ment may require excessive reach beyond the musician’s modified instruments to accommodate individual musicians anthropometric capabilities (Wagner, 1988). Young players’ (see Figures 8 and 9) (Nabb, 2006). hands may be too small to comfortably reach the keys of their instruments. Observing a child’s play on an instrument Some musical instruments have specific characteristics that is too large will reveal excessive reaching to cover the that may predispose musicians to injury (Hopmann, 1998). keys of the instrument or to depress the keys on the Evaluating the physical interface with the musical instru- keyboard. Violins come in different sizes to accommodate ment can provide valuable insights. Therefore, all musi- cians should be encouraged to bring their instrument to the clinic. A unique aspect of performing arts medicine is that as part of the initial examination, the patient is examined Figure 6 Eighteen-year-old college student with painful Figure 8 Flute key modification to accommodate a musician hypermobility of the left thumb interfering with her ability to with an unusual short fifth finger (photograph courtesy of play violin. She was referred to physical therapy by her music Maarten Visser, www.flutelab.com). teacher (ª 2008 e Jan Dommerholt).
Performing arts medicine e Instrumentalist musicians 69 Figure 9 One-handed flute (photograph courtesy of Maarten Figure 11 Contact pressure of the left index finger against Visser, www.flutelab.com). the flute increasing the risk of nerve compression (ª 2008 e Jan Dommerholt). while playing the instrument. Every performing arts medi- cine clinic should have a piano on the premises to examine teachers or pedagogists, they should be cautious with keyboard players while playing. Those musicians who questioning technique or musical performance, even cannot bring in their instrument, such as organ players or though it has been established that different playing vibraphonists, may need to be evaluated playing their techniques may have distinctly different biomechanical instrument outside the clinical setting, if the nature of the demands (Bejjani et al., 1989). A pianist who was able to problem cannot be identified satisfactorily in the clinic. play with different styles of technique underwent an Video recordings of the musician playing the instrument can extensive kinetic and kinematic analysis of the different be very useful especially when evaluated in slow motion techniques and some were found to be much more (Norris and Dommerholt, 1995). Since healthcare providers demanding than others (Bejjani et al., 1989). do not have the same experience and insights of music Clinicians must analyze localized contact stresses caused by compression of the musical instrument against body parts. Examples include the clarinet, English horn, and oboe, which rest on the player’s right thumb, poten- tially leading to tendonitis and overuse injury (see Figure 10) (Fry, 1987; Smutz et al., 1995). Compression of the flute against the lateral aspect of the left index finger may cause nerve compression (see Figure 11) (Cynamon, 1982; Wainapel and Cole, 1988; Norris, 1996). Visser has modified the keys on the flute to avoid excessive reach and added a finger support to reduce direct compression of the finger against the instrument (see Figure 12). Instrument-specific examination Clinicians will be better able to develop evidence-informed treatment strategies by actively engaging musicians in the Figure 10 Contact pressure at the right thumb of an 11-year- Figure 12 Key modification and finger support to avoid old clarinetist (ª 2008 e Jan Dommerholt). compression against the flute (photograph courtesy of Maarten Visser, www.flutelab.com).
70 J. Dommerholt Figure 13 e Double bass German bow and bowing tech- supporting, and carrying the instrument. The intrinsic hand nique; note how the fifth finger supports the bow (photograph muscles are used for playing the instrument, including courtesy of Barbara Fitzgerald). manipulation of the keys, valves, or strings, and fine-tuning diagnostic process (Ackermann and Adams, 2004b; Brand- the sound (Meinke, 1998; Dawson, 2005). fonbrener, 2006). Awareness of the demands of playing musical instruments greatly improved the interrater reli- For some instruments, musicians will have to use ability of postural examinations by physical therapists a combination of extrinsic and intrinsic muscles to play the (Ackermann and Adams, 2004a). For most instruments, the instrument, for example with the right (bowing) arm of extrinsic forearm, upper arm, shoulder and trunk muscles double bass players. The actual bowing is performed with are used for producing the sound, and for holding, extrinsic muscles, but holding the bow requires the use of the intrinsic hand muscles. Double bass players may have a preference for the so-called German or French bow and bowing technique, which have different biomechanical demands. A German bow is held with a side-hand grip. The bow tends to be lighter, but has a taller frog. With the German bowing technique, the bow rests on the fifth finger, which may contribute to intrinsic muscle strain of the palmar interosseus muscle between digits 4 and 5, and the opponens digiti minimi muscle (see Figure 13). A French bow is similar to bows in the violin family, but it is thicker and heavier. With the French bowing technique, the bow is held with an over- hand grip and the bow rests on digits 2e5 (see Figure 14). As healthcare providers may not be familiar with the demands of each instrument, musicians may need to educate clini- cians about different techniques or approaches. Summary and conclusions The examination of musicians needs to expand considerably beyond the general aspects of the physical examination used with all patients. Healthcare providers need to become familiar with the demands of each instrument and their impact on posture, range of motion, injury patterns, and ergonomic demands. All musicians should be examined while playing their instruments, which frequently points the clinician toward the correct diagnosis and injury pattern. Performing arts clinics should have at least a piano available to examined keyboard players. Frequently, musicians may need to educate healthcare providers about certain aspects of their instrument, repertoire, or playing techniques. References Figure 14 e Double bass French bow and bowing technique; Ackermann, B., Adams, R., 2003. Physical characteristics and pain the bow is supported by fingers 2e5 (photograph courtesy of patterns of skilled violinists. Med. Probl. Perform. Artists 18 (2), Barbara Fitzgerald). 65e71. Ackermann, B.J., Adams, R., 2004a. Interobserver reliability of general practice physiotherapists in rating aspects of the movement patterns of skilled violinists. Med. Probl. Perform. Artists 19 (1), 3e11. Ackermann, B.J., Adams, R.D., 2004b. Perceptions of causes of performance-related injuries by music health experts and injured violinists. Percept. Mot. Skills 99 (2), 669e678. Amadio, P.C., Russoti, G.M., 1990. Evaluation and treatment of hand and wrist disorders in musicians. Hand Clin. 6 (3), 405e416. Balfoort, B., 1985. Houding, adem en keel; Fundamenten voor zangers, blazers en sprekers. Bosch & Keuning, Baarn. Batson, G., 1996. Conscious use of the human body in movement. Med. Probl. Perform. Artists 11, 3e11. Batson, G., 1997. Traditional and nontraditional approaches to performing arts physical therapy. In: Gallagher, S.P. (Ed.),
Performing arts medicine e Instrumentalist musicians 71 Orthopaedic Physical Therapy Clinics of North America; Physical posture in episodic tension-type headache. Headache 47 (5), Therapy for the Performing Artists, Part II: Music and Dance, 662e672. vol. 6. W.B. Saunders Company, Philadelphia, pp. 207e230. Feuerstein, M., Hickey, P.F., 1992. Ergonomic approaches in the Bejjani, F.J., Ferrara, L., Xu, N., Tomaino, C.M., Pavlidis, L., clinical assessment of occupational musculoskeletal disorders. Wu, J., Dommerholt, J., 1989. Comparison of three piano In: Turk, D.C., Melzack, R. (Eds.), Handbook of Pain Assessment. techniques as an implementation of a proposed experimental The Guilford Press, New York, pp. 71e99. design. Med. Probl. Perform. Artists 4, 109e113. Fry, H.J.H., 1984. Occupational maladies of musicians: their cause Bejjani, F.J., Kaye, G.M., Benham, M., 1996. Musculoskeletal and and prevention. Int. J. Music Ed. 4, 59e63. neuromuscular conditions of instrumental musicians. Arch. Fry, H.J.H., 1987. Overuse syndrome in clarinetists. Clarinet 14 (3). Phys. Med. Rehabil. 77 (4), 406e413. Hopmann, R.A., 1998. Musculoskeletal problems in instrumental Bengtson, K.A., Schutt, A.H., Swes, R.G., Berquist, T.H., 1993. musicians. In: Sataloff, R.T., Brandfonbrener, A.G., Musicians overuse syndrome; a pilot study of magnetic reso- Lederman, R.J. (Eds.), Performing Arts Medicine. Singular nance imaging. Med. Probl. Perform. Artists 8, 77e80. Publishing Group, San Diego, pp. 205e229. Blanken, W.C.G., Rijst, Hvd, Mulder, P.G.H., Eijsden- Hullegie, W., 1995. Fysiotherapie; een wetenschapstheoretische en Bessling, M.D.F., Lankhorst, G.J., 1991. Interobserver and vakfilosofische analyse. De Tijdstroom, Utrecht. intraobserver reliability of postural examination. Med. Probl. Kapandji, A.I., 2000. Anatomy of the sine. In: Tubiana, R., Perform. Artists 6, 93e97. Amadio, P.C. (Eds.), Medical Problems of the Instrumentalist Brandfonbrener, A.G., 1990. Joint laxity in instrumental musicians. Musician. Martin Dunitz, London, pp. 55e68. Med. Probl. Perform. Artists 5, 117e119. Keer, R.J., Grahame, R., 2003. Hypermobility Syndrome: Diagnosis Brandfonbrener, A.G., 1998. The etiologies of medical problems in and Management for Physiotherapists. Butterworth Heinemann, performing artists. In: Sataloff, R.T., Brandfonbrener, A.G., London. Lederman, R.J. (Eds.), Performing Arts Medicine. Singuler Knebelman, S., Ralson Dressler, P., Mathews Brion, M., et al., 1994. Publishing Group, San Diego, pp. 19e45. The essentials of the Alexander technique. In: Gelb, H. (Ed.), Brandfonbrener, A.G., 2002. Joint laxity and arm pain in a large New Concepts in Craniomandibular and Chronic Pain Manage- clinical sample of musicians. Med. Probl. Perform. Artists 17, ment. Mosby-Wolfe, London, pp. 177e185. 113e115. Kopfstein-Penk, A., 1994. The Healthy Guitar. Kopfstein-Penk, Brandfonbrener, A.G., 2006. Special issues in the medical assess- Arlington. ment of musicians. Phys. Med. Rehabil. Clin. N. Am. 17 (4), Kuorinka, I., Forcier, L., 1995. Work Related Musculoskeletal 747e753. v. Disorders (WMSDs); a Reference Book for Prevention. Taylor & Brouw, N.A.B., 1983. Stem en lichaam. Alphen a/d Rijn, Stafleu. Francis, Inc., Bristol. Bryant, G.W., 1989. Myofascial pain dysfunction and viola playing. Lambert, C.M., 1992. Hand and upper limb problems of instru- Br. Dent. J. 166 (9), 335e336. mental musicians. Br. J. Rheumatol. 31 (4), 265e271. Cailliet, R., 1990. Abnormalities of the sitting posture of musicians. Larsson, L.G., Baum, J., Mudholkar, G.S., Kollia, G.D., 1993. Med. Probl. Perform. Artists 5, 131e135. Benefits and disadvantages of joint hypermobility among Chen, S.-M., Chen, J.-T., Kuan, T.-S., Hong, J., Hong, C.-Z., 2000. musicians. N. Engl. J. Med. 329 (15), 1079e1082. Decrease in pressure pain thresholds of latent myofascial Larsson, S.E., Bengtsson, A., Bodegard, L., Henriksson, K.G., trigger points in the middle finger extensors immediately after Larsson, J., 1988. Muscle changes in work-related chronic continuous piano practice. J. Musculoskeletal Pain 8 (3), myalgia. Acta Orthop. Scand. 59 (5), 552e556. 83e92. Markison, R.E., 1998. Adjustment of the musical interface. In: Cynamon, K.B., 1982. Flutist’s neuropathy. N. Engl. J. Med. 305 Winspur, I., Wynn Parry, C.B. (Eds.), The Musician’s Hand. (16) 961. Martin Dunitz, London, pp. 149e159. Davies, C., 2002. Musculoskeletal pain from repetitive strain in Mayers, H., Babits, L., 1987. A balanced approach: the Alexander musicians: insights into an alternative approach. Med. Probl. technique. Music Ed. J. 7 (3), 51e54. Perform. Artists, 42e49. Meador, R., 1989. The treatment of shoulder pain and dysfunction Dawson, W.J., 2005. Intrinsic muscle strain in the instrumentalist. in a professional viola player: implications of the latissimus Med. Probl. Perform. Artists 20 (2), 66e69. dorsi and teres major muscles. J. Orthop. Sports Phys. Ther. 11 De Smet, L., Ghyselen, H., Lysens, R., 1998. Incidence of overuse (2), 52e55. syndromes of the upper limb in young pianists and its correla- Meinke, W.B., 1998. Risks and realities of musical performance. tion with hand size, hypermobility and playing habits. Chir. Main Med. Probl. Perform. Artists 13, 56e60. 17 (4), 309e313. Moulton, B., Spence, S.H., 1992. Site-specific muscle hyper-reac- Dommerholt, J., 2000. Posture. In: Tubiana, R., Amadio, P. (Eds.), tivity in musicians with occupational upper limb pain. Behav. Medical Problems of the Instrumentalist Musician. Martin Res. Ther. 30 (4), 375e386. Dunitz, London, pp. 399e419. Nabb, D., 2006. Interview with Maarten Visser. Med. Probl. Dommerholt, J., Norris, R.N., 1997. Physical therapy management Perform. Artists 21 (4), 159e163. of the instrumental musician. In: Gallagher, S.P. (Ed.), Physical Norris, R.N., Summer 1996. Clinical observations on the 1991 Therapy for the Performing Artist, Part II; Music and Dance; National Flute Association survey. Flutist Quarterly, 77e80. Orthop. Phys. Ther. Clin. N. Am, vol. 6. W.B. Saunders Norris, R.N., Dommerholt, J., 1995. Orthopa¨dische Probleme und Company, Philadelphia, pp. 185e206. Rehabilitation bei muskuloskeletalen Sto¨rungen. In: Blum, J. Eijsden-Besseling, M.D.Fv., Kuijers, M., Kap, B., 1993. (Ed.), Medizische Probleme bei Musikern. Georg Thieme Verlag, Differences in posture and postural disorders between Stuttgart, pp. 116e159. musici and medical students. Med. Probl. Perform. Artists Norris, R.N., Dommerholt, J., 1996. Applied ergonomics; adaptive 8, 110e114. equipment and instrument modification for musicians. Orthop. Ferna´ndez de las Pen˜as, C., Alonso-Blanco, C., Cuadrado, M.L., Phys. Ther. Clin. N. Am. 5, 159e183. Gerwin, R.D., Pareja, J.A., 2006. Trigger points in the sub- Ostwald, P.F., 1992. Psychodynamics of musicians; the relationship occipital muscles and forward head posture in tension-type of performers to their musical instruments. Med. Probl. headache. Headache 46 (3), 454e460. Perform. Artists 7, 110e113. Ferna´ndez de las Pen˜as, C., Cuadrado, M.L., Pareja, J.A., 2007. Russek, L.N., 1999. Hypermobility syndrome. Phys. Ther. 79 (6), Myofascial trigger points, neck mobility, and forward head 591e599.
72 J. Dommerholt Russek, L.N., 2000. Examination and treatment of a patient with Wainapel, S.F., Cole, J.L., 1988. The not-so-magic flute: two cases hypermobility syndrome. Phys. Ther. 80 (4), 386e398. of distal ulnar nerve entrapment. Med. Probl. Perform. Artists 5, 63e65. Samama, A., 1981. Muscle Control for Musicians. Bohn, Scheltema & Holkema, Utrecht. Williamson, M., 1998. Means to Means: the Role of the Alexander Technique in Music Available from: http://www.alexander- Smutz, W.P., Bishop, A., Niblock, H.M.M., Drexler, M., An, K., 1995. technique-london.co.uk/alexander_technique_articles. Load on the right thumb of the oboist. Med. Probl. Perform. php?articleZ35. Artists 10, 94e99. Williamson, M., Summer 2003. Making connections: an introduction Wagner, C., 1988. Success and failure in musical performance; to the Alexander Technique for practitioners of performing arts Biomechanics of the hand. In: Roehmann, F.L., Wilson, F.R. medicine. J. Br. Assoc. Perform. Arts Med. 4. (Eds.), The Biology of Music Making. Proceedings of the 1984 Denver Conference. MMB Music, St. Louis. Williamson, M., Roberts, N., Moorhouse, A., 2007. The role of the Alexander technique in musical training and performing. Int. Wagner, C., 1995. Physiologische und pathophysiologische Grund- Symp. Performance Sci., 369e374. www.performancescience. lagen des Musizierens. In: Blum, J. (Ed.), Medizinische Probleme org. bei Musikern. Georg Thieme Verlag, Stuttgart, pp. 2e29.
Journal of Bodywork & Movement Therapies (2010) 14, 73e79 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt REVIEW AND HYPOTHESES Qi Gong’s relationship to educational kinesiology: A qualitative approach Paul Posadzki a,*, Sheetal Parekh b, Marie-Luce O’Driscoll b, Dariusz Mucha c,1 a University of East Anglia, School of Medicine, Health Policy and Practice, United Kingdom b University of East Anglia, School of Allied Health Professions, United Kingdom c Radom Politechnic, Malczewskiego 29, 26-600 Radom, Poland Received 27 February 2008; received in revised form 25 November 2008; accepted 27 November 2008 KEYWORDS Summary This paper qualitatively reviews two complementary therapies; Qi Gong and Qi Gong; educational kinesiology (EK). It is being suggested that Qi Gong and EK may be united through Educational kinesiology; a qualitative convergence and a shared underlying concept. The authors hypothesize that Complementary and a coherent rationale can be formed through this conceptual synthesis and propose that to some Alternative Medicine extent Qi Gong movements and EK can be considered to work in unison with each other. The logical synthesis of these two therapies is being presented to identify Qi Gong movements with concepts of brain gymnastics and also to explain how this new construct can be developed and implemented into practice. When verified, this hypothesis will allow individuals to better understand Chinese health exercises from the modern science perspective such as neuro- anatomy, neurophysiology and psychoneuroimmunology. Crown Copyright ª 2008 Published by Elsevier Ltd. All rights reserved. Introduction system, through the use of movement, to improve cognitive functioning, emotional well-being and self-awareness. There is a growing body of evidence, which suggests the Educational kinesiology (EK) therapy, is a relatively modern usefulness of Qi Gong; a Complementary and Alternative approach compared to Qi Gong, but also has some evidence Medicine therapy. Qi Gong practitioners claim to be able to underpinning claims about its efficacy. EK is a method and influence the functional status of the central nervous form of brain gymnastics that can be defined as an enhanced ability to process information and learn more * Corresponding author. Tel.: þ44 1603 591223. effectively due to certain types of movements (Prashnig, E-mail addresses: [email protected] (P. Posadzki), 2004). EK and brain gymnastics can be used interchangeably insofar as the concentration and focused movements [email protected] (S. Parekh), [email protected] (M.-L. embodied by their direction and technique may facilitate O’Driscoll), [email protected] (D. Mucha). neuroplasticity. This is a qualitative study that offers a new 1 Tel.: þ48 (0) 601 482162. 1360-8592/$ - see front matter Crown Copyright ª 2008 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.11.002
74 P. Posadzki et al. way of looking at Qi Gong and EK. To be more precise, from promote deeper insights and better understanding of this the viewpoint of various systems of the body, this article therapeutic modality through concentrating on what can be reviews in narrative manner the clinical applications of known from these studies. these two modalities, examines their beneficial effects and the concepts that underpin both approaches. Ultimately, The physiological effects of Qi Gong exercises include the article aims to present an argument for combining Qi changes in electroencephalogram (EEG), electromyography Gong and EK through a coherent construct. The authors aim (EMG), respiratory movement, heart rate, skin tempera- to explore the qualitative convergence of both Qi Gong and ture, fingertip volume, and sympathetic nerve function. It EK through a common conceptual neuroscientific lens, with also includes changes in the functioning of the stomach and a view of identifying the similarities and differences intestine, metabolic activities, and endocrine and immu- between these two techniques. However, it is important to nity systems (Lee et al 2003b; Lee et al 2005a) (Xu, 1994) as emphasize that the level of abstraction presented within a result of soft body movements. As theta rhythm has been the scope of this article is grounded in the qualitative suggested to be one of the normal EEG patterns occurring in approaches. This approach offers a range of epistemolog- mental concentration, it is concluded that the theta rhythm ical, theoretical and methodological possibilities for is an indicator of mental concentration during Qi Gong state knowledge building, that can be unique in content, focus, (Pan et al., 1994). In addition neuromonitoring during Qi and form (Hesse-Biber and Leavy, 2005). Therefore, during Gong appears to objectify the accompanied cerebral the discourse, analysis of some information regarding Qi modulations with a 22.2% increase in mean blood flow Gong’s and EK’s essence will be derived from the presented velocity (vm) in the posterior cerebral artery (Litscher data to reveal the underlying core principles and the et al., 2001). As a result the increased blood circulation congruent essence of both practices. after Qi Gong exercises brings ‘warmness’ in the body (Agishi, 1998). Moreover, significant differences were found Brief characteristics of Qi Gong in the volume of oxygen consumed, carbon dioxide produced, frequency of breath and expired ventilation. The Qi Gong is a therapeutic Chinese practice that has been study also showed an improvement of nearly 20% in venti- used and developed over thousands of years to restore latory efficiency for oxygen uptake and carbon dioxide energy (Qi) to the body, mind, and spirit (Litscher et al., production suggesting that Qi Gong may have useful ther- 2001). The Taoist and Buddhist philosophies, which apeutic value (Lim et al., 1993). Qi Gong is valuable and promote health and vitality through gentle exercises for reliable as described by Mayer (1999) in a study that took breath, body and mind form the foundation for the Qi Gong place over 20 years ago and reported significant differences theory (McCaffrey and Fowler, 2003). Basic principles of Qi between a group practicing Qi Gong and a control group in Gong are grounded in traditional Chinese medicine (Dorcas a variety of outcome measures including reduction in total and Yung, 2003). Qi Gong in Chinese means Qi (vital energy) mortality rate. The evidence further suggests that prac- and Gong (skill or art) and is essentially regarded by prac- ticing Qi Gong may have a positive effect on hypertension titioners as a way of working with energy. Western science (Mayer, 1999). Qi Gong exercises can cause bradycardia considers Qi Gong as a combination of meditation, (Skoglund and Jansson, 2007). Qi Gong is beneficial for controlled breathing and gentle physical movements lowering blood pressure and pH (Lee et al., 2007; Lee et al., designed to manage the vital energy (Qi) of the body and 2003c), and increasing aerobic endurance (Lan et al., 2004; consequently a way to improve spiritual, physical and Lee et al., 2004b). The physical symptoms of stress including mental health (Jones, 2001). Qi Gong uses specific move- levels of norepinephrine and cortisol were lowered after Qi ments in order that psychological concentration may be Gong exercises (Skoglund and Jansson, 2007). Similarly, directly channeled to particular parts of the body. The Qi heart rate and body temperature were also decreased after Gong experts frame it as a ‘‘mind-in-body’’ practice rather Qi Gong exercises (Lee et al., 2003c). This brief overview of than mindebody interaction. It is a form of complementary Qi Gong and its physiological benefits on the body’s therapy and a method of health improvement that is both performance emphasizes the existence of considerable efficient and effective (Sancier, 2003). This form of fluent potential that can be utilized by the practitioner on movements, with harmonic breathing techniques tranquil- a regular basis to prevent diseases and develop positive izes the mind and is known to reduce the psychosomatic health states. Additionally, all the above data may suggest tensions (Skoglund and Jansson, 2007). that gentle activation of the body’s muscles, through Qi Gong exercises, may have positive impact on homeostasis Physiological effects of Qi Gong (Lee et al 2003a). These findings can be interpreted as further support to the value of Qi Gong in optimizing the It is suggested that the practice of Qi Gong leads to body’s status for more balanced structure and function. significant improvements in physical health, which are Therefore, holistic harmony may be achieved as a result of discussed below. However, the limitation of narrative such more effective and efficient interference of the review may relate to the quality of included studies, physiological systems with one another. Consequently, because these results may or may not have been critically optimal or total well-being with the highest life quality is assessed with or without focusing on their methodological achievable. quality. Nevertheless, the purpose of this section is to present to the reader Qi Gong’s ‘multidimensionality’ and Psychological benefits of Qi Gong exercises its potential effects on health in order to facilitate and Psychological outcome of Qi Gong practice includes perceptual changes such as individuals’ experience of
Qi Gong’s relationship to educational kinesiology 75 warmness, chilliness, relaxation, tension and the perception resulting in an overall health improvement. Qi Gong can of floating (Xu, 1994). It also positively affects the mood also modulate the level of triglycerides, HDL-cholesterol changes and relieves exhaustion and tension (Jung et al., and apolipoproteins in disorders of lipid metabolism 2006). Qi Gong helps to normalize and stabilize positive and (Xin et al., 2007). Qi Gong walking reduced plasma glucose pleasant emotional states of human mind (Lee et al., 2003a; after lunch without inducing a large increase in the pulse Lee et al., 2006) and improves the overall well-being of an rate in patients with diabetes (Iwao et al., 1999). individual. It also relieves depression in chronic physical illness sufferers by improving the individual’s self-identity, It has been suggested that Qi Gong exercises may also social well-being and quality of life (Tsang et al., 2003, alleviate asthma symptoms, as well as modulate wound 2006). In this context, Bandura’s Social Learning Theory healing and inflammation processes (Chen and Turner, a development of the perception of self-efficacy was 2004). In asthma patients, the combination therapy resul- observed (Lee et al., 2004a; Lee et al., 2005b). From a health ted in reduced drug dosage, sick leaves, duration of resource perspective, Qi Gong may improve an individual’s hospitalization, and costs of therapy. An improvement in sense of coherence, regain a sense of safety and active airway capability and a decrease in illness severity can be control, and can be a specific stress coping strategy (Siu achieved by regular self-conducted Qi Gong exercises et al., 2007). Qi Gong training was found to result in transient (Reuther and Aldridge, 1998). long-term anxiety and pain reduction (Wu et al., 1999). This can be partially explained by Ryu et al. (1996) as the authors Qi Gong may also have a role in cancer management Lee observed the effects of Qi Gong training on the levels of et al 2005b (Yan et al., 2006); other authors have suggested human endogenous opioid peptides, such as beta-endorphin, a significant reduction in tumor size (Chen and Yeung, and other stress hormones adrenocorticotrophic hormone 2002). It can be useful in the advanced stages of cancer as (ACTH). The level of beta-endorphin was significantly it helps to reduce vomiting, insomnia, anorexia, and facil- increased during the mid-time of training while the level of itates serenity and emotional control as well as minimizes ACTH declined at the mid and post-time of training. The distress and helplessness (Lee et al., 2006). In cancer result suggests that Qi Gong training, when used as a stress patients, the combination therapy reduced the side effects coping method, affects and plays a role in hormonal regu- of cancer therapy. However, the reported studies do not lation related to the maintenance of homeostasis in humans necessarily measure up to the strict protocols required for (Ryu et al., 1996). Results obtained by Jones (2001) have randomized controlled clinical trials (Sancer, 1999). indicated that blood levels of the stress-related hormone cortisol may be lowered by short-term practice of Qi Gong as From the clinical perspective, Qi Gong exercises have been well. Another study showed that the practice of Qi Gong shown to improve activities of daily living, social interactions helped in the rehabilitation of drug addicts (Sancier, 1999). and quality of interpersonal relations in elderly patients Evidence also suggests that Qi Gong may be an effective (Tsang et al., 2003). In the same group of patients other alternative for heroin detoxification without side effects (Li authors have reported increased balance parameters, which et al., 2002). A few positive impacts on various dimensions of resulted in decreased risk of fractures (Yang et al., 2007). human mind functioning proposes a huge potential of Qi Gong in maintaining health related goals. Furthermore, Qi Gong may be successfully incorporated into orthodox various states and processes of the mind can be consciously physiotherapy, as it is known to improve motor function affected due to Qi Gong exercises. This may include cogni- (Schmitz-Halbsch et al., 2006) and movement coordination tive processes (memory, attention), emotional reactions (Mannerkorpi and Arndorw, 2004). It is worth emphasizing (including positive feelings), intelligence (emotional and that pain was diminished significantly among low back pain spiritual) or creativity. From the psychological perspective, sufferers, woman with pre-menstrual symptoms (Jang and Qi Gong exercises may help practitioners to influence the Lee, 2004), and chronic pain patients (Chen et al., 2006). body’s homeostasis via brain gymnastics and thus help to Moreover, Qi Gong’s multidimensional influence on the expand own capacities and broaden the horizons. As a result, whole person should be acknowledged as a standard the structure of one’s consciousness could be developed method of rehabilitation, health promotion and prevention. thanks to self-realization and self-actualization during Qi For these reasons Qi Gong can be named as the art of self- Gong practice. healing (Lee et al., 2003a). Clinical applications of Qi Gong It can be suggested to the reader or the practitioner that the existence of complex mechanisms that influence various Qi Gong can have a broad spectrum of clinical applications. functions of the holistic body is embedded in Qi Gong exer- It has been suggested that in hypertensive patients, cises. A practitioner’s homeostatic mechanisms, on different combining Qi Gong practice with drug therapy (combination levels, and with different intensity may be affected therapy) resulted in reduced risk of stroke incidence and constructively. Additionally, these compound mechanisms related mortality and reduced dosage of drugs required for that social and life scientists are trying to comprehend, can blood pressure maintenance (Mayer, 1999). It is an efficient mobilize the individuals’ positive health resources, self- method of improving quality of life in cardiac disease regulatory mechanisms and adaptive capacities. patients (Hui et al., 2006) and decreasing systolic blood pressure in hypertensive patients (Lee et al., 2007). Body At the end of the Qi Gong section of this article, the mass index, waist circumstance, level of cholesterol and reader is asked to form his or her own opinion on Qi Gong’s albumin excretion can be controlled by means of Qi Gong qualities, attributes and ‘mechanisms’ beyond the description provided and ask why it works, how and on what level it works? The answers for these questions may enhance self-education, increase the level of knowledge and own understanding of Qi Gong’s underlying principles. In the following section another therapeutic modality-EK will be discussed. Finally, fusion on the conceptual level
76 P. Posadzki et al. will occur with some practical examples to follow up. These motor skills such as movement smoothness (Morris et al., examples will include specially designed Qi Gong move- 1998). This could have powerful practical implication, i.e. ments embedded in the principles of EK to stimulate a flow movement therapists could use EK’s movement patterns of information within the holistic body. and directions in order to improve their patient’s function, or develop more adaptable movement patterns. Brief characteristics educational kinesiology Another EK study showed significant improvement in an EK is applicable to various cognitive skills, i.e. memory, ability involving the interaction of perception and voluntary attention, thinking and entails a number of techniques to movement of those examined. This analysis has indicated enhance hemispheric communication and functioning a significant improvement in perceptual motor skills in (Gallo, 2005). EK’s exercises were originally derived from the individuals following the EK program (Cammisa, 1994). work of neuro-rehabilitation specialists and include kines- Therefore, it is suggested that EK may positively affect thetic experience such as movement with new learning. changes in the time taken to initiate and complete move- ment sequences, as well as changes in the features of The concept of EK is based on the assumption that specific movement sequences themselves (Ericsson et al., 2006). movements (similar to those performed naturally by chil- Nevertheless, further quantitative research is inevitably dren as part of the process of brain development) can needed in order to investigate EK’s efficacy in various improve bodyemind integration. This integration can be clinical and non-clinical settings. Additionally, more quali- obtained through brain gymnasticsestrategy that imple- tative designs could find out why and how it works? ments the concept of EK (Northey, 2005). Cammisa (1994) explained EK as a method that uses specific movements to Qi Gong viewed through the lens of examine the quality of various levels of brain function. In educational kinesiology other words during testing of particular muscles, responsible for certain movements, the examiner is able to understand Through the synthesis of these two areas of Complementary the structural and functional status of the central nervous Medicine e Qi Gong and EK, it is possible to make a number of system, of the individual, due to the wide and complex deductions. First of all EK can view Qi Gong movements as connections between the muscular and nervous system. This the ‘final effects’ of the central nervous system functioning. is because such examinations may reveal the extent to which Secondly, similarly to EK, Qi Gong exercises consist of various there are wide and complex connections and other (not fully and complex body movements utilizing a wide range of understood) neurophysiological systems. If we accept this muscles. From the neuroanatomical and neurophysiological premise then moving and examining muscles may provide perspective, this association between muscular and nervous significant insight into how the body is working as a whole. As system and the potential benefits of such a relationship may it can be noticed human muscle movements might have be regarded as a common dimension of Qi Gong and EK. As an various positive health effects and hence muscle function explanation it can be suggested that some Qi Gong exercises may be related with the body’s integrity. If so, then using may combine effects of lateralization (L), focusing (F) and specific muscles precisely and appropriately may bring centering (C) during precisely performed sequences of individual benefits to the brain and the whole body. From the movements. In terms of EK, in order to provide more Qi Gong perspective, a practitioner may realize how specific reasonable explanation during Qi Gong exercises, the prac- movements generated by the muscles may influence his or titioner may and should perform his or her movements in her brain levels. To be more precise, during Qi Gong exer- such a manner that the central or mid-line of the body cises, motor abilities such as coordination, agility, move- (sagittal line that is parallel to vertical axis and separates the ments’ perception itself as well as cognitive and social human body into left and right equal parts) may be crossed, functioning, personal development, emotional well-being as this would facilitate experience of functional integration and self-awareness can be influenced through the use of between the right and left hemisphere. To be more explicit these muscles. While working, these muscles ‘create’ in this statement both upper and lower extremities’ direc- neuroanatomical and neurophysiological connections with tions of movements in Qi Gong exercises indicate that the other parts of the CNS, this is not as yet fully understood. mid-line is being crossed. As a justification of this argument This may have various clinical and non-clinical applications. the authors give the example of a basic breathing technique Some of them will be presented below. used in Qi Gong exercises, where during the exhalation the practitioner moves his or her upper extremities in the Main applications of educational kinesiology cephalo-caudal direction (from the top of the face down to the lower abdominal region) passing central line several There is a limited evidence of EK’s clinical efficacy. However, times in the front of the body simultaneously. Coordination the existence of its health potential can be easily noticed. between thought and movement may improve as a result, and in social context the ability to communicate with others For example, Sifft and Khalsa (1991) investigated the and the quality of interpersonal relationships may also influence of the integrated movements in EK, on reaction improve (Masgutowa and Akhmatova, 2004). Subsequently, time to visual stimuli. The results showed statistically in Qi Gong exercises, movements may contain components of significant improvement in agility where EK was used to crossing between anterior and posterior, as well as upper and develop whole body movement. This could mean enhanced lower parts of the body. In Qi Gong movements, in the synchronisation of movement responses due to EK. Further superioreinferior directions within the sagittal plane, using efficacy of EK is evident in coordination tests as Morris et al. upper extremities, and posterioreanterior ones, using lower (1998) claim that this modality can influence the quality of
Qi Gong’s relationship to educational kinesiology 77 extremities, within the same plane are similar to EK move- emotions, knowledge and self-consciousness. On the other ments. This might suggest that the brain cortex, which is hand EK therapy, quite a contemporary approach compared responsible for innovative ideas and creativity, is being to Qi Gong, refers to the resources that an individual stimulated in Qi Gong in a manner similar to that found in EK. possesses and is able to ‘materialize’ them through move- Additionally, integration can be observed between rational ment (Masgutowa and Akhmatova, 2004). The main purpose thinking and emotions, feelings and movements in both Qi of this article was to combine the evidence from Qi Gong and Gong and EK. Furthermore, the limbic system and its inter- EK studies and investigate the underlying mutual processes relations with autonomic nervous system can be stimulated and the essence of these two therapeutic modalities. By during Qi Gong exercises. This may balance the functioning looking at Qi Gong and EK through the lenses of one coherent of heart, lungs, liver or blood vessels. construct, it has been possible to raise an argument that Qi Gong and EK share a number of basic underlying principles. During Qi Gong exercises posture stability is increased Additionally, the benefits of undertaking both Qi Gong and EK and the reaction pattern for environmental stimulus can can be seen to be broadly similar. The effects and the change (orientation reflex). A Qi Gong practitioner is able concepts that underpin both approaches suggest that to concentrate his or her attention on both the detail and consciously performed movements can be beneficial through the wholeness of a visible object, and this causes a better their influence on various systems of the body such as the understanding of the reality (Masgutowa and Akhmatova, immunological, cardio-respiratory, nervous, endocrine, and 2004). From the psychological point of view, both Qi Gong musculoskeletal systems and that these results in better and EK have the potential to improve human’s self-aware- self-perception and personality integration. The principles ness, sense of coherence, level of optimism, self-esteem, of EK complement those of Qi Gong’s insofar as the individual self-appraisal, emotional awareness and sharpen cognitive performs movements form that comprise elements of processes such as attention, memory, imagination and lateralization (L), concentration or focusing (F) and thinking. Ideally a Qi Gong practitioner may concentrate on centering (C) (Masgutowa and Akhmatova, 2004). Further- combination of all three components (Lateralization more, Qi Gong, like EK can be used as a form of brain (L) þ Focusing (F) þ Centering (C)) simultaneously during gymnastics insofar as the concentration and focused move- the movement performance and potentially benefit from ments embodied by the techniques may facilitate neuro- such a ‘three dimensional strategy’. On the other hand an plasticity. Qi Gong and EK can also ‘mobilise’ similar, not individual may also choose particular elements that he or fully understood neuroanatomical and neurophysiological she intends to develop, i.e. rational thinking and emotions pathways (Ashe et al., 2006; Haaland, 2006). Qi Gong prac- together with attention focused on both the detail and the titioners, like EK practitioners, might therefore be able to wholeness of a visible object as this would require a combi- influence the functional status of the central nervous nation of F and C respectively. Conversely, it can be sug- system, through the use of movement to improve cognitive gested that EK practitioner may incorporate Qi Gong functioning, emotional well-being and self-awareness. Qi movements’ characteristic (consciousness, smoothness, Gong practitioners may also be able to facilitate personal softness, effortless concentration, breathing and energy development, better social functioning via interpersonal management) into his or her ‘session’ in order to generate relationship improvement and whole personality integrity. potential biopsychosocial benefits. To some extent it can be Moreover it may also be successfully used in health promo- concluded that, although Qi Gong and EK have their roots in tion, disease prevention through social comparisons and/or different cultures and different historical timeframes, they modeling. From the EK point of view, Qi Gong may be may share a common conceptual background. If verified, this regarded as an appropriate way of using muscles that offers hypothesis may be a useful adjunct both to Qi Gong practi- enhanced mindebody integration as well as various psycho- tioners, permitting further development of their psycho- physiological benefits. logical or social awareness, and to educational kinesiologists, who might consider expanding their ‘thera- Conversely, from Qi Gong’s perspective EK may be peutic toolkit’ by using Qi Gong movements. The authors thought as a form of movements that encourages self- suggest that the assumptions presented within the scope of organization in social, pscychological and biological this article may not necessarily induce change of the existing spheres. If Qi Gong and EK practitioners could entertain the paradigm in which Qi Gong and EK are embedded. There- proposed notion that the two practices share conceptual fore, it is being recommended that within the proposed roots there might be an opportunity for both disciplines to worldview through which knowledge is filtered, one may or draw upon the other’s understandings. Of course one may may not acknowledge the other modality’s attributes or argue that this study may have limitations such as diverse qualities, intend to incorporate them into practice and quantity and various quality and scientific rigor of the subjectively judge the effects of this convergence and its presented studies. The first author (PP) also acknowledges relevance. This model, if verified by the future research may that his interest in the topic could have shaped findings promote change of the existing ontological, epistemological presented within the scope of this article. However, the and methodological questions (Guba and Lincoln, 1998). discussion regarding the concept itself is open and the authors will be keen on accepting any thoughts and insights Conclusions in order to modify or develop the presented concept. Qi Gong is regarded as a therapy that harmonizes the well- Future research being of an individual through simultaneous integrity of structure and function, such as unity of breathing, Future research could comprise the definite and exact (also movement, attention (concentration), memory, positive quantitative) analysis of Qi Gong and EK’s movement
78 P. Posadzki et al. patterns and their influence on various bodies’ systems. Jung, M.J., Shin, B.C., Kim, Y.S., Shin, Y.I., Lee, M.S., 2006 Sep. Is If similar effects of the movement patterns on the body there any difference in the effects of I therapy (external were detected, this could be an indirect but trustworthy Qigong) with and without touching? A pilot study. Int. J. Neu- indicator of congruence of these modalities on the biopsy- rosci. 116 (9), 1055e1064. chosocial level. Unquestionably, further conceptual devel- opment, as well as more both qualitative and quantitative Lan, C., Chou, S.W., Chen, S.Y., Lai, J.S., Wong, M.K., 2004. The aerobic designs would be desirable in order to expand our knowl- capacity and ventilatory efficiency during exercise in Qigong and Tai edge on these therapies and their essence. Chi Chuan practitioners. Am. J. Chin. Med. 32 (1), 141e150. Acknowledgements Lee, M.S., Hong, S.S., Lim, H.J., Kim, H.J., Woo, W.H., Moon, S.R., 2003a. Retrospective survey on therapeutic efficacy of Qigong The authors wish to thank Dr Simon Donell and Mr James in Korea. Am. J. Chin. Med. 31 (5), 809e815. Hands for their contribution to this article. Sincere thanks to Professor Tadeusz Kasperczyk for his support and Dr Chen Lee, M.S., Huh, H.J., Jeong, S.M., Lee, H.S., Ryu, H., Park, J.H., Yong Fa for his efforts to promote Qi Gong around the Chung, H.T., Woo, W.H., 2003b. Effects of Qigong on immune world. cells. Am. J. Chin. Med. 31 (2), 327e335. References Lee, M.S., Lee, M.S., Kim, H.J., Moon, S.R., 2003c. Qigong reduced blood pressure and catecholamine levels of patients with Agishi, T., 1998 Aug. Effects of the external qigong on symptoms essential hypertension. Int. J. Neurosci. 113 (12), 1691e1701. of arteriosclerotic obstruction in the lower extremities evalu- ated by modern medical technology. Artif. Organs 22 (8), Lee, M.S., Lim, H.J., Lee, M.S., 2004a. Impact of qigong exercise on 707e710. self-efficacy and other cognitive perceptual variables in patients with essential hypertension. J. Altern. Complement. Ashe, J., Lungu, O.V., Basford, A.T., Lu, X., 2006 Apr. Cortical Med. 10 (4), 675e680. control of motor sequences. Curr. Opin. Neurobiol. 16 (2), 213e221. Epub 2006 Mar 24. Lee, M.S., Ryu, H., Song, J., Moon, S.R., 2004b. Effects of I-training (Qigong) on forearm blood gas concentrations. Int. J. Neurosci. Cammisa, K.M., 1994 Feb. Educational kinesiology with learning 114 (11), 1503e1510. disabled children: an efficacy study. Percept. Mot. Skills 78 (1), 105e106. Lee, M.S., Kim, M.K., Ryu, H., 2005a. I-training (qigong) enhanced immune functions: what is the underlying mechanism? Int. Chen, K., Yeung, R., 2002 Dec. Exploratory studies of Qigong therapy J. Neurosci. 115 (8), 1099e1104. for cancer in China. Integr. Cancer Ther. 1 (4), 345e370. Lee, M.S., Yang, S.H., Lee, K.K., Moon, S.R., 2005b. Effects of I Chen, K.W., Turner, F.D., 2004 Feb. A case study of simultaneous therapy (external Qigong) on symptoms of advanced cancer: recovery from multiple physical symptoms with medical qigong a single case study. Eur. J. Cancer Care (Engl.) 14 (5), 457e462. therapy. J. Altern. Complement. Med. 10 (1), 159e162. Lee, M.S., Pittler, M.H., Guo, R., Ernst, E., 2007 Aug. Qigong for Chen, K.W., Hassett, A.L., Hou, F., Staller, J., Lichtbroun, A.S., 2006 hypertension: a systematic review of randomized clinical trials. Nov. A pilot study of external qigong therapy for patients with J. Hypertens. 25 (8), 1525e1532. fibromyalgia. J. Altern. Complement. Med. 12 (9), 851e856. Lee, T.I., Chen, H.H., Yeh, M.L., 2006. Effects of chan-chuang Dorcas, A., Yung, P., 2003 Nov. Qigong: harmonising the breath, the qigong on improving symptom and psychological distress in body and the mind. Complement. Ther. Nurs. Midwifery 9 (4), chemotherapy patients. Am. J. Chin. Med. 34 (1), 37e46. 198e202. Li, M., Chen, K., Mo, Z., 2002. Use of qigong therapy in the Ericsson, K.A., Charness, N., Feltovich, P.J., Hoffman, R.R., 2006. detoxification of heroin addicts. Altern Ther Health Med Jan- The Cambridge Handbook of Expertise and Expert Performance. Feb 8 (1), 50e54, 56e9. Cambridge University Press. Lim, Y.A., Boone, T., Flarity, J.R., Thompson, W.R., 1993. Effects Gallo, F.P., 2005. Energy Psychology. CRC Press. of qigong on cardiorespiratory changes: a preliminary study. Guba, E.G., Lincoln, Y.S., 1998. Competing paradigms in qualita- Am. J. Chin. Med. 21 (1), 1e6. tive research: theories and issues. In: Denzin, N.K., Lincoln, Y.S. Litscher, G., Wenzel, G., Niederwieser, G., Schwarz, G., 2001 Jul. (Eds.), The Landscape of Qualitative Research: Theories and Effects of QiGong on brain function. Neurol. Res. 23 (5), 501e505. Issues. Sage, Thousand Oaks, CA. Haaland, K.Y., 2006 Dec. Left hemisphere dominance for move- Mannerkorpi, K., Arndorw, M., 2004 Nov. Efficacy and feasibility of ment. Clin. Neuropsychol. 20 (4), 609e622. a combination of body awareness therapy and qigong in patients Hesse-Biber, S.N., Leavy, P., 2005. The Practice of Qualitative with fibromyalgia: a pilot study. J. Rehabil. Med. 36 (6), 279e281. Research. Sage, London. Hui, P.N., Wan, M., Chan, W.K., Yung, P.M., 2006 May. An evalua- Masgutowa, S., Akhmatova, N., 2004. Integration of Dynamic and tion of two behavioral rehabilitation programs, qigong versus Postural Reflexes with Whole Body’s Movement System. Inter- progressive relaxation, in improving the quality of life in cardiac national NeuroKinesiology Institute. patients. J. Altern. Complement. Med. 12 (4), 373e378. Iwao, M., Kajiyama, S., Mori, H., Oogaki, K., 1999 Aug. Effects of Mayer, M., 1999 Aug. Qigong and hypertension: a critique of qigong walking on diabetic patients: a pilot study. J. Altern. research. J. Altern. Complement. Med. 5 (4), 371e382. Complement. Med. 5 (4), 353e358. Jang, H.S., Lee, M.S., 2004 Jun. Effects of qi therapy (external McCaffrey, R., Fowler, N.L., 2003 MareApr. Qigong practice: a pathway qigong) on premenstrual syndrome: a randomized placebo- to health and healing. Holist. Nurs. Pract. 17 (2), 110e116. controlled study. J. Altern. Complement. Med. 10 (3), 456e462. Jones, B.M., 2001. Changes in cytokine production in healthy Morris, G.S., Sifft, J.M., Khalsa, G.K., 1998 Aug. Effect of educa- subjects practicing Guolin Qigong: a pilot study. BMC Comple- tional kinesiology on static balance of learning disabled ment. Altern. Med. 1, 8. Epub 2001 Oct 18. students. Percept. Mot. Skills 67 (1), 51e54. Northey, S.S., 2005. Handbook on Differentiated Instruction for Middle and High Schools. Eye on Education, Inc. Pan, W., Zhang, L., Xia, Y., 1994 Sep. The difference in EEG theta waves between concentrative and non-concentrative qigong states e a power spectrum and topographic mapping study. J. Tradit. Chin. Med. 14 (3), 212e218. Prashnig, B., 2004. The Power of Diversity: New Ways of Learning and Teaching Through Learning Styles. Continuum International Publishing Group. Reuther, I., Aldridge, D., 1998 Summer. Qigong Yangsheng as a complementary therapy in the management of asthma: a single- case appraisal. J. Altern. Complement. Med. 4 (2), 173e183.
Qi Gong’s relationship to educational kinesiology 79 Ryu, H., Lee, H.S., Shin, Y.S., Chung, S.M., Lee, M.S., Kim, H.M., with chronic physical illnesses: a randomized clinical trial. Int. Chung, H.T., 1996. Acute effect of qigong training on stress J. Geriatr. Psychiatry 18 (5), 441e449. hormonal levels in man. Am. J. Chin. Med. 24 (2), 193e198. Tsang, H.W., Fung, K.M., Chan, A.S., Lee, G., Chan, F., 2006 Sep. Effect of a qigong exercise programme on elderly with depres- Sancer, K.M., 1999 Aug. Therapeutic benefits of qigong exercises in sion. Int. J. Geriatr. Psychiatry 21 (9), 890e897. combination with drugs. J. Altern. Complement. Med. 5 (4), Wu, W.H., Bandilla, E., Ciccone, D.S., Yang, J., Cheng, S.C., 383e389. Carner, N., Wu, Y., Shen, R., 1999 Jan. Effects of qigong on late- stage complex regional pain syndrome. Altern. Ther. Health Sancier, K.M., 2003 Apr. Electrodermal measurements for moni- Med. 5 (1), 45e54. toring the effects of a qigong workshop. J. Altern. Complement. Xin, L., Miller, Y.D., Brown, W.J., 2007 May. A qualitative review of Med. 9 (2), 235e241. the role of qigong in the management of diabetes. J. Altern. Complement. Med. 13 (4), 427e433. Schmitz-Halbsch, T., Pyfer, D., Kielwein, K., Fimmers, R., Xu, S.H., 1994 Mar. Psychophysiological reactions associated with Klockgether, T., Wu¨llner, U., 2006 Apr. Qigong exercise for the qigong therapy. Chin. Med. J. (Engl.) 107 (3), 230e233. symptoms of Parkinson’s disease: a randomized, controlled Yan, X., Shen, H., Jiang, H., Zhang, C., Hu, D., Wang, J., Wu, X., pilot study. Mov. Disord. 21 (4), 543e548. 2006. External I of Yan Xin Qigong differentially regulates the Akt and extracellular signal-regulated kinase pathways and is Sifft, J.M., Khalsa, G.C., 1991 Dec. Effect of educational kinesi- cytotoxic to cancer cells but not to normal cells. Int. J. Bio- ology upon simple response times and choice response times. chem. Cell Biol. 38 (12), 2102e2113. Percept. Mot. Skills 73 (3 Pt 1), 1011e1015. Yang, Y., Verkuilen, J.V., Rosengren, K.S., Grubisich, S.A., Reed, M.R., Hsiao-Wecksler, E.T., 2007 Aug. Effect of Siu, J.Y., Sung, H.C., Lee, W.L., 2007 Apr. Qigong practice among combined Taiji and Qigong training on balance mechanisms: chronically ill patients during the SARS outbreak. J. Clin. Nurs. a randomized controlled trial of older adults. Med. Sci. Monit. 16 (4), 769e776. 13 (8), CR339eCR348. Skoglund, L., Jansson, E., 2007 May. Qigong reduces stress in computer operators. Complement. Ther. Clin. Pract. 13 (2), 78e84. Epub 2006 Nov 28. Tsang, H.W., Mok, C.K., Au Yeung, Y.T., Chan, S.Y., 2003 May. The effect of Qigong on general and psychosocial health of elderly
Journal of Bodywork & Movement Therapies (2010) 14, 80e83 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt PREVENTION & REHABILITATION: EDITORIAL Core stability is a subset of motor control PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL Warrick McNeill, MCSP, Associate Editor United Kingdom Love it or hate it the term ‘core stability’ is ubiquitous, and shoulder movement in subjects with low back pain. In the is a firm part of the lexicon of modern life. While preparing notes given out at a course I attended in 1996, presented by to write this editorial I asked many people, from therapists, Paul Hodges (Richardson et al., 1996), the term core to clients, to the non-injured and healthy ‘man-in-the-gym’ stability was not used. ‘Motor control’ was consistently what they thought of the term and what it meant. ‘‘I don’t referred to, as was ‘local joint stabilization.’ The term core use the term when I am talking to my patients,’’ said Chris stability appears to have developed, concurrently or later Dorgu, an elite football Osteopath, working in the UK, ‘‘I and seems to have become the default term applied to all prefer to talk about the specifics of what I am working on motor control training around the trunk, through to with them. The term core stability is imprecise and open to (possibly!) ‘a clean and jerk then squatting a water filled interpretation.’’ Suzy Barton, a London based Pilates Swiss ball’ (youtube.com). Teacher said that, ‘‘The term core stability is used by everyday people and, to most, it means a strong centre There does seem to be consensus that there may be while moving the arms and legs. People often have no idea some differences in the meaning of core stability as the about the science behind the concept.’’ Phillip O’Calla- term core strengthening is also frequently found in the ghan, currently working hard with a Personal Trainer in literature and on the web. Comerford and Mottram (2001), a late stage rehab of an ACL reconstruction said, ‘‘It’s all Comerford (2004) points out that some therapeutic exer- about the abdominals, isn’t it?’’ cises are aimed at strengthening weak muscles around the core, and others are designed to improve the recruitment In this Prevention and Rehabilitation section, the JBMT is of muscles that may be underactive and not fulfilling their publishing an article by Eyal Lederman, entitled ‘‘The myth role in the synergy of neuromuscular control about the of core stability.’’ It is likely to be an interesting, perhaps trunk and girdles. The difference Comerford suggests is challenging, read for clinicians who use the concepts of related to the threshold of the recruitment required for core stability in their everyday practice. each type of exercise, with ‘core strengthening’ needing to bias the fast fatiguing, fast motor unit to effectively Lederman reflects a current increase in the popular strengthen, and ‘motor control core stability’ training of press, including the ‘New York Times’ (nytimes.com) and smaller postural loads, aimed at improving the recruitment the United Kingdom’s ‘The Times’ (timesonline.co.uk) and endurance of the slow motor unit. The clinical problem newspapers, questioning aspects of core stability theory. is in providing the assessment of the clients’ faults so that Lederman’s approach to this article looks at identifying the correct threshold of exercise is given (Mottram and assumptions within core stability theory and applying Comerford, 2008). research findings to see if the assumptions bear scrutiny. Do we need a model of muscle function? In Lederman’s article the term core stability particularly relates to the mid 1990s work of Hodges and Richardson Regardless of how a model of muscle function is created, (1996), Richardson et al., 2004 from Australia’s Queensland the construction of a model is important for clinicians to University, and the identification of a timing delay in the use to try and better understand the complexities of the firing of the transversus abdominis (TrA) during rapid brains control of muscle, both voluntary and sub-conscious. E-mail address: [email protected] 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.10.001
Core stability commentary 81 PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL For me local muscles such as ‘Hodges’ TrA, (Hodges and handling, imagery, or anatomical or pathological explana- Richardson, 1996), or ‘Hides’ deep fibres of Multifidus (DM) tions, gives the client raw material for their Central (Hides et al., 1996, 2001) have helped me build a concept Nervous System (CNS) to process and to come up with its (however flawed?) of how the deeper muscles may work to own solution(s) to the presenting motor control problems. control joint translation which, if uncontrolled, may lead to micro-trauma, wear and tear and possible injury (Panjabi, Hodges (2004) identifies that there are multiple strate- 1992). This led me, in my practice, to offer to those who I gies available to the CNS for motor control and considerable felt would benefit from having the deeper muscle struc- redundancy within this system. This means that there may tures brought to their attention, an ‘educational’ session well be many correct solutions to ‘fix’ a motor control identifying those muscles and a ‘muscle recruitment’ quiz problem, and each individual may need a different to see if they can ‘turn them on.’ approach to get to a solution that works for them. This identifies to me a key difference between research and the Muscle inhibition due to pain is identified in the litera- clinic. When a client comes in I have to provide a reasoned ture (Hides et al., 1996), as is increased activation (van approach to address the problems I find. Doing ‘something’ Dieen et al., 2003). If pain does cause DM inhibition and may only provide a placebo effect, though this can help leads to eventual DM atrophy over an affected motion (Wittink and Michel, 2002), but it may also be doing segment, I feel justified in teaching a client in the clinic something positive that changes the situation and assists how to recruit this muscle. I have read MacDonald et al.’s the client back to a healthier footing than they were before (2006) ‘The lumbar multifidus: does the evidence support their presentation. What I think I am doing, may produce clinical beliefs?’ in which a review of data about the DM and the desired result, however, it may conceivably be by an superficial multifidus (SM) is applied to the Queensland entirely different process! Furthermore, in the clinic we approach, and though some beliefs are supported by the don’t just do ‘one’ thing to the client, we provide multi- data (for example: SM and DM are both segmental motion modal treatment regimes which result in the clients even- controllers, DM can work as a translational movement tual outcome. We may reflect and discard for an individual, controller without having an antagonist), others are not (for or all our clients, some approaches that may not have example: SM is not solely a rotator or extensor, DM is not appeared to work, but it is difficult to know with certainty, tonically active during static postures). The paper advises that we are discarding the ineffective technique. Often, that the findings have implications in clinical practice. It through good luck, good management or the natural history appears, in my reading of the paper, that the DM remains an of a condition, the client improves to a greater or lesser important component of the integrated musculature of the extent. The problem for the Researcher is to identify which body, so I will continue to address its under-activation. modality, or which combination of modalities had what effect, which bears up to the rigour of evidence based I certainly do not believe that any one muscle is any practice and which do not. This is clearly exceptionally more important than another in the so-called ‘core.’ ‘All difficult. Being a clinician seems to be the easier choice. muscles are created equal’ but this does not mean we are For me, the choice to use ‘core stability’ techniques not allowed to shine a spotlight on a single cog in the remains valid under the current body of evidence. clockworks to discuss its role. All the cogs in a clockwork mechanism need to work together to show the passing of Core robustness exercises time. Is ‘core stability’ new? Is it a re-badging of other concepts? In my practice not all of my clients get a ‘Queensland’ Wallden (2009), My Co-Editor of this section, in his recent approach. History and presenting pain will inform my clin- ‘Neutral spine principle’ Wallden (2009) discusses ‘neutral’ ical decisions. Some clients do not appear to have any which is an integral component of ‘core stability’ yet there difficulty in proving a voluntary contact with their trunk is not a mention of core stability in his piece. Why is this? muscles, superficial or deep, statically, or dynamically. Perhaps its because neutral concepts aren’t exclusive to They have a ‘flow’ while performing whole body move- core stability? ments that appears to be a smooth sequencing of muscles working in an efficient order, with no one muscle being Siff (2009b) suggests that at one time we had kin- more dominant than another, or more correctly, no one aesthetic, proprioceptive, or motor skill training, but now it movement more dominant e as the ‘body knows move- is core stability training, he suggests that this is not a suit- ments, not muscles’ (Siff, 2009a). If no indicators suggest I able modern substitute. He opines that the core, in most use a ‘Queensland’ approach then I need to look for instances, operates in a world where peripheral contact another technique in my toolkit for an appropriate treat- with a surface is important and peripheral stabilization is ment for the problems I do identify. more important than the stabilization of the core. In rela- tion to knee injury risk, however, Zazulak et al. (2007a,b, Explain muscles 2008) show that deficits in neuromuscular control of the trunk predicts knee injury, in female, but not male If Butler and Moseley (2003) can ‘Explain Pain’ to a chronic athletes. Forces affecting the body from foot contact up pain sufferer and a year later, with no other intervention, the kinetic chain are clearly important, but, so too, it improve their pain, perhaps an ‘Explain Muscles’ approach appears, are centre down forces. could have a similar effect? In researching Complex regional pain syndrome ‘motor imagery’ has proved (Moseley, 2004) ‘Stability’ itself is poorly understood (Reeves et al., to be an effective tool. I feel that connecting a client to 2007), differentiating between static and dynamic systems under-recruited muscles using visual feedback, self is important. Reeves states that ‘static stability
PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL 82 W. McNeill explanations’ account for the findings ‘that there is Liebenson therefore advocates an abdominal co-contrac- a potential for injury under low level loading’ (Cholewicki tion (bracing) exercise regime in this paper. and McGill, 1996) and ‘that a lack of stiffness was associ- ated with injury’ and that this led to the development of Tsao and Hodges (2008) in their study on subjects with concepts of core stability. Reeves suggests that this was low back pain, reported validating a motor control training taken from a static understanding of spinal stability where strategy that improved TrA timing (feedforward) and increasing stiffness does increase stability. In a dynamic maintained it for the follow up at six months. It was the first model of stability, however, there are times when less study to show such a finding. The authors took care to stiffness is desirable to help in the precision of motor emphasise that the study, ‘‘does not advocate that controlled activities such as standing, balancing or gait by repeated isolated voluntary contractions is sufficient to providing a more supple spine. The ‘central controller’ treat low back pain (LBP). Rather, the study indicates that needs to exhibit a variable control and efficient feedback, one impairment often identified in LBP (i.e., delayed and this continues in a loop. Reeves goes on to say that activity of TrA) can be changed with training.’’ a system is either stable or unstable, but it is the robustness (how well the system copes with uncertainties and distur- A similar study by Hall et al. (2009) (including in the bances) of the system that is important. Reeves comments authorship Tsao and Hodges), looked at the co-contraction that stability is often confused with robustness, ‘‘Core exercises favoured by McGill and showed that a single stabilizing exercises do not make the spine more stable, session of this type of training did not change the feed- they make it more robust, thus reducing risk of injury.’’ forward timing of the TrA in low back pain subjects. Perhaps the next new hot exercise fad to take over from core stability training will be ‘core robustness exercise!’ Admittedly both these studies had a low number of subjects but the findings are very interesting and may show Canada Vs. Australia there still is life in the theory of core stability. Within the world of core stability research there appears to It is very possible that in the future we will look back and be two schools of thought perhaps best personalised by say that McGill and Hodges’ theories both had merit Stuart McGill from Canada and Paul Hodges from Australia. and were looking at the same problem; that their views and Their work frequently references each other as it appears exercises were not mutually exclusive, as the CNS has many they both produce good science with interesting results strategies to deal with movement control. In the clinic, that can be applied to the theoretical models that they where distinctions are blurred, I am happy to use both propose. Both are passionate (Chaitow, 2005), and if you commentators’ ideas at different times. I contend that have to identify the key area of research for each you may McGill and Hodges, in the field of low back biomechanics possibly choose spinal biomechanics for McGill and spinal and motor control, may have more common ground they motor control for Hodges, though the distinctions between agree on than ground over which they do not. them would be blurred. Both advocate exercise regimes for the prevention or treatment of spinal pain. Some of Hodges Future research exercises are regarded as isolationist (Siff, 2009a), this could be interpreted, and has been, according to Leder- Chronic low back pain (CLBP) is a complex subject to man, in that the TrA and Mf are to be exercised and investigate, not least because of the many various influ- strengthened in isolation. This is reminiscent of the fitness ences that may cause the pain. Hebert et al. (2008) (gym) worlds isolated exercise of the ‘biceps curl’ (not truly attempted to subgroup patients with non-specific low back just a biceps brachii exercise, it is the synergy of elbow pain (LBP) to place them into various treatment categories flexion/extension that is actually exercised). Admittedly including specific exercise, stabilization exercise, manipu- the TrA and Mf muscles are identified and recruited in lation and traction. It appears that subgrouping LBP may isolation, (not strengthened!) but this immediately help in future experimental design and provide cleaner precedes integrating those muscles into function, so it may results for interpretation. be fair to say ‘isolationist’ but only until functional move- ment is added to the regime. Where is core stability research going? In fact is that the real question we should be asking? If Lederman is effective McGill’s exercises reflect his opinion that ‘‘the relative in his argument the term core stability will be phased out contribution from every muscle source is dynamically and research funding placed elsewhere. McGill, Hodges and changing’’ (McGill, 2007). His exercises, such as bird dog others are perhaps less likely to think they are specifically (see a description of this exercise in Leibenson’s ‘The undertaking core stability research but would refer to their missing link in protecting against back pain’ later in this work as research in motor control. editions Prevention and Rehabilitation section), and side bridge could be called co-contraction exercises as they Core stability has really only ever been a subset of the recruit all muscles in the trunk, though will bias different broader church of ‘motor control’. muscle groups, and are aimed at promoting control of spinal posture in positions that are bio-mechanically sound. So where is motor control research going? It seems that Liebenson (2007) reports on Koumantakis et al. (2005) study the assessment of movement control is starting to show that demonstrated the ‘‘general’’ approach (McGill’s) interesting results Luomajoki et al. (2008) looked at 6 was superior to the Australian ‘‘deep’’ local stabilization. motor control tests of the lumbar spine with a study size involving 210 subjects, half with LBP and the control half without. The study showed a significant difference in the ability between the groups to actively control the move- ments of the low back. The LBP groups control was poorer. Roussel et al. (2009) has shown in dancers that two lumbo-pelvic movement control tests (standing bow and
Core stability commentary 83 PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL a crook lying single knee lift) are predictive of injury risk to difference between patients with low back pain and healthy the low back or lower limb. Roussel’s findings suggest that controls. BMC Musculoskeletal Disorders 9, 170. motor control or strengthening interventions may reduce MacDonald, D.A., Moseley, G.L., Hodges, P.W., 2006. The lumbar the chance of an injury happening at all. multifidus: does the evidence support clinical beliefs? Manual Therapy 11, 254e263. Conclusion McGill, S., 2007. Low back disorders evidence-based prevention and rehabilitation. Human Kinematics. Is the term ‘core stability’ limiting? I believe it is. Leder- Moseley, G.L., 2004. Graded motor imagery is effective for long man’s article shows how some ideas around core stability standing complex regional pain syndrome: a randomised have become part of the problem and not part of the controlled trial. Pain 108, 192e198. solution, and it is definitely time to move on from there. Mottram, S.L., Comerford, M.J., 2008. A new perspective in risk assessment. Physical Therapy in Sport 9, 40e51. If this topic and this edition provokes a response from Panjabi, M., 1992. The stabilising system of the spine. Part 1. you, please email me as I would like to report back to the Function, dysfunction, adaptation and enhancement. Journal of readership in my next editorial what your views are. Spinal Disorders 5, 383e389. Reeves, N.P., Narendra, K.S., Cholewicki, J., 2007. Spine stability: The last word comes from the Pilates Teacher Suzy the six blind men and the elephant. Clinical Biomechanics 22, Barton we met earlier. ‘‘If the public are asking for core 266e274. stability exercises, don’t send them away saying we don’t Richardson, C., Hodges, P., Hides, J., 2004. Therapeutic Exercise do that any more, take their request and give them exer- for Lumbopelvic Stabilization. Churchill Livingstone. cises to fit their individual issues!’’ Richardson, C., Jull, G., Hodges, P., Hides, J., 1996. Local joint stabilisation: specific assessment and exercises for low back References pain. Course notes. Roussel, N.A., Nijs, J., Mottram, S., Van Moorsel, A., Truijen, S., Butler, D., Moseley, G.L., 2003. Explain Pain. Noigroup Publica- Stassijns, G., 2009. Altered lumbopelvic movement control but tions, Adelaide. not generalized joint hypermobility is associated with increased injury in dancers. Manual Therapy. doi: Chaitow, L., 2005. Melbourne conference. Journal of Bodywork and 10.1016/j.math.2008.12.004. Movement Therapies 9, 85e87. Tsao, H., Hodges, P.W., 2008. Persistence of improvements in postural strategies following motor control training in people Cholewicki, J., McGill, S., 1996. Mechanical stability in the vivo with recurrent low back pain. Journal of Electromyography and lumbar spine: implications for injury and chronic low back pain. Kinesiology 18 (4), 559e567. Clinical Biomechanics 11 (1), 1e15. van Dieen, J.H., Selen, L.P.J., Cholewicki, J., 2003. Trunk muscle activation in low-back pain patients, an analysis of the Comerford, M.J., Mottram, S.L., 2001. Functional stability re- literature. Journal of Electromyography and Kinesiology 13, training: principles and strategies for managing mechanical 333e351. dysfunction. Manual Therapy 6 (1), 3e14. Wallden, M., 2009. The neutral spine principle. Journal Bodywork and Movement Therapies 13, 350e361. Comerford, M.J., 2004. Core stability: priorities in rehab of the Wittink, H., Michel, THoskins, 2002. Chronic Pain Management for athlete. SportEx Medicine 22, 15e22. Physical Therapists, second ed. Oxford, New York. Zazulak, B., Hewett, T.E., Reeves, N.P., Goldberg, B., Hall, L., Tsao, H., MacDonald, D., Coppieters, M., Hodges, P.W., Cholewicki, J., 2007. The effects of core proprioception on 2009. Immediate effects of co-contraction training on motor knee injury: a prospective biomechanical-epidemiological control of the trunk muscles in people with recurrent low back study. American Journal of Sports Medicine 35, 368e374. pain. Journal of Electromyography and Kinesiology 19, 763e Zazulak, B., Hewett, T.E., Reeves, N.P., Goldberg, B., 2773. Cholewicki, J., 2007. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical- Hebert, J., Koppenhaver, S., Fritz, J., Parent, E., 2008. Clinical epidemiologic study. American Journal of Sports Medicine 35, prediction for success of interventions for managing low back 1123e1131. pain. Clinics in Sports Medicine 27 (3), 463e479. Zazulak, B., Cholewicki, J., Reeves, N.P., 2008. Neuromuscular control of trunk stability: clinical implications for sports injury Hides, J.A., Richardson, C.A., Jull, G.A., 1996. Multifidus recovery prevention. Journal of the American Academy of Orthopaedic is not automatic after resolution of acute, first-episode low Surgeons 16, 497e5025. back pain. Spine 21 (23), 2763e2769. Web sources Hides, J.A., Jull, G.A., Richardson, C.A., 2001. Long term effects of specific stabilizing exercises for first episode low back pain. http://www.youtube.com/results?search_queryZcleanþjerkþSwissþ Spine 26 (11), 243e248. Ball&;search_typeZ&aqZf. Hodges, P.W., Richardson, C.A., 1996. Inefficient muscular stabi- Siff, 2009. http://drmelsiff.wordpress.com/2009/07/31/ lisation of the lumbar spine associated with low back pain: transversusabdominus-and-core-training-part-i/. a motor control evaluation of transversus abdominis. Spine 21 (22), 2640e2650. Siff, 2009. http://drmelsif85.blogspot.com/2009/06/dr-mel-siff- on-core-stability.html. Hodges, P.W., 2004. Motor control of the trunk. In: Boyling, J.D., Jull, G.A. (Eds.), Grieves Modern Manual Therapy the Vertebral http://women.timesonline.co.uk/tol/life_and_style/women/ Column. Churchill Livingstone, pp. 119e139. diet_and_fitness/article6068862.ece. Koumantakis, G.A., Watson, P.J., Oldham, J.A., 2005. Trunk muscle http://well.blogs.nytimes.com/2009/06/17/core-myths/ stabilization training versus general exercise only: randomized ?apageZ4. controlled trial of patients with recurrent low back pain. Physical Therapy 85, 209e225. Liebenson, C., 2007. A modern approach to abdominal training. Journal of Bodywork and Movement Therapies 11, 194e198. Luomajoki, H., Kool, J., de Bruin, E.D., Airaksinen, O., 2008. Movement control tests of the low back: evaluation of the
Journal of Bodywork & Movement Therapies (2010) 14, 84e98 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt CRITICAL REVIEW The myth of core stability Eyal Lederman* CPDO Ltd., 15 Harberton Road, London N19 3JS, UK Received 26 October 2008; received in revised form 3 May 2009; accepted 4 August 2009 PREVENTION & REHABILITATIONdCRITICAL REVIEW KEYWORDS Summary The principle of core stability has gained wide acceptance in training for the Core stability; prevention of injury and as a treatment modality for rehabilitation of various musculoskeletal Spinal stabilisation; conditions in particular of the lower back. There has been surprisingly little criticism of this Transversus abdominis; approach up to date. This article re-examines the original findings and the principles of core Chronic lower back and stability/spinal stabilisation approaches and how well they fare within the wider knowledge neuromuscular of motor control, prevention of injury and rehabilitation of neuromuscular and musculoskel- rehabilitation etal systems following injury. ª 2009 Elsevier Ltd. All rights reserved. Introduction back, and influences from Pilates, have promoted several assumptions prevalent in CS training: Core stability (CS) arrived in the latter part of the 1990s. It was largely derived from studies that demonstrated That certain muscles are more important for stabilisa- a change in onset timing of the trunk muscles in back injury tion of the spine than other muscles, in particular and chronic lower back pain (CLBP) patients (Hodges and transversus abdominis (TrA). Richardson, 1996, 1998). The research in trunk control has been an important contribution to the understanding of That weak abdominal muscles lead to back pain neuromuscular reorganisation in back pain and injury. As That strengthening abdominal or trunk muscles can long as four decades ago it was shown that motor strategies change in injury and pain (Freeman et al., 1965). The CS reduce back pain studies confirmed that such changes take place in motor That there is a unique group of ‘‘core’’ muscle working control of the trunk muscles of patients who suffer from back injury and pain. independently of other trunk muscles That back pain can be improved by normalising the However, these findings combined with general beliefs about the importance of abdominal muscles for a strong timing of core muscles That there is a relationship between stability and back * Tel.: þ44 207 263 8551. E-mail address: [email protected] pain As a consequence of these assumptions, a whole industry grew out of these studies with gyms and clinics worldwide teaching the ‘‘tummy tuck’’ and trunk bracing exercise to athletes for prevention of injury and to patients as a cure 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.08.001
The myth of core stability 85 PREVENTION & REHABILITATIONdCRITICAL REVIEW for lower back pain (Jull and Richardson, 2000; Richardson and Pohjanen, 2005), low socioeconomic class, existence et al., 2002). In this article some of these basic assumptions of previous LBP, posterior/fundal location of the placenta will be re-examined. and a significant correlation between foetal weight and LBP (Orvieto et al., 1990). Assumptions about stability and the role of TrA and other core muscle Another interesting period for us, concerning the role of abdominal muscles and stabilisation is immediately after In essence the passive human spine is an unstable structure delivery. Postpartum, it would take the abdominal muscle and therefore further stabilisation is provided by the about 4e6 weeks to reverse the length changes and for activity of the trunk muscles. These muscles are often motor control to reorganise. For example, rectus abdominis referred to in the CS approach as the ‘‘core’’ muscles, takes about 4 weeks postpartum to re-shorten, and it takes assuming that there is a distinct group, with an anatomical about 8 weeks for pelvic stability to normalise (Gilleard and and functional characteristics specifically designed to Brown, 1996). It would be expected that during this period provide for the stability. One of the muscles in this group to there would be minimal spinal support/stabilisation from have received much focus is TrA. It is widely believed that the slack abdominal muscles and their fasciae. Would this this muscle is the main anterior component of trunk stabi- increase the likelihood for back pain? lisation. It is now accepted that many different muscles of the trunk contribute to stability and that their action may In a recent study, the effects of a cognitive-behavioural change according to varying tasks (see further discussion approach were compared with standard physiotherapy on below). pelvic and lower back pain immediately after delivery (Bastiaenen et al., 2006). An interesting aspect of this The TrA has several functions in the upright posture. research was that out 869 pregnant women suffering from Stability is one, but this function is in synergy with every back pain during pregnancy, 635 were excluded because of other muscle that makes up the abdominals wall and their spontaneous unaided recovery within a week of beyond (Hodges et al., 1997, 2003; Sapsford et al., 2001). It delivery. This spontaneous recovery was during a period, acts in controlling pressure in the abdominal cavity for well before the abdominal muscles had time to return to vocalisation, respiration, defecation, vomiting, etc. (Misuri their pre-pregnancy length, strength or control (Gilleard et al., 1997). TrA forms the posterior wall of the inguinal and Brown, 1996). Yet, this was a period when back pain canal and where its valve-like function prevents the viscera was dramatically reduced. How can it be that back and from popping out through the canal (Bendavid and pelvic pain is improving during a period of profound Howarth, 2000). abdominal muscle inefficiency? Why does the spine not collapse? Has the relationship between abdominal muscles How essential is TrA for spinal stabilisation? One way to and spinal stability been over-emphasised? assess this is to look at situations where the muscle is damaged or put under abnormal mechanical stress. Would Similarly studies on weight gain and obesity and LBP this predispose the individual to lower back pain? challenge the CS theory. One would expect, as in preg- nancy, the distension of the abdomen to disrupt the normal According to Gray’s Anatomy (36th edition 1980, page mechanics and control of the trunk muscles, including TrA. 555) TrA is absent or fused to the internal oblique muscle as According to the CS model this should result in an increased a normal variation in some individuals. It would be inter- incidence of back pain among this group. Yet, epidemio- esting to see how these individuals stabilise their trunk and logical studies demonstrate that weight gain and obesity whether they suffer more back pain. are only weakly associated with lower back pain (Leboeuf- Yde, 2000) According to the CS model we should be seeing Pregnancy is another state that raises some important an epidemic of back pain in over-weight individuals. questions about the role of TrA or any abdominal muscle in spinal stabilisation. During pregnancy the abdominal Another area that can shed light on the control and wall muscles undergo dramatic elongation, associated stability of the abdominal muscles is the study of abdom- with force losses and inability to stabilise the pelvis inal muscles that have been damaged by surgery. Would against resistance (Fast et al., 1990; Gilleard and Brown, such damage affect spinal stability or contribute to back 1996). Indeed, in a study of pregnant women (n Z 318) pain? In breast reconstruction after mastectomy, one side they were shown to have lost the ability to perform sit- of the rectus abdominis is used for reconstruction of the ups due to this extensive elongation and subsequent force breast. Consequently, the patient is left with only one side losses (Fast et al., 1990). Whereas all non-pregnant of rectus abdominis and weakness of the abdominal women could perform a sit-up, 16.6% of pregnant women muscles. Such alteration in trunk biomechanics would also could not perform a single sit-up. However, there was no be expected to result in profound motor control changes. correlation between the sit-up performance and back- Despite all these changes there seems to be no relation- ache, i.e. the strength of abdominal muscle was not ship to back pain or impairment to the patient’s related to backache. Despite this, CS exercises are often functional/movement activities, measured up to several prescribed as a method for retraining the abdominal years after the operation (Mizgala et al., 1994; Simon muscles and ultimately as a treatment for LBP during et al., 2004). pregnancy. There is little evidence that localised muscu- loskeletal mechanical issues, including spinal stability play One area for further study would be that of subjects who a role in the development of LBP during pregnancy. Often have had inguinal hernia repair. In this operation the TrA cited predisposing factors are, for example, body mass is known to be affected by the surgical procedure index, a history of hypermobility and amenorrhea (Mogren (Berliner, 1983; Condon and Carilli, 1994). To date there is no known epidemiological study linking such surgery and back pain.
PREVENTION & REHABILITATIONdCRITICAL REVIEW 86 E. Lederman In summary we can conclude: were about 20 ms, i.e. one fiftieth of a second difference (Hodges and Richardson, 1996, 1998; Radebold et al., That abdominal musculature can demonstrate dramatic 2000). It should be noted that these were not strength but physiological changes, such as during pregnancy, post- timing differences. Such timings are well beyond the partum and obesity, with no detriment to spinal patient’s conscious control and the clinical capabilities of stability and health. the therapist to test or alter. Damage to abdominal musculature does not seem to be Often, in CS exercise there is an emphasis on strength detrimental to spinal stability or contribute to LBP. training for the TrA or low velocity exercise performed lying or kneeling on all fours (Richardson and Jull, 1995). It No study to date has demonstrated that LBP is due to is believed that such exercise would help normalise motor spinal instability. Despite a decade of research in this control which would include timing dysfunction. This kind area it remains a theoretical model. of training is unlikely to help reset timing differences. It is like aspiring to play the piano faster by exercising with The timing issue finger weights or performing push-ups. The reason why this is ineffective is related to a contradiction which CS training In one of the early studies it was demonstrated that during creates in relation to motor learning principles (similarity/ rapid arm/leg movement, the TrA in CLBP patients had transfer principle) and training principles (specificity prin- delayed onset timing when compared with asymptomatic ciple, see further discussion below). In essence these subjects (Hodges and Richardson, 1996, 1998). It was principles state that our bodies, including the neuromus- consequently assumed that the TrA, by means of its cular and musculoskeletal systems will adapt specifically to connection to the lumbar fascia, is dominant in controlling particular motor events. What is learned in one particular spinal stability (Hodges et al., 2003). Therefore any situation may not necessarily transfer to a different phys- weakness or lack of control of this muscle would spell ical event, i.e. if strength is required e lift weights, if trouble for the back. speed is needed e increase the speed of movement during training and along these lines if you need to control onset This assumption is a dramatic leap of faith. Firstly, in our timing switch your movement between synergists at a fast body all structures are profoundly connected in many rate, and hope that the system will reset itself (Lederman, different dimensions, including anatomically and biome- 2005, in press). chanically. You need a knife to separate them from each other. It is not difficult to emphasise a connection that To overcome the timing problem the proponents of CS would fit the theory, i.e. that the TrA is the main anterior came up with a solution e teach everyone to continuously muscle that controls spinal stability. In normal human contract the TrA or to tense/brace the core muscle movement postural reflexes are organised well ahead in (O’Sullivan, 2000; Jull and Richardson, 2000). By continuously anticipation of movement or perturbation to balance. TrA is contracting it would overcome the need to worry about onset one of the many trunk muscles that takes part in this timing. What is proposed here is to impose an abnormal, anticipatory organisation (Hodges and Richardson, 1997). non-functional pattern of control to overcome a functional Just because in healthy subjects it kicks off before all other reorganisation of the neuromuscular system to injury: anterior muscles (in one particular posture), does not mean a protective strategy that is as old as human evolution. it is more important in any way. It just means it is the first in a sequence of events (Cresswell et al., 1994a,b). Indeed, We now know that following injury, one motor strategy is it has been recently suggested that earlier activity of TA to co-contract the muscles around the joint (amongst many may be a compensation for its long elastic anterior fasciae other complex strategies, Figure 1). (Macdonald et al., 2006). This injury response has also been shown to occur in It can be equally valid to assume that a delay in onset CLBP patients (Nouwen et al., 1987; Arena et al., 1991; timing in subjects with LBP may be an advantageous Hubley-Kozey and Vezina, 2002a,b; Marras et al., 2005), protection strategy for the back rather than a dysfunctional who tend to co-contract their trunk flexors and extensors activation pattern. Furthermore, it could be that during the during movement (van Dieen et al., 2003a,b). This strategy fast movement of the outstretched arm the subject per- is subconscious, and very complex. It requires intricate formed a reflexive pain evasion action that involved interactions between the relative timing, duration, force, delayed activation of TrA, an action unrelated to stabili- muscle lengths and velocities of contraction of immediate sation (Moseley et al., 2003a,b, 2004). An analogy would be synergists (Shirado et al., 1995a,b; Radebold et al., 2000, the reflex pulling of the hand from a hot surface. One could see Table 1). Further complexity would arise from the fact imagine that a patient with a shoulder injury would use that these patterns would change on a moment-to-moment a different arm withdrawal pattern from a normal indi- basis and with different movement/postural tasks (McGill vidual. This movement pattern would be unrelated to the et al., 2003; Cordo et al., 2003; Moseley et al., 2003a,b). control of shoulder stability but would be intended to This pattern of muscle activity observed in standing with produce the least painful path of movement, even if the the arm outstretched is likely to change in bending forward movement is not painful at the time. A similar phenomenon or twisting. Indeed, in the original studies of the onset has been demonstrated in trunk control where just the timing of TrA delays in onset timing were observed during perception of a threat of pain to the back resulted in fast but not during slow arm movements (Hodges and altered postural strategies (Moseley and Hodges, 2006). Richardson, 1996). Even during a simple trunk rotation or exercise the activity in TrA is not uniform throughout the In the original studies of CS onset time differences muscle (Urquhart and Hodges, 2005; Urquhart et al., between asymptomatic individuals and patients with CLBP 2005a).
The myth of core stability 87 Skills Composite abilities Balance, coordination, Transition time, motor relaxation Motor complexity Synergetic abilities PREVENTION & REHABILITATIONdCRITICAL REVIEW Co-contraction & reciprocal activation Parametric abilities Force, velocity, length, endurance Figure 1 Motor control of movement is composed of several underlying factors which include force, velocity, range and endurance (parametric group of abilities); co-contraction and reciprocal activation which represent the synergistic level of control and the more complex composite motor abilities that include coordination, balance transition time between different activities and motor relaxation. All these motor components play a part during movement. By altering one, all the other control factors will also change. Adapted from: Lederman E, Neuromuscular rehabilitation in manual and physical therapy, to be published 2010. London, Elsevier. These studies demonstrate the complexity that a patient That loss of core muscle strength could lead to back re-learning trunk control may have to face. How would injury, a person know which part of the abdomen to contract during a particular posture or movement? How would they That increasing core strength can alleviate back pain know when to switch between synergists during movement? How would they know what is their optimal co-contraction To what force level do the trunk muscles need to force? If CLBP patients already use a co-contraction co-contract in order to stabilise the spine? It seems that the strategy why increase it? It is na¨ıve to assume that by answer is e not very much (Figure 2). continuously contracting the TrA it will somehow override or facilitate these patterns. Furthermore no study to date During standing and walking the trunk muscles are mini- has demonstrated that core stability exercise will reset mally activated (Andersson et al., 1996). In standing the deep onset timing in CLBP patients (Hall et al., 2007). spinal erectors, psoas and quadratus lumborum are virtually silent! In some subjects there is no detectable EMG activity in In summary we can conclude: these muscles. During walking rectus abdominis has an average activity of 2% maximal voluntary contraction (MVC) That there is motor reorganisation of the trunk muscles and external oblique 5% MVC (White and McNair, 2002). in response to the experience or the fear of spinal pain During standing ‘‘active’’ stabilisation is achieved by very low levels of co-contraction of trunk flexors and extensors, There is no evidence that such motor reorganisation is estimated at less than 1% MVC rising up to 3% MVC when the cause of spinal pain or recurrence of back pain a 32 kg weight is added to the torso. With a back injury it is estimated to raise these values by only 2.5% MVC for the Most prescribed CS exercise/manoeuvres are not well unloaded and loaded models (Cholewicki et al., 1997). During designed to challenge onset time of synergists and are bending and lifting a weight of about 15 kg co-contraction therefore unlikely to reset the onset timing of the trunk increases by only 1.5% MVC (van Dieen et al., 2003a,b). muscles These low levels of activation raise the question why No study to date have as demonstrated that core stability strength exercises are prescribed when such low levels of exercise will reset onset timing in CLBP patients. co-contraction forces are needed for functional movement. Such low co-contraction levels suggest the strength losses The strength issue are unlikely ever to be an issue for spinal stabilisation. A person would have to lose substantial trunk muscle or force There is more confusion about the issue of trunk strength control before it will destabilise the spine. and its relation to back pain and injury prevention. What we do know is that trunk muscle control including force These low levels of trunk muscle co-contraction also losses can be present as a consequence of back pain/injury. have important clinical implications. It means that most However, from here several assumptions are often made: individuals would find it impossible to control such low
PREVENTION & REHABILITATIONdCRITICA Table 1 The complexity of motor reorganisation during spinal/trunk injury and pain. All the particular motor components. A therapeutic error is to focus on single issues such as force or co Conditions Parametric motor abilities Force Length Velocity Endurance Lower Force losses in Loss of flexion Reduced velocity Increased back pain trunk muscles in relaxation in the of trunk movement fatigability trunk acute and CLBP spinal muscles during induced muscles in patient patients during flexion in back pain (Zedka with CLBP (Roy (Airaksinen et al., patients with et al., et al., 1989; 1996; Hides et al., CLBP.Extensors 1999)Individuals Shirado et al., 1994, 1996; Ng activation prevents with high pain- 1995a,b; Suter and et al., 1998; full forward related fear had Lindsay 2001) Shirado et al., bending smaller peak 1995a) (Shirado et al., velocities and 1995b). Individuals accelerations of with high pain- the lumbar spine related fear had and hip joints, smaller excursions even after of the lumbar spine resolution of back for reaches to all pain (Thomas targets at 3 and 6 et al., 2008). weeks, but not at Walking velocity 12 weeks following significantly lower pain onset (Thomas in LBP patients et al., 2008). (Lamoth et al., Smaller stride 2006a,b, 2008) length (Lamoth et al., 2008)
AL REVIEW levels of motor abilities are affected. It is an overall control reorganisation rather than failure of 88 E. Lederman o-contraction. Synergistic Composite Co-contraction/ Coordination Balance/postural Transition time Relaxation reciprocal stability activation Impaired postural Lumbar spineehip Changes in Compared to Not studied control of the joint coordination postural control in healthy controls, (but should be) lumbar spine is altered in back CLBP (Leinonen persons with LBP associated with pain subjects et al., 2001; Popa exhibited a delayed trunk/ (Shum et al., et al., reduced ability to abdominal muscles 2005)Dis- 2007)Impaired adapt trunkepelvis response times in coordination in postural control of coordination and CLBP patients pelvisethorax the lumbar spine spinal muscle (Hodges and coordination in LBP associated with activity to sudden Richardson, 1999; (Lamoth et al., delayed muscle changes in walking Hodges et al., 2006a,b) response times in velocity (Lamoth 2003a,b; Hodges CLBP patients et al., and Richardson (Radebold et al., 2006a,b)Slower 1996, 1998; 2001)Changes in reaction time in MacDonald et al., postural control LBP patients. 2006; O’Sullivan unrelated to pain Demonstrated et al., 1997a,b; in CLBP (della recovery of Radebold et al., Volpe et al., reaction time with 2001; Thomas and 2006)Postspinal training (Luoto France, 2007; surgery postural et al., 1996) Thomas et al., control changes 2007).Increase in both in pain and trunk co- pain-free subjects. contraction in However, more CLBP patients evident in the (Cholewicki et al., symptomatic 2005; van Dieen subjects (Bouche et al., et al., 2006)Hip 2003a)Increased strategy for co-contraction in balance control in trunk during quiet standing is walking and affected in CLBP additional (Mok et al., cognitive demands 2004)Experimental (Lamoth et al., muscle pain 2008) changes feedforward postural responses of the trunk muscles (Hodges et al., 2003)
The myth of core stability 89 Increase co-contraction Increase spinal stability Optimal level Increase spinal compression Range of active stability Reduce range of movement Increase energy expenditure Diminish co-contraction Reduce spinal stability Reduce spinal compression Increase range of movement Reduce energy expenditure Figure 2 Co-contraction has several roles during movement such as to help stabilise the joints and refine movement. The co- contraction levels in the trunk are kept at optimal low levels e an increase in co-contraction will raise the compression force on the disc and it is more energy consuming. It also tends to rigidify the trunk which is an unsuitable control strategy where range of movement or flexibility is required. levels of activity or even be aware of it. If they are aware of is unlikely that during CS exercise abdominal muscle would PREVENTION & REHABILITATIONdCRITICAL REVIEW it they are probably co-contracting well above the normal reach this force level (Stevens et al., 2007). levels needed for stabilisation. This would come at a cost of increasing the compression of the lumbar spine and We can conclude that: reducing the economy of movement (see discussion below). There is no evidence that reduced trunk muscle Is there a relationship between weak abdominals (e.g. strength or endurance will predispose the individual to TrA) and back pain? A common belief amongst therapists and LBP (Hamberg-van Reenen, 2007) trainers who use CS is that trunk strength will improve existing back pain. It has been shown that a muscle such as multifidus There are inconclusive finding regarding loss of trunk (Hides et al., 1994) can undergo atrophy in acute and CLBP muscle strength and atrophy in response to CLBP (although this is still inconclusive). Furthermore, it is well established that the motor strategy changes in the recruit- CS exercises do not provide an overtraining challenge ment of the abdominal muscles in patients with CLBP (Ng that is expected to result in strength or endurance gains et al., 2002a,b; Moseley et al., 2003a,b), with some studies in these muscles. demonstrating weakness of abdominal muscles (Helewa et al., 1990, 1993; Shirado et al., 1995a,b). However, The single/core muscle activation problem strengthening these muscles does not seem to improve the pain level or disability in CLBP patients (Mannion et al., One of the principles of CS is to teach the individuals how to 2001a). Improvement appeared to be mainly due to changes isolate their TrA from the rest of the abdominal muscles or in neural activation of the lumbar muscles and psychological to isolate the ‘‘core muscle’’ from ‘‘global’’ muscles. changes concerning, for example, motivation or pain toler- ance (Mannion et al., 2001b). To date there are no studies It is doubtful that there exists a ‘‘core’’ group of trunk that show atrophy of abdominal muscles or that strength- muscles that are recruited operate independently of all ening the core muscles, in particular the abdominal muscle other trunk muscles during daily or sport activities (McGill and TrA, would reduce back pain (see discussion below). et al., 2003; Kavcic et al., 2004). Such classification is anatomical but has no functional meaning. The motor There are also examples where abdominal muscle output and the recruitment of muscles are extensive activity is no different between asymptomatic and CLBP (Hodges et al., 2000; Cholewicki et al., 2002a,b), affecting subjects. For instance, in studies of elite golfers, abdominal the whole body. To specifically activate the core muscles muscle activity and muscle fatigue characteristics were during functional movement the individual would have to similar between asymptomatic and CLBP subjects after override natural patterns of trunk muscle activation. This repetitive golf swings (Horton et al., 2001). Yet, this is the would be impractical, next to impossible and potentially type of sportsperson who would often receive CS exercise dangerous; as stated by Brown et al. (2006) ‘‘Individuals in advice. an externally loaded state appear to select a natural muscular activation pattern appropriate to maintain spine Doubts have also been raised concerning the effective- stability sufficiently. Conscious adjustments in individual ness of many of CS exercise in helping to increase the muscles around this natural level may actually decrease the strength of core muscles. It has been shown that during CS stability margin of safety’’. exercise, the maximal voluntary contraction (MVC) of the ‘‘core muscles’’ is well below the level required for muscle Training focused on a single muscle is even more hypertrophy and is therefore unlikely to provide strength difficult. Muscle-by-muscle activation does not exist gains (Souza et al., 2001; Vezina and Hubley-Kozey, 2000; (Georgopoulos, 2000). If you bring your hand to your mouth Hubley-Kozey and Vezina, 2002a,b). Furthermore, in the nervous system ‘‘thinks’’ hand to mouth rather than a study of fatigue in CLBP, four weeks of stabilisation flex the biceps, then the pectorals, etc. Single muscle exercise failed to show any significant improvement in control is relegated in the hierarchy of motor processes to muscle endurance (Sung, 2003) A recent study has demon- spinal motor centres e a process that would be distant from strated that as much as 70% MVC is needed to promote conscious control (interestingly even the motor neurons of strength gains in abdominal muscle (Stevens et al., 2008). It particular muscles are intermingled rather than being distinct anatomical groups in the spinal cord) (Luscher and
PREVENTION & REHABILITATIONdCRITICAL REVIEW 90 E. Lederman Clamann, 1992). Indeed, it has been demonstrated that profound physical manifestations e hence a weight trainer when tapping the tendons of rectus abdominis, external looks physically different to a marathon runner (specificity oblique and internal oblique the evoked stretch reflex principle in training, Roels et al., 2005). responses can be observed in the muscle tapped, but also spreading extensively to muscles on the ipsilateral and If a subject is trained to contract their TrA or any contralateral sides of the abdomen (Beith and Harrison, anterior abdominal muscle while lying on their back (Karst 2004). This suggests sensory feedback and reflex control of and Willett, 2004), there is no guarantee that this would the abdominal muscles is functionally related and would transfer to control and physical adaptation during standing, therefore be difficult to separate by conscious effort. running, bending, lifting, sitting, etc. Such control would have to be practiced during some of these activities This simple principle in motor control poses two problems (Lederman, in press, see Figure 3). Anyone who is giving CS to CS training. First, it is doubtful that following injury only exercise to improve sports performance should re-famil- one group or single muscles would be affected. Indeed, the iarise themselves with this basic principle. more EMG electrodes applied the more complex the picture becomes (Cholewicki et al., 2002a,b). It is well documented It seems that such basic principles can escape many of the that other muscles are involved e multifidus (Carpenter and proponents of CS. This is reflected in one study which Nelson, 1999), psoas (Barker et al., 2004), diaphragm assessed the effect of training on a Swiss ball on core stability (Hodges et al., 1997, 2003), pelvic floor muscles (Pool- muscles and the economy of running (Stanton et al., 2004)! In Goudzwaard et al., 2005), gluteals (Leinonen et al., 2000), this study it was rediscovered that practicing the banjo does etc. Basically in CLBP we see a complex and wide reorgan- not help to play the piano. The subjects got very good at using isation of motor control in response to damage or pain. their muscles for sitting on a large inflatable rubber ball but it had no effect on their running performance. An often quoted The second problem for CS is that it would be next to study by Tsao and Hodges (2008) does show transfer of impossible to contract a single muscle or specific group. learning from CS training to postural activity. However, this is Even with extensive training this would be a major problem a low quality study, carried out on a small number of subjects (Beith et al., 2001). Indeed, there is no support from (n Z 9) without any control/sham. The transfer observed in research that TrA can be singularly activated (Cholewicki this study is in conflict with the vast knowledge of motor et al., 2002a,b). The novice patient is more likely to control that suggests that such transfer is highly unlikely (see contract wide groups of abdominal muscles (Sapsford et al., Schmidt and Lee, 2005 for extensive review of transfer of 2001; Urquhart et al., 2005a,b). So why focus on TrA or any learning). other specific muscle or muscle group? Trunk control will change according to the specific We can summaries that: activity the subject is practicing. Throwing a ball would require trunk control, which is different to running. Trunk The control of the trunk (and body) is whole. There is control in running will be different in climbing and so on. no evidence that there are core muscles that work There is no one universal exercise for trunk control that independently from other trunk muscle during normal would account for the specific needs of all activities. Is it functional movement. possible to train the trunk control to specific activity? Yes, and it is simple e just train in that activity and don’t worry There is no evidence that individuals can effectively about the trunk. The beauty of it all is that no matter what learn to specifically activate one muscle group inde- activity is carried out the trunk muscles are always pendently of all other trunk muscles. specifically exercised. CS and training in relation to motor learning Internal and external focus in training and training issues CS has evolved over time in response to many of the model’s Further challenges for the CS model arise from motor limitations described above. Currently, the control of TrA is learning and training principles. attempted in different standing and moving patterns (O’Sullivan, 2000). Speed of movement, balance and coor- CS training seems to clash with three important dination has been introduced to the very basic early elements principles: of CS. The new models encourage the subjects to ‘‘think about their core’’ during functional activities. One wonders if The similarity (transfer) principle in motor learning and David Beckham thinks about the ‘‘core’’ before a free kick or specificity principle in training Michael Jordan when he slam-dunks or for that matter our patient who is running after a bus, cooking or during any other Internaleexternal focus principles daily activities. How long can they maintain that thought Economy of movement. while multitasking in complex functional activities? Similarity/specificity principles Maybe thinking about the core is not such a good idea for sports training. When learning movement a person can be When we train for an activity we become skilled at per- instructed to focus on their technique (called internal focus) forming it. So if we practice playing the piano we become or on the movement goal (called external focus). When a good pianist, hence a similarity principle. We can’t learn a novice learns a novel movement focusing on technique to play the piano by practicing the banjo or improve playing (internal focus) could help their learning (Beilock et al., by lifting weight with our fingers. This adaptation to the 2002) For a skilled person, performance improves if training activity is not only reserved to learning processes, it has focuses on tasks outside the body (external focus) but it
The myth of core stability 91 Highly transferable Least transferable Rehabilitating: Dissimilar Similar Dissimilar Similar out of context out of context within context within context Trunk control during Lumbro-pelvic tilts Laying on the floor moving Core tensing or bracing in Walk walking practiced on the floor both legs in a walking-like walking pattern Core tensing or bracing (this may seem surprising. However, as long as the person is Extension exercise on the walking they are practicing floor walking. The dissimilar movement is redundant as far as motor learning) Figure 3 Similarity and context principle. Training and practice of movement can be dissimilar and out of context, similar but out PREVENTION & REHABILITATIONdCRITICAL REVIEW of context, dissimilar within context or similar and within context. Ideal neuromuscular organisation to movement occurs when the movement is in similar patterns to the goal movement and practiced in context of the particular movement. Most CS training regimes contain movement patterns that are dissimilar and out of context to the trunk patterns used during normal activities. Adapted from Lederman E, Neuromuscular rehabilitation in manual and physical therapy, to be published 2010. London, Elsevier. reduces when the focus is on internal processes within the efficiency of movement during daily and sports activities. body (McNevin et al., 2000, 2003). For example, there is Our bodies are designed for optimal expenditure of energy greater accuracy in tennis serves and football shots when the during movement. It is well established that when a novice subjects use external focus rather than internal-focus learns a new motor skill they tend to use a co-contraction strategies (Wulf et al., 2002, 2003). This principle strongly strategy until they learn to refine their movement (Lay et al., suggests that internal focus on TrA or any other muscle group 2002). Co-contraction is known to be an ‘‘energy waster’’ in will reduce skilled athletic performance. Interestingly, initial motor learning situations. To introduce it to skilled tensing the trunk muscle has even been shown to potentially movement will have a similar ‘‘wasteful’’ effect on the degrade postural control (Reeves et al., 2006). economy of movement. Minetti (2004) states: ‘‘to improve locomotion (and motion), mechanical work should be What about movement rehabilitation for CLBP patients? limited to just the indispensable type and the muscle effi- Would internal focus on specific muscles improve functional ciency be kept close to its maximum. Thus it is important to use of trunk muscles? Let’s imagine two scenarios where we avoid: .. using co-contraction (or useless isometric force)’’. are teaching a patient to lift a weight from the floor using a squat position. In the first scenario, we can give simple Such energy wastage is likely to occur during excessive internal-focus advice such as bend your knees, and bring the use of trunk muscles as taught in CS. In sporting activity this weight close to your body, etc (van Dieen et al., 1999; Kingma would have a detrimental effect on performance. Anderson et al., 2004). This type of instruction contains a mixture of (1996) in a study on the economy of running states: ‘‘At external focusing (e.g. keep the object close to your body higher levels of competition, it is likely that ‘natural and between your knees) and internal focus about the body selection’ tends to eliminate athletes who failed to either position during lifting. In the second scenario which is akin to inherit or develop characteristics which favour economy’’. CS training approach, the patient is given the following instructions: focus on co-contracting the hamstrings and the We can conclude for the evidence that: quads, gently release the gluteals, let the calf muscles elongate, while simultaneously shortening the tibialis ante- CS exercises are in conflict with motor learning and rior etc. Such complex internal focusing is the essence of CS training principles training, but applied to the trunk muscles. It would be next to impossible for a person to learn simple tasks using such CS exercises are dissimilar and out of context to normal complicated internal-focus approach. physiological movement. This represents the most ineffective approach to learning motor skills Economy of movement The internal-focus approach on individual muscles in CS The advice given to CS trainees is to continuously tighten is likely to degrade motor learning as well as skilled their abdominal and back muscles. This could reduce the performance Additional tensing of trunk muscles during daily activi- ties or sports are likely to be more energetically taxing on the body
PREVENTION & REHABILITATIONdCRITICAL REVIEW 92 E. Lederman CS in prevention of injury and approaches are demonstrated to be equally effective therapeutic value (Ariyoshi et al., 1999; van der Velde and Mierau, 2000; Franke et al., 2000; Reeves, 2006; Nilsson-Wikmar et al., Therapist and trainers have been exalting the virtues of CS 2005; Koumantakis et al., 2005; Cairns et al., 2006). as an approach for improving sports performance (Kibler Systematic reviews repeat this message (van Tulder et al., et al., 2006), preventing injury and as the solution to lower 2000; Abenhaim et al., 2000; Hurwitz et al., 2005). back pain. No matter what the underlying cause for the complaint CS was going to save the day. However, these These studies strongly suggest that improvements are due claims are not supported by clinical studies: to the positive effects that physical exercise may have on the patient rather than on improvements in spinal stability (it is Abdominal/stability exercise as known that general exercise can also improve CLBP) prevention of back pain (Ariyoshi et al., 1999; van der Velde and Mierau, 2000). In one study, asymptomatic subjects (n Z 402) were given So why give the patient complex exercise regimes that back education or back education þ abdominal strength- will both be expensive and difficult to maintain? Perhaps ening exercise (Helewa et al., 1999). They were monitored our patients should be encouraged to maintain their own for lower back pain for one year and the number of back preferred exercise regime or provide them with exercises pain episodes were recorded. No significant differences that they are more likely to enjoy. This of course could were found between the two groups. There was a curious include CS exercise. But the patient should be informed aspect to this study, which is important to the strength that it is only as effective as any other exercise. issue in CS. This study was carried out on asymptomatic subjects who were identified as having weak abdominal We can thus conclude: muscles. Four hundred individuals with weak abdominal muscles and no back pain! That CS exercise may better than general medical care (which is not difficult to achieve) Another large-scale study examined the influence of a core-strengthening programme on low back pain (LBP) in CS exercise is no better than other forms of manual or collegiate athletes (n Z 257). In this study too, there were physical therapy or general exercise no significant advantage of core strengthening in reducing LBP occurrence (Nadler et al., 2002). Find out what exercise the patient enjoys and add it to the management plan. CS a treatment for recurrent LBP and CLBP CS in relation to aetiology of back pain At first glance, studies of CS exercise for the treatment of recurrent LBP look promising e significant improvements Why has CS not performed better than any other exercise? In can be demonstrated when compared to other forms of part, due to all the issues that have been discussed above. therapy (O’Sullivan et al., 1997a,b; Hides et al., 2001; More importantly, in the last decade our understanding of Moseley, 2002; Rasmussen-Barr et al., 2003; Niemisto et al., the aetiology of back pain has dramatically changed. 2003; Stuge et al., 2004; Goldby et al., 2006). Indeed, Psychological and psychosocial factors have become systematic reviews found stabilisation exercise to be better important risk and prognostic factors for recurrent back pain than general practitioner care, but not from any other form and the transition of acute to chronic pain states of physical therapy (Rackwitz et al., 2006; Ferreira et al., (Hasenbring et al., 2001). Genetic factors (MacGregor et al., 2006; Macedo et al., 2009). 2004) and behavioural/‘‘use of body’’ are also known to be contributing factors. Localised, structural factors such as However is could be argued that none of these studies trunk/spinal asymmetries, have been reduced in their actually showed a relationship between improvement in importance as contributing factors to back pain (Dieck, LBP and spinal stabilisation or core control. In all the 1985; Nadler, 1998; Franklin and Conner-Kerr, 1998; Levan- studies there was no attempt to effectively identify gie, 1999; Fann, 2002; Norton, 2004; Poussa, 2005; Reeves, patients who had timing or other control issues or had 2006; Mitchell et al., 2008). This shift in understanding LBP underlying instability. There was no attempt to evaluate would include stability issues which are an extension of how well the subjects learned CS manoeuvres and whether a biomechanical model. they were able to maintain that learning throughout the duration of the studies. Furthermore, there was no attempt It is difficult to imagine how improving biomechanical to evaluate if there is a correlation between improvement factors such as spinal stabilisation can play a role in of the condition and the recovery of stabilisation. It should reducing back pain when there are such evident biopsy- also be noted that many of these studies did not have chosocial factors associated with LBP conditions. Even in a control group. This means that although CS training may the behavioural/biomechanical spheres of spinal pain it is be better when compared to another form of therapy, we difficult to imagine how CS can act as prevention or cure. still don’t know if it is any better than a placebo/sham This can be clarified by grouping potential causes for back treatment. injury into two broad categories: An interesting trend emerges when CS exercise are Behavioural group: individuals who use their back in compared to general exercise (Table 2). Both exercise ways that exert excessive loads on their spine, such as bending to lift (Gallagher et al., 2005) or repetitive sports activities (Fairclough et al., 1986; Renstro¨m, 1996; Reid and McNair, 2000).
The myth of core stability 93 Table 2 CS studies, description of study, CS compared to other therapeutic modalities and outcome. Description of CS compared to Result Notes condition O’Sullivan CLBP (spondylolysis/ General exercise CS better General exercises were et al., 1997a,b spondylolisthesis) consisted of swimming, not of the walking and gym CS better same duration as CS Hides et al., 2001 First episode LBP work þ pain relief CS/MT better than exercise.The pain Moseley, 2002 CLBP including heat medical care relief methods chosen CLBP application, massage CS better in the short are known to have Rasmussen-Barr and ultrasound term but not long-term little effect on et al., 2003 LBP in pregnancy back pain General practitioner CS better Stuge et al., 2004 care þ medication We still don’t know if CS þ MT compared to CS is better because it medical management was combined with MT Manual therapy The duration of MT was (muscle stretching, shorter than the CS segmental traction, exercise soft tissue and facet mobilisation Physical therapy Niemisto et al., 2003 LBP CS þ MT þ physician CS/MT better We still don’t know if PREVENTION & REHABILITATIONdCRITICAL REVIEW care compared to: CS is better because it physician care was combined with MT Goldby et al., 2006 CLBP Back education and MT CS > MT > education Generally considered to be poor quality Bastiaenen LBP postpartum Cognitive-behavioural CBT better study et al., 2006 therapy (CBT) Same LBP in pregnancy Other studiers suggest Nilsson-Wikmar General exercise that CS is better than et al., 2005 CLBP MT.. Sub-acute or CLBP General exercise Same Franke et al., 2000 General exercise General exercise Koumantakis slightly Exercise þ MT better et al., 2005 CS þ CBT compared to: Same 1. General exer- SM and CS same Cairns et al., 2006 Recurrent LBP outcome but slightly cise þ CBT þ stretching better than general Ferreira et al., 2007 CLBP and strengthening all exercise in the short main muscles groups in but not long term body, þ cardiovascular exercise 2. Spinal manipulation (SM) Critchley et al., 2007 No difference between the groups 1. MT 2. Pain management þ CBT 3. General exercise Bad luck group: individuals who had suffered a back activity, which contributes to further spinal compression injury from sudden unexpected events, such as falls or (de Looze et al., 1999). In patients with CLBP lifting is sporting injuries (Fairclough et al., 1986). associated with higher levels of trunk co-contraction and spinal loading (Marras et al., 2005). Any further tensing of In the behavioural group, bending and lifting is associ- the abdominal muscles may lead to additional spinal ated with a low level increase in abdominal muscle compression. Since the spinal compression in lifting
PREVENTION & REHABILITATIONdCRITICAL REVIEW 94 E. Lederman approaches the margins of safety of the spine, these could exert potentially damaging forces on various pelvic seemingly small differences are not irrelevant (Biggemann ligaments (Mens et al., 2006). et al., 1988). It is therefore difficult to imagine how CS can offer any additional protection to the lumbar spine during Maybe our patients should be encouraged to relax their these activities. trunk muscle rather than hold them rigid? In a study of the effects of psychological stress during lifting it was found Often in CS advice is given to patients to brace their core that mental processing/stress had a large impact on the muscle while sitting to reduce or prevent back pain. spine. It resulted in an increase in spinal compression Although sitting is not regarded as a predisposing factor for associated with increases in trunk muscle co-contraction LBP (Hartvigsen et al., 2002), some patients with existing and less controlled movements (Davis et al., 2002). back pain find that standing relieves the back pain of sitting. This phenomenon has been shown in CLBP patients Psychological factors such as catastrophising and soma- who during sitting exhibit marked anterior loss of disc space tisation are often observed in patients suffering from CLBP. in flexion or segmental instability (Maigne et al., 2003). One wonders if CS training colludes with these factors, Sitting, however, is associated with increased activity of encouraging excessive focusing on back pain and abdominal muscles (when compared to standing) (Snijders re-enforcing the patient’s notion that there is something et al., 1995). Increasing the co-contraction activity of the seriously wrong with their back. Perhaps we should be anterior and back muscles is unlikely to offer any further shifting the patient’s focus away from their back. (I often protection for patients with disc narrowing/pathology. stop patients doing specific back exercise). Conversely, it may result in greater spinal compression. It is unknown whether core tensing can impede the movement Furthermore, CS training may shift the therapeutic focus of the unstable segments during sitting. This seems unlikely away from the real issues that maintain the patient in their because even in healthy individuals creep deformation of chronic state. It offers a simplistic solution to a condition spinal structures will eventually take place during sitting that may involve complex biopsychosocial factors. The (Hedman and Fernie, 1997). The creep response is likely to issues that underline the patient’s condition may be be increased by further co-contraction of trunk muscles. neglected, with the patient remaining uninformed about the real causes of their condition. Under such circumstance In the bad luck group, CS will have very little influence CS training may promote chronicity. on the outcome of sudden unexpected trauma. Most injuries occur within a fraction of a second, before the Conclusion nervous system manages to organise itself to protect the back. Often injuries are associated with factors such as Weak trunk muscles, weak abdominals and imbalances fatigue (Gabbett, 2004) and overtraining (Smith, 2004). between trunk muscles groups are not a pathology just These factors when combined with sudden, unexpected a normal variation. high velocity movement are often the cause of injury (Fairclough et al., 1986). It is difficult to see the benefit of The division of the trunk into core and global muscle strong TrA, abdominals or maintaining a constant contrac- system is a reductionist fantasy, which serves only to tion in these muscles in injury prevention. promote CS. Potential damage with CS? Weak or dysfunctional abdominal muscles will not lead to back pain. Continuous and abnormal patterns of use of the trunk muscles could also be a source of potential damage for spinal Tensing the trunk muscles is unlikely to provide any or pelvic pain conditions. It is known that when trunk muscles protection against back pain or reduce the recurrence contract they exert a compressive force on the lumbar spine of back pain. (van Dieen et al., 2003a,b) and that CLBP patients tend to increase their co-contraction force during movement (Chol- Core stability exercises are no more effective than, and ewicki et al., 1997). This results in further increases of spinal will not prevent injury more than, any other forms of compression (Marras et al., 2005; Brown et al., 2006). exercise or physical therapy. Another recent study examined the effects of abdominal stabilisation manoeuvres on the control of spine motion and Core stability exercises are no better than other forms stability against sudden trunk perturbations (Vera-Garcia of exercise in reducing chronic lower back pain. Any et al., 2007). The abdominal stabilisation manoeuvres were therapeutic influence is related to the exercise effects e abdominal hollowing, abdominal bracing and a ‘‘natural’’ rather than stability issues. strategy. Abdominal hollowing was the most ineffective and did not increase stability. Abdominal bracing did improve There may be potential danger of damaging the spine stability but came at a cost of increasing spinal compression. with continuous tensing of the trunk muscles during The natural strategy group seems to employ the best strategy daily and sports activities. e ideal stability without excessive spinal compression. Patients who have been trained to use complex An increase in intra-abdominal pressure could be abdominal hollowing and bracing manoeuvres should be a further complication of tensing the trunk muscle (Cress- discouraged from using them. well et al., 1994a,b). It has been estimated that in patients with pelvic girdle pain, increased intra-abdominal pressure Epilogue Many of the issues raised in this article were known well before the emergence of CS training. It is surprising that the researchers and proponents of this method ignored such important issues. Despite a decade of extensive research in
The myth of core stability 95 PREVENTION & REHABILITATIONdCRITICAL REVIEW this area, it is difficult to see what contribution CS had to the Carpenter, D.M., Nelson, B.W., 1999. Low back strengthening for understanding and care of patients suffering from back pain. the prevention and treatment of low back pain. Med. Sci. Sports Exerc. 31 (1), 18e24. Acknowledgement Cholewicki, J., Panjabi, M.M., Khachatryan, A., 1997. Stabilizing I would like to thank Prof. Jaap H. van Diee¨n, for his kind function of trunk flexoreextensor muscles around a neutral help in writing this article. spine posture. Spine 22 (19), 2207e2212. References Cholewicki, J., Ivancic, P.C., Radebold, A., 2002a. Can increased intra-abdominal pressure in humans be decoupled from trunk Abenhaim, L., Rossignol, M., Valat, J.P., et al., 2000. The role of muscle co-contraction during steady state isometric exertions? activity in the therapeutic management of back pain: report of Eur. J. Appl. Physiol. 87 (2), 127e133. the international Paris Task Force on Back Pain. Spine 25 (Suppl. 4), 1Se33S. Cholewicki, J., et al., 2002b. Neuromuscular function in athletes following recovery from a recent acute low back injury. J. Airaksinen, O., Herno, A., Kaukanen, E., et al., 1996. Density of Orthop. Sports Phys. Ther. 32 (11), 568e575. lumbar muscles 4 years after decompressive spinal surgery. Eur. Spine J. 5 (3), 193e197. Cholewicki, J., Silfies, S.P., Shah, R.A., et al., 2005. Delayed trunk muscle reflex responses increase the risk of low back injuries. Anderson, T., 1996. Biomechanics and running economy. Sports Spine 30 (23), 2614e2620. Med. 22 (2), 76e89. Condon, R.E., Carilli, S., 1994. The biology and anatomy of ingui- Andersson, E.A., et al., 1996. EMG activities of the quadratus nofemoral hernia. Semin. Laparosc. Surg. 1 (2), 75e85. lumborum and erector spinae muscles during flexionerelaxation and other motor tasks. Clin. Biomech. (Bristol, Avon) 11 (7), Cordo, P.J., et al., 2003. The sit-up: complex kinematics and 392e400. muscle activity in voluntary axial movement. J. Electromyogr. Kinesiol. 13 (3), 239e252. Arena, J.G., et al., 1991. Electromyographic recordings of low back pain subjects and non-pain controls in six different positions: Cresswell, A.G., Oddsson, L., Thorstensson, A., 1994a. The influ- effect of pain levels. Pain 45 (1), 23e28. ence of sudden perturbations on trunk muscle activity and intra-abdominal pressure while standing. Exp. Brain Res. 98 (2), Ariyoshi, M., et al., 1999. Efficacy of aquatic exercises for patients 336e341. with low-back pain. Kurume Med. J. 46 (2), 91e96. Cresswell, A.G., Blake, P.L., Thorstensson, A., 1994b. The effect of Barker, K.L., Shamley, D.R., Jackson, D., 2004. Changes in the an abdominal muscle training program on intra-abdominal cross-sectional area of multifidus and psoas in patients with pressure. Scand. J. Rehabil. Med. 26 (2), 79e86. unilateral back pain: the relationship to pain and disability. Spine 29 (22), E515eE519. Critchley, D.J., Ratcliffe, J., Noonan, S., et al., 2007. Effectiveness and cost-effectiveness of three types of physiotherapy used to Bastiaenen, C.H., et al., 2006. Effectiveness of a tailor-made reduce chronic low back pain disability: a pragmatic random- intervention for pregnancy-related pelvic girdle and/or low ized trial with economic evaluation. Spine 32 (14), 1474e1481. back pain after delivery: short-term results of a randomized clinical trial [ISRCTN08477490]. BMC Musculoskelet. Disord. 7 Davis, K.G., et al., 2002. The impact of mental processing and (1), 19. pacing on spine loading: 2002 Volvo Award in biomechanics. Spine 27 (23), 2645e2653. Beilock, S.L., et al., 2002. When paying attention becomes coun- terproductive: impact of divided versus skill-focused attention de Looze, M.P., et al., 1999. Abdominal muscles contribute in on novice and experienced performance of sensorimotor skills. a minor way to peak spinal compression in lifting. J. Biomech. J. Exp. Psychol. Appl. 8 (1), 6e16. 32 (7), 655e662. Beith, I.D., Harrison, P.J., 2004. Stretch reflexes in human della Volpe, R., Popa, T., Ginanneschi, F., et al., 2006. Changes in abdominal muscles. Exp. Brain Res. 159 (2), 206e213. coordination of postural control during dynamic stance in chronic low back pain patients. Gait Posture 24 (3), 349e355. Beith, I.D., Synnott, R.E., Newman, S.A., 2001. Abdominal muscle activity during the abdominal hollowing manoeuvre in the four Dieck, G.S., 1985. An epidemiologic study of the relationship point kneeling and prone positions. Man. Ther. 6 (2), 82e87. between postural asymmetry in the teen years and subsequent back and neck pain. Spine 10 (10), 872e877. Bendavid, R., Howarth, D., 2000. Transversalis fascia rediscovered. Surg. Clin. North Am. 80 (1), 25e33. Fairclough, J.A., Evans, R., Farquhar, G.A., 1986. Mechanisms of injury e a pictorial record. Br. J. Sports Med. 20 (3), 107e108. Berliner, S.D., 1983. Adult inguinal hernia: pathophysiology and repair. Surg. Annu. 15, 307e329. Fann, A.V., 2002. The prevalence of postural asymmetry in people with and without chronic low back pain. Arch. Phys. Med. Biggemann, M., Hilweg, D., Brinckmann, P., 1988. Prediction of the Rehabil. 83 (12), 1736e1738. compressive strength of vertebral bodies of the lumbar spine by quantitative computed tomography. Skeletal Radiol. 17 (4), Fast, A., et al., 1990. Low-back pain in pregnancy. Abdominal 264e269. muscles, sit-up performance, and back pain. Spine 15 (1), 28e30. Bouche, K., Stevens, V., Cambier, D., et al., 2006. Comparison of Ferreira, P.H., Ferreira, M.L., Maher, C.G., et al., 2006. Specific postural control in unilateral stance between healthy controls stabilisation exercise for spinal and pelvic pain: a systematic and lumbar discectomy patients with and without pain. Eur. review. Aust. J. Physiother. 52 (2), 79e88. Spine J. 15 (4), 423e432. Ferreira, M., Ferreira, P., Latimer, J., Herbert, R., Hodges, P., Brown, S.H., Vera-Garcia, F.J., McGill, S.M., 2006. Effects of Matthew, D., Jennings, C., 2007. Comparison of general exer- abdominal muscle coactivation on the externally preloaded cise, motor control exercise and spinal manipulative therapy for trunk: variations in motor control and its effect on spine chronic low back pain: a randomized trial. Pain 131, 31e37. stability. Spine 31 (13), E387eE393. Franke, A., et al., 2000. Acupuncture massage vs Swedish massage and Cairns, M.C., Foster, N.E., Wright, C., 2006. Randomized controlled trial individual exercise vs group exercise in low back pain suffererse of specific spinal stabilization exercises and conventional a randomized controlled clinical trial in a 2 Â 2 factorial design. physiotherapy for recurrent low back pain. Spine 31 (19), Forsch Komplementarmed Klass Naturheilkd 7 (6), 286e293. E670eE681. Franklin, M.E., Conner-Kerr, T., 1998. An analysis of posture and back pain in the first and third trimesters of pregnancy. J. Orthop. Sports Phys. Ther. 28 (3), 133e138. Freeman, M.A., Dean, M.R., Hanham, I.W., 1965. The etiology and prevention of functional instability of the foot. J. Bone Joint Surg. Br. 47 (4), 678e685.
PREVENTION & REHABILITATIONdCRITICAL REVIEW 96 E. Lederman Gabbett, T.J., 2004. Reductions in pre-season training loads reduce Hodges, P.W., Richardson, C.A., 1997. Feedforward contraction of training injury rates in rugby league players. Br. J. Sports Med. transversus abdominis is not influenced by the direction of arm 38 (6), 743e749. movement. Exp. Brain Res. 114 (2), 362e370. Gallagher, S., et al., 2005. Torso flexion loads and the fatigue failure of Hodges, P.W., et al., 2000. Three dimensional preparatory trunk human lumbosacral motion segments. Spine 30 (20), 2265e2273. motion precedes asymmetrical upper limb movement. Gait Posture 11 (2), 92e101. Georgopoulos, A.P., 2000. Neural aspects of cognitive motor control. Curr. Opin. Neurobiol. 10 (2), 238e241. Horton, J.F., Lindsay, D.M., Macintosh, B.R., 2001. Abdominal muscle activation of elite male golfers with chronic low back Gilleard, W.L., Brown, J.M., 1996. Structure and function of the pain. Med. Sci. Sports Exerc. 33 (10), 1647e1654. abdominal muscles in primigravid subjects during pregnancy and the immediate postbirth period. Phys. Ther. 76 (7), 750e762. Hubley-Kozey, C.L., Vezina, M.J., 2002a. Differentiating temporal electromyographic waveforms between those with chronic low Goldby, L.J., et al., 2006. A randomized controlled trial investi- back pain and healthy controls. Clin. Biomech. (Bristol, Avon) gating the efficiency of musculoskeletal physiotherapy on 17 (9e10), 621e629. chronic low back disorder. Spine 31 (10), 1083e1093. Hubley-Kozey, C.L., Vezina, M.J., 2002b. Muscle activation during Hall, L., et al., Nov 21, 2007. Immediate effects of co-contraction exercises to improve trunk stability in men with low back pain. training on motor control of the trunk muscles in people with Arch. Phys. Med. Rehabil. 83 (8), 1100e1108. recurrent low back pain. J. Electromyogr. Kinesiol. [Epub ahead of print]. Hurwitz, E., Morgenstern, H., Chiao, C., 2005. Effects of recrea- tional physical activity and back exercises on low back pain and Hamberg-van Reenen, H.H., 2007. A systematic review of the psychological distress: findings from the UCLA low back pain relation between physical capacity and future low back and study. Am. J. Public Health 95 (10), 1817e1824. neck/shoulder pain. Pain 130 (1e2), 93e107. Jull, G.A., Richardson, C.A., 2000. Motor control problems in Hartvigsen, J., et al., 2002. Does sitting at work cause low back patients with spinal pain: a new direction for therapeutic pain? Ugeskr Laeger 164 (6), 759e761. exercise. J. Manipulative Physiol. Ther. 23 (2), 115e117. Hasenbring, M., Hallner, D., Klase, B., 2001. Psychological mech- Karst, G.M., Willett, G.M., 2004. Effects of specific exercise anisms in the transition from acute to chronic pain: over- or instructions on abdominal muscle activity during trunk curl underrated?. Schmerz 15 (6), 442e447. exercises. J. Orthop. Sports Phys. Ther. 34 (1), 4e12. Hedman, T.P., Fernie, G.R., 1997. Mechanical response of the Kavcic, N., Grenier, S., McGill, S.M., 2004. Determining the stabi- lumbar spine to seated postural loads. Spine 22 (7), 734e743. lizing role of individual torso muscles during rehabilitation exercises. Spine 29 (11), 1254e1265. Helewa, A., et al., 1990. An evaluation of four different measures of abdominal muscle strength: patient, order and instrument Kibler, W.B., Press, J., Sciascia, A., 2006. The role of core stability variation. J. Rheumatol. 17 (7), 965e969. in athletic function. Sports Med. 36 (3), 189e198. Helewa, A., Goldsmith, C.H., Smythe, H.A., 1993. Measuring Kingma, I., et al., 2004. Foot positioning instruction, initial vertical abdominal muscle weakness in patients with low back pain and load position and lifting technique: effects on low back loading. matched controls: a comparison of 3 devices. J. Rheumatol. 20 Ergonomics 47 (13), 1365e1385. (9), 1539e1543. Koumantakis, G.A., Watson, P.J., Oldham, J.A., 2005. Supplementa- Helewa, A., et al., 1999. Does strengthening the abdominal tion of general endurance exercise with stabilisation training muscles prevent low back pain e a randomized controlled trial. versus general exercise only. Physiological and functional J. Rheumatol. 26 (8), 1808e1815. outcomes of a randomised controlled trial of patients with recur- rent low back pain. Clin. Biomech. (Bristol, Avon) 20 (5), 474e482. Hides, J.A., Richardson, C.A., Jull, G.A., 1996. Multifidus muscle recovery is not automatic after resolution of acute, first- Lamoth, C.J., Stins, J.F., Pont, M., et al., 2008. Effects of attention episode low back pain. Spine 21 (23), 2763e2769. on the control of locomotion in individuals with chronic low back pain. J. Neuroeng. Rehabil. 5, 13. Hides, J.A., et al., 1994. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute Lamoth, C.J., Daffertshofer, A., Meijer, O.G., et al., 2006a. How do low back pain. Spine 19 (2), 165e172. persons with chronic low back pain speed up and slow down? Trunkepelvis coordination and lumbar erector spinae activity Hides, J.A., Jull, G.A., Richardson, C.A., 2001. Long-term effects during gait. Gait Posture 23 (2), 230e239. of specific stabilizing exercises for first-episode low back pain. Spine 26 (11), E243eE248. Lamoth, C.J., Meijer, O.G., Daffertshofer, A., et al., 2006b. Effects of chronic low back pain on trunk coordination and back muscle Hodges, P.W., Richardson, C.A., 1999. Altered trunk muscle activity during walking: changes in motor control. Eur. Spine J. recruitment in people with low back pain with upper limb 15 (1), 23e40. movement at different speeds. Arch. Phys. Med. Rehabil. 80 (9), 1005e1012. Lay, B.S., et al., 2002. Practice effects on coordination and control, metabolic energy expenditure, and muscle activation. Hodges, P.W., Moseley, G.L., Gabrielsson, A., Gandevia, S.C., 2003. Hum. Mov. Sci. 21 (5e6), 807e830. Experimental muscle pain changes feed-forward postural responses of the trunk muscles. Exp. Brain Res. 151 (2), Leboeuf-Yde, C., 2000. Body weight and low back pain. A system- 262e271. atic literature review of 56 journal articles reporting on 65 epidemiologic studies. Spine 25 (2), 226e237. Hodges, P.W., Richardson, C.A., 1996. Inefficient muscular stabi- lization of the lumbar spine associated with low back pain. A Lederman, E., 2005. The Science and Practice of Manual Therapy, motor control evaluation of transversus abdominis. Spine 21 second ed. Elsevier, , London. (22), 2640e2650. Lederman E. Neuromuscular rehabilitation in manual and physical Hodges, P.W., Richardson, C.A., 1998. Delayed postural contraction therapy. Elsevier, London, in press. of transversus abdominis in low back pain associated with movement of the lower limb. J. Spinal Disord. 11 (1), 46e56. Leinonen, V., Kankaanpaa, M., Luukkonen, M., et al., 2001. Disc herniation-related back pain impairs feed-forward control of Hodges, P.W., et al., 1997. Contraction of the human diaphragm paraspinal muscles. Spine 26 (16), E367eE372. during rapid postural adjustments. J. Physiol. 505 (Pt 2), 539e548. Leinonen, V., et al., 2000. Back and hip extensor activities during trunk flexion/extension: effects of low back pain and rehabili- Hodges, P., et al., 2003. Intervertebral stiffness of the spine is tation. Arch. Phys. Med. Rehabil. 81 (1), 32e37. increased by evoked contraction of transversus abdominis and the diaphragm: in vivo porcine studies. Spine 28 (23), Levangie, P.K., 1999. The association between static pelvic asym- 2594e2601. metry and low back pain. Spine 24 (12), 1234e1242.
The myth of core stability 97 PREVENTION & REHABILITATIONdCRITICAL REVIEW Luoto, S., Taimela, S., Hurri, H., et al., 1996. Psychomotor speed Moseley, G.L., Hodges, P.W., Gandevia, S.C., 2003b. External and postural control in chronic low back pain patients. A perturbation of the trunk in standing humans differentially controlled follow-up study. Spine 21 (22), 2621e2627. activates components of the medial back muscles. J. Physiol. 547 (Pt 2), 581e587. Luscher, H.R., Clamann, H.P., 1992. Relation between structure and function in information transfer in spinal monosynaptic Nadler, S.F., 1998. Low back pain in college athletes: a prospective reflex. Physiol. Rev. 72 (1), 71e99. study correlating lower extremity overuse or acquired ligamentous laxity with low back pain. Spine 23 (7), 828e833. Macdonald, D.A., Lorimer Moseley, G., Hodges, P.W., 2006. The lumbar multifidus: does the evidence support clinical beliefs? Nadler, S.F., et al., 2002. Hip muscle imbalance and low back pain Man. Ther. 11 (4), 254e263. in athletes: influence of core strengthening. Med. Sci. Sports Exerc. 34 (1), 9e16. Macedo, L.G., Maher, C.G., Latimer, J., et al., 2009. Motor control exercise for persistent, nonspecific low back pain: a systematic Ng, J.K., Richardson, C.A., Kippers, V., et al., 1998. Relationship review. Phys. Ther. 89 (1), 9e25. between muscle fiber composition and functional capacity of back muscles in healthy subjects and patients with back pain. J. MacGregor, A.J., et al., 2004. Structural, psychological, and Orthop. Sports Phys. Ther. 27 (6), 389e402. genetic influences on low back and neck pain: a study of adult female twins. Arthritis Rheum. 51 (2), 160e167. Ng, J.K., et al., 2002a. Fatigue-related changes in torque output and electromyographic parameters of trunk muscles during isometric Maigne, J.Y., et al., 2003. Pain immediately upon sitting down and axial rotation exertion: an investigation in patients with back relieved by standing up is often associated with radiologic pain and in healthy subjects. Spine 27 (6), 637e646. lumbar instability or marked anterior loss of disc space. Spine 28 (12), 1327e1334. Ng, J.K., et al., 2002b. EMG activity of trunk muscles and torque output during isometric axial rotation exertion: a comparison Mannion, A.F., et al., 2001a. Increase in strength after active between back pain patients and matched controls. J. Orthop. therapy in chronic low back pain (CLBP) patients: muscular Res. 20 (1), 112e121. adaptations and clinical relevance. Schmerz 15 (6), 468e473. Niemisto, L., Lahtinen-Suopanki, T., Rissanen, P., 2003. A random- Mannion, A.F., et al., 2001b. Active therapy for chronic low back ized trial of combined manipulation, stabilizing exercises, and pain part 1. Effects on back muscle activation, fatigability, and physician consultation compared to physician consultation alone strength. Spine 26 (8), 897e908. for chronic low back pain. Spine 28 (19), 2185e2191. Marras, W.S., et al., 2005. Functional impairment as a predictor of Nilsson-Wikmar, L., et al., 2005. Effect of three different spine loading. Spine 30 (7), 729e737. physical therapy treatments on pain and activity in pregnant women with pelvic girdle pain: a randomized clinical trial with 3, McGill, S.M., et al., 2003. Coordination of muscle activity to assure 6, and 12 months follow-up postpartum. Spine 30 (8), 850e856. stability of the lumbar spine. J. Electromyogr. Kinesiol. 13 (4), 353e359. Norton, B.J., 2004. Differences in measurements of lumbar curvature related to gender and low back pain. J. Orthop. McNevin, N.H., Wulf, G., Carlson, C., 2000. Effects of attentional Sports Phys. Ther. 34 (9), 524e534. focus, self-control, and dyad training on motor learning: impli- cations for physical rehabilitation. Phys. Ther. 80 (4), 373e385. Nouwen, A., Van Akkerveeken, P.F., Versloot, J.M., 1987. Patterns of muscular activity during movement in patients with chronic McNevin, N.H., Shea, C.H., Wulf, G., 2003. Increasing the distance low-back pain. Spine 12 (8), 777e782. of an external focus of attention enhances learning. Psychol. Res. 67 (1), 22e29. Orvieto, R., et al., 1990. Low-back pain during pregnancy. Hare- fuah 119 (10), 330e331. Mens, J., et al., 2006. Possible harmful effects of high intra-abdominal pressure on the pelvic girdle. J. Biomech. 39 (4), 627e635. O’Sullivan, P.B., 2000. Lumbar segmental ‘instability’: clinical presentation and specific stabilizing exercise management. Minetti, A.E., 2004. Passive tools for enhancing muscle-driven Man. Ther. 5 (1), 2e12. motion and locomotion. J. Exp. Biol. 207 (Pt 8), 1265e1272. O’Sullivan, P.B., et al., 1997a. Evaluation of specific stabilizing Misuri, G., et al., 1997. In vivo ultrasound assessment of respiratory exercise in the treatment of chronic low back pain with radio- function of abdominal muscles in normal subjects. Eur. Respir. logic diagnosis of spondylolysis or spondylolisthesis. Spine 22 J. 10 (12), 2861e2867. (24), 2959e2967. Mitchell, T., O’Sullivan, P.B., Burnett, A.F., et al., 2008. Regional O’Sullivan, P., Twomey, L., Allison, G., et al., 1997b. Altered differences in lumbar spinal posture and the influence of low patterns of abdominal muscle activation in patients with back pain. BMC Musculoskelet. Disord. 9, 152. chronic low back pain. Aust. J. Physiother. 43 (2), 91e98. Mizgala, C.L., Hartrampf Jr., C.R., Bennett, G.K., 1994. Assessment Pool-Goudzwaard, A.L., et al., 2005. Relations between pregnancy- of the abdominal wall after pedicled TRAM flap surgery: 5- to 7- related low back pain, pelvic floor activity and pelvic floor year follow-up of 150 consecutive patients. Plast. Reconstr. dysfunction. Int. Urogynecol. J. Pelvic Floor Dysfunct. 16 (6), Surg. 93 (5), 988e1002. discussion 1003e1004. 468e474. Mogren, I.M., Pohjanen, A.I., 2005. Low back pain and pelvic pain during Popa, T., Bonifazi, M., Della Volpe, R., et al., 2007. Adaptive pregnancy: prevalence and risk factors. Spine 30 (8), 983e991. changes in postural strategy selection in chronic low back pain. Exp. Brain Res. 177 (3), 411e418. Mok, N.W., Brauer, S.G., Hodges, P.W., 2004. Hip strategy for balance control in quiet standing is reduced in people with low Poussa, M.S., 2005. Anthropometric measurements and growth as back pain. Spine 29 (6), E107eE112. predictors of low-back pain: a cohort study of children follo- wed up from the age of 11 to 22 years. Eur. Spine J. 14 (6), Moseley, L., 2002. Combined physiotherapy and education is effica- 595e598. cious for chronic low back pain. Aust. J. Physiother. 48, 297e302. Rackwitz, B., de Bie, R., Limm, H., et al., 2006. Segmental stabi- Moseley, G.L., et al., 2003a. The threat of predictable and lizing exercises and low back pain. What is the evidence? A unpredictable pain: differential effects on central nervous systematic review of randomized controlled trials. Clin. Reha- system processing? Aust. J. Physiother. 49 (4), 263e267. bil. 20 (7), 553e567. Moseley, G.L., Nicholas, M.K., Hodges, P.W., 2004. Pain differs Radebold, A., et al., 2000. Muscle response pattern to sudden trunk from non-painful attention-demanding or stressful tasks in its loading in healthy individuals and in patients with chronic low effect on postural control patterns of trunk muscles. Exp. Brain back pain. Spine 25 (8), 947e954. Res. 156 (1), 64e71. Radebold, A., Cholewicki, J., Polzhofer, G.K., Greene, H.S., 2001. Moseley, G.L., Hodges, P.W., 2006. Reduced variability of postural Impaired postural control of the lumbar spine is associated with strategy prevents normalization of motor changes induced by back pain: a risk factor for chronic trouble? Behav. Neurosci. 120 (2), 474e476.
PREVENTION & REHABILITATIONdCRITICAL REVIEW 98 E. Lederman delayed muscle response times in patients with chronic idio- Sung, P.S., 2003. Multifidi muscles median frequency before and pathic low back pain. Spine 26 (7), 724e730. after spinal stabilization exercises. Arch. Phys. Med. Rehabil. 84 Rasmussen-Barr, E., Nilsson-Wikmar, L., Arvidsson, I., 2003. Stabi- (9), 1313e1318. lizing training compared with manual treatment in sub-acute and chronic low-back pain. Man. Ther. 8 (4), 233e241. Suter, E., Lindsay, D., 2001. Back muscle fatigability is associated Reeves, N.P., 2006. Muscle activation imbalance and low-back injury with knee extensor inhibition in subjects with low back pain. in varsity athletes. J. Electromyogr. Kinesiol. 16, 264e272. Spine 26 (16), E361eE366. Reeves, N.P., et al., 2006. The effects of trunk stiffness on postural control during unstable seated balance. Exp. Brain Res. 174 (4), Thomas, J.S., France, C.R., 2007. Pain-related fear is associated 694e700. with avoidance of spinal motion during recovery from low back Reid, D.A., McNair, P.J., 2000. Factors contributing to low back pain. Spine 32 (16), E460eE466. pain in rowers. Br. J. Sports Med. 34 (5), 321e322. Renstro¨m, P., et al., 1996. An introduction to chronic overuse Thomas, J.S., France, C.R., Sha, D., et al., 2007. The effect of injuries. In: Harries (Ed.), Oxford Textbook of Sports Medicine. chronic low back pain on trunk muscle activations in target Oxford University Press, Oxford, pp. 531e545. reaching movements with various loads. Spine 32 (26), Richardson, C.A., et al., 2002. The relation between the trans- E801eE808. versus abdominis muscles, sacroiliac joint mechanics, and low back pain. Spine 27 (4), 399e405. Thomas, J.S., France, C.R., Lavender, S.A., et al., 2008. Effects of Richardson, C.A., Jull, G.A., 1995. Muscle controlepain control. fear of movement on spine velocity and acceleration after What exercises would you prescribe? Man. Ther. 1 (1), 2e10. recovery from low back pain. Spine 33 (5), 564e570. Roels, B., et al., 2005. Specificity of VO2MAX and the ventilatory threshold in free swimming and cycle ergometry: comparison Tsao, H., Hodges, P.W., 2008. Persistence of improvements in between triathletes and swimmers. Br. J. Sports Med. 39 (12), postural strategies following motor control training in people 965e968. with recurrent low back pain. J. Electromyogr. Kinesiol. 18 (4), Roy, S.H., De Luca, C.J., Casavant, D.A., 1989. Lumbar muscle 559e567 [Epub 2007 Mar 2]. fatigue and chronic lower back pain. Spine 14 (9), 992e1001. Sapsford, R.R., et al., 2001. Co-activation of the abdominal and Urquhart, D.M., Hodges, P.W., 2005. Differential activity of regions pelvic floor muscles during voluntary exercises. Neurourol. of transversus abdominis during trunk rotation. Eur. Spine J. 14 Urodyn. 20 (1), 31e42. (4), 393e400. Schmidt, R.A., Lee, T.D., 2005. Motor Control and Learning: A Behavioural Emphasis. Human Kinetics, Champaign, IL. Urquhart, D.M., et al., 2005a. Abdominal muscle recruitment Shirado, O., Ito, T., Kaneda, K., Strax, T.E., 1995a. Concentric and during a range of voluntary exercises. Man. Ther. 10 (2), eccentric strength of trunk muscles: influence of test postures 144e153. on strength and characteristics of patients with chronic low- back pain. Arch. Phys. Med. Rehabil. 76 (7), 604e611. Urquhart, D.M., Hodges, P.W., Story, I.H., 2005b. Postural activity of Shirado, O., Ito, T., Kaneda, K., Strax, T.E., 1995b. Flexione the abdominal muscles varies between regions of these muscles relaxation phenomenon in the back muscles. A comparative and between body positions. Gait Posture 22 (4), 295e301. study between healthy subjects and patients with chronic low back pain. Am. J. Phys. Med. Rehabil. 74 (2), 139e144. van der Velde, G., Mierau, D., 2000. The effect of exercise Shum, G.L., Crosbie, J., Lee, R.Y., 2005. Symptomatic and on percentile rank aerobic capacity, pain, and self-rated asymptomatic movement coordination of the lumbar spine and disability in patients with chronic low-back pain: a retro- hip during an everyday activity. Spine 30 (23), E697eE702. spective chart review. Arch. Phys. Med. Rehabil. 81 (11), Simon, A.M., et al., 2004. Comparison of unipedicled and bipedicled 1457e1463. TRAM flap breast reconstructions: assessment of physical function and patient satisfaction. Plast. Reconstr. Surg. 113 (1), 136e140. van Dieen, J.H., Cholewicki, J., Radebold, A., 2003a. Trunk muscle Smith, L.L., 2004. Tissue trauma: the underlying cause of over- recruitment patterns in patients with low back pain enhance training syndrome? J. Strength Cond. Res. 18 (1), 185e193. the stability of the lumbar spine. Spine 28 (8), 834e841. Snijders, C.J., et al., 1995. Oblique abdominal muscle activity in standing and in sitting on hard and soft seats. Clin. Biomech. van Dieen, J.H., Kingma, I., van der Burg, P., 2003b. Evidence for (Bristol, Avon) 10 (2), 73e78. a role of antagonistic cocontraction in controlling trunk stiffness during lifting. J. Biomech. 36 (12), 1829e1836. Souza, G.M., Baker, L.L., Powers, C.M., 2001. Electromyographic activity of selected trunk muscles during dynamic spine stabili- van Dieen, J.H., Hoozemans, M.J., Toussaint, H.M., 1999. Stoop or zation exercises. Arch. Phys. Med. Rehabil. 82 (11), 1551e1557. squat: a review of biomechanical studies on lifting technique. Clin. Biomech. (Bristol, Avon) 14 (10), 685e696. Stanton, R., Reaburn, P.R., Humphries, B., 2004. The effect of short-term swiss ball training on core stability and running van Tulder, M., et al., 2000. Exercise therapy for low back economy. J. Strength Cond. Res. 18 (3), 522e528. pain: a systematic review within the framework of the cochrane collaboration back review group. Spine 25 (21), Stevens, V.K., et al., 2008. The effect of increasing resistance on 2784e2796. trunk muscle activity during extension and flexion exercises on training devices. J. Electromyogr. Kinesiol. 18 (3), 434e445. Vera-Garcia, F.J., et al., 2007. Effects of abdominal stabilization maneuvers on the control of spine motion and stability against Stevens, V.K., et al., 2007. Electromyographic activity of trunk and sudden trunk perturbations. J. Electromyogr. Kinesiol. 17 (5), hip muscles during stabilization exercises in four-point kneeling 556e567. in healthy volunteers. Eur. Spine J. 16 (5), 711e718. Vezina, M.J., Hubley-Kozey, C.L., 2000. Muscle activation in ther- Stuge, B., et al., 2004. The efficacy of a treatment program apeutic exercises to improve trunk stability. Arch. Phys. Med. focusing on specific stabilizing exercises for pelvic girdle pain Rehabil. 81 (10), 1370e1379. after pregnancy: a two-year follow-up of a randomized clinical trial. Spine 29 (10), E197eE203. White, S.G., McNair, P.J., 2002. Abdominal and erector spinae muscle activity during gait: the use of cluster analysis to iden- tify patterns of activity. Clin. Biomech. (Bristol, Avon) 17 (3), 177e184. Wulf, G., et al., 2002. Enhancing the learning of sport skills through external-focus feedback. J. Mot. Behav. 34 (2), 171e182. Wulf, G., et al., 2003. Attentional focus on suprapostural tasks affects balance learning. Q. J. Exp. Psychol. A 56 (7), 1191e1211. Zedka, M., Prochazka, A., Knight, B., et al., 1999. Voluntary and reflex control of human back muscles during induced pain. J. Physiol. 520 (Pt 2), 591e604.
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