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