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Clasificacion internacional del funcionamiento, de la discapacidady de la salud en Rehabilitacion: de la teorıa a la practica

S. Laxea,�, M. Bernabeua, R. Lopezb, A. Garcıac y J.M. Tormosd

aUnidad de Dano Cerebral, Instituto Guttmann, Universidad Autonoma de Barcelona, Badalona, EspanabEstadıstica, Departamento de Investigacion, Instituto Guttmann, Universidad Autonoma de Barcelona, Badalona, EspanacDepartamento de Neuropsicosocial, Instituto Guttmann, Universidad Autonoma de Barcelona, Badalona, EspanadDepartamento de Investigacion, Instituto Guttmann, Universidad Autonoma de Barcelona, Badalona, Espana

Recibido el 6 de septiembre de 2009; aceptado el 21 de octubre de 2009Disponible en Internet el 26 de febrero de 2010

PALABRAS CLAVEClasificacioninternacional delfuncionamiento, de ladiscapacidad y de lasalud;Core sets;Instrumentos demedida;Rehabilitacion

ResumenObjetivo: La Clasificacion internacional del funcionamiento, de la discapacidad y de lasalud fue creada en el 2001 con el fin de proporcionar un marco conceptualmente universalpara clasificar y describir el funcionamiento, la discapacidad y la salud desde unaperspectiva biopsicosocial. El uso de esta clasificacion es enormemente util en el campo dela Rehabilitacion, ya que permite describir el estado de salud de un paciente de formaglobal, universal y, ademas, etiologicamente neutral.Resultados: No obstante, la gran cantidad de categorıas de la Clasificacion internacionaldel funcionamiento, de la discapacidad y de la salud la hacen poco practica en la realidaddiaria, por lo que el objetivo de este artıculo es el de presentar las diferentes iniciativasque existen sobre el desarrollo de nuevas herramientas de trabajo basadas en ella queposibilitan su uso en las diferentes practicas profesionales.& 2009 Elsevier Espana, S.L. y SERMEF. Todos los derechos reservados.

KEYWORDSInternationalClassification ofFunctioning, Disabilityand Health;Core Sets;Measuringinstruments;Rehabilitation

The international classification of functioning, disability and health in rehabilitation:From the theory to the practice

AbstractObjetive: The International Classification of Functioning, Disability and Health wascreated in 2001 with the aim of promoting a universally accepted conceptual framework toclassify and describe functioning, disability and health from a biopsycosocial perspective.This classification is very useful in the rehabilitation field because it provides a way ofdescribing the health status of a patient based on an universally globally agreedperspective and moreover neutral.

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0048-7120/$ - see front matter & 2009 Elsevier Espana, S.L. y SERMEF. Todos los derechos reservados.doi:10.1016/j.rh.2009.10.007

�Autor para correspondencia.

Correo electronico: [email protected] (S. Laxe).

Rehabilitacion (Madr). 2010;44(2):152–157

Documento descargado de http://zl.elsevier.es el 27/05/2014. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.

dx.doi.org/10.1016/j.rh.2009.10.007

mailto:[email protected]

Results: Nevertheless, the great number of categories from the ICF, makes it unpracticalfor the daily reality, therefore the objetive of this article is to present the diferentinitiatives that exist in the developing of different new tools to posibilitate the use of theICF in different sectors.& 2009 Elsevier Espana, S.L. and SERMEF. All rights reserved.

Introduccion

Una valoracion global del paciente, teniendo en cuenta nosolo su funcion, sino tambien como esta afecta a lasactividades que el desempena, al igual que su participacionen estas, y la valoracion de aquellos factores ambientales,tales como nucleo de convivencia, barreras arquitectonicas,ayudas sociales, uso de medicacion o dispositivos ortesicosque precisen, son uno de los principales retos a los que seenfrenta el medico rehabilitador. Existen numerosos instru-mentos de valoracion y escalas para medir la funcion y ladiscapacidad, pero existe poca regularizacion en su uso, loque en muchas ocasiones dificulta la comparacion entreestudios de diferentes centros.

La prevalencia de la discapacidad en Europa esta en tornoa un 10%1, y se estima que esta cifra se vera incrementadadebido al aumento de la supervivencia tras una lesion opatologıa, de la esperanza de vida en la poblacion general yde un mayor porcentaje de supervivencia en enfermedadesen gente joven (cancer infantil, ictus, traumatismo cra-neoencefalico, lesion medular, etc.). Ademas, existe unademanda social que reivindica una mayor calidad de vida ybienestar fısico, psıquico y social2, lo que se traduce en unanecesidad para incrementar los servicios de Rehabilitacion.

Por todo esto, se puede considerar a la Rehabilitacioncomo una estrategia de salud tras la fase de prevencion y detratamiento, que esta dotada de un gran significado por sucontribucion a disminuir la carga economica de la enferme-dad y en el enriquecimiento de la calidad de vida de laspersonas que sufren una discapacidad3. Esta estrategia tieneuna perspectiva transversal incluyendo diferentes profesio-nales (medicos, enfermeros, fisioterapeutas, trabajadoressociales, terapeutas ocupacionales, psicologos, etc.) y unaperspectiva longitudinal en tanto en cuanto que el procesohabrıa de iniciarse en la fase aguda explotando laplasticidad de los sistemas afectados para continuar elseguimiento a lo largo del tiempo para la deteccion deposibles complicaciones. Por ello, la rehabilitacion necesitade un marco conceptual amplio con una vision unificadora ycon un enfoque cientıfico que permita poder proporcionarun informe mas detallado y global de la situacion funcionalde un individuo ası como que sirva de nexo de comunicaciony de intercambio de informacion entre los diferentesprofesionales o disciplinas sanitarias.

Una base posible para generar esta comprension delestado de salud de un individuo es la Clasificacioninternacional del funcionamiento, de la discapacidad y dela salud (CIF) basada en el modelo biopsicosocial de laOrganizacion Mundial de la Salud (OMS)4 (fig. 1).

El objetivo de este artıculo es promover la difusion de laCIF entre los profesionales del ambito rehabilitador ası comodescribir el desarrollo de nuevas herramientas de trabajo

basadas en ella que posibiliten su uso en las diferentespracticas profesionales.

Descripcion de la Clasificacion internacionaldel funcionamiento, de la discapacidad y de lasalud y herramientas de trabajo

En el ano 2001 en la quincuagesima cuarta reunion de la OMSfue aprobada la CIF con la intencion de proporcionar unmarco conceptual universalmente aceptado para clasificar ydescribir el funcionamiento, la discapacidad y la saluddentro del llamado modelo biopsicosocial definitorio deestado de salud. Este modelo supone que las consecuenciaso limitaciones que un individuo posee tras una enfermedadno son consecuencia directa de esta (modelo biologico) o delentorno en donde vive (modelo social), sino que es resultadode una conjuncion de varios factores, entre los que habrıaque anadir las caracterısticas personales y medioambienta-les. Esta clasificacion permitirıa, por otro lado, comple-mentar a otras, como la ICD 10 o el DSM IV, que tienen unenfoque predominantemente etiologico y que, por tanto,desestiman las consecuencias funcionales de la enfermedad.

Dicho modelo pretende ofrecer una perspectiva integral ydetallada sobre la funcion y la discapacidad en torno alindividuo, lo que permite un acercamiento a traves de susdiferentes dominios para la elaboracion de un perfil sobre elfuncionamiento, la discapacidad y la salud de una persona.Ası, se podrıa clasificar y describir el estado de salud de dospersonas que, aun teniendo la misma patologıa, podrıantener una funcionalidad diferente, ya fuese porque esten enun estadio diferente, por distinta edad, por variaciones en lafuerza fısica, en la accesibilidad a recursos sanitarios,sociales, apoyo familiar, etc.

Entre los objetivos de la CIF destaca la intencion deproporcionar una base cientıfica para comprender losestados de salud y todo aquello con lo que se relaciona. Elestablecimiento de un lenguaje comun para describir lasalud contribuye a una mejora en la comunicacion entrediferentes profesionales y permite la comparacion de datosentre diferentes paıses, diferentes disciplinas sanitarias ydiferentes momentos a lo largo del tiempo. Igualmente,posibilitarıa la generacion de un esquema de codificacionsistematizado para ser aplicado en los sistemas de informa-cion sanitaria. Todo ello hace posible que sea utilizada comouna herramienta no solo en los ambitos clınico y sanitario,sino tambien en investigacion, estadıstica, educacion ycomo herramienta para el desarrollo de una polıticasanitaria.

Por todo ello, desde su aprobacion la CIF se dispone comoun marco universal de trabajo para la descripcion de la

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La CIF en Rehabilitacion: de la teorıa a la practica 153


funcion y discapacidad empleando un lenguaje universal yun modelo descriptivo globalmente aceptado.

Estructura de la Clasificacion internacional delfuncionamiento, de la discapacidad y de la salud

La clasificacion esta estructurada en dos partes, cada una delas cuales contiene 2 componentes. La parte 1, denominadafuncionamiento y discapacidad, incluye los componentes defunciones corporales (b) y de estructuras corporales (s) y elcomponente de actividades y participacion (d). La parte 2,que corresponde a los factores contextuales, incluye loscomponentes de los factores ambientales (e) y los factorespersonales (aun por determinar) (figs. 1 y 2).

Las funciones corporales son aquellas funciones fisiolo-gicas de todos los sistemas corporales en un individuo.

Las estructuras corporales son las partes anatomicas delas que se constituye un individuo.

La actividad es la realizacion de una determinada tarea oaccion.

La participacion es el acto de involucrarse en unasituacion vital.

Los factores ambientales constituyen el ambiente fısico,social y actitudinal en donde viven las personas y llevan acabo su vida.

Cada uno de estos apartados tiene una serie de capıtulosorganizados de forma jerarquica, de forma que se podrıaobtener una serie de codigos alfanumericos que representa-rıa a las llamadas )categorıas* y que servirıan, por ejemplo,

para describir un estado de salud. Ademas, la CIF tambienofrece la posibilidad de calificar a dichas categorıasmediante puntuaciones que oscilan desde el 0 (ausencia deproblema) hasta el 4 (problema total).

Desarrollo de nuevas herramientas de trabajobasadas en la Clasificacion internacional delfuncionamiento, de la discapacidad y de la salud

En total, la CIF esta constituida por mas de 1.400 categorıas,lo que genera su principal problema y la escasa facilidadpara su uso diario. Por ello, diversas iniciativas se estanllevando a cabo para encontrar herramientas de trabajo quefaciliten su utilizacion.

En 2001, cuando la CIF fue presentada en la AsambleaGeneral de la OMS, se hizo un llamamiento a los paısesmiembros a que fomentasen su uso, esto ha hecho que ennumerosos centros a nivel mundial se esten llevando a cabodiversos estudios para encontrar herramientas practicas quefavorezcan su uso, y cada vez es mayor el interes por la CIF.

Prueba de ello es el incremento de comunicaciones sobretemas referentes a ella en los congresos, el aumento depublicaciones en revistas cientıficas, el interes de losgobiernos mediante la otorgacion de becas destinadas a lapromocion de estudios relacionados, su introduccion en losprogramas de formacion curricular e incluso se ha notado unaumento en el numero de preguntas relacionadas con ellatanto en los boards americanos como en los europeos.

Una de las iniciativas para facilitar el uso de la CIF fue eldesarrollo de la ICF checklist, que no dejaba de ser unaseleccion de 125 ıtems de la CIF5–8. Sin embargo, una de susdesventajas es que no es especıfica para las diferentespatologıas, por lo que la OMS, a traves de su delegacion de laCIF (ICF Branch de la WHO Collaboration Centre of theFamiliy of International Classifications [DIMDI], LudwigMaximilians University, Munich), promovio el desarrollo deun conjunto mınimo de categorıas especıficas para cadapatologıa o lo que en el mundo anglosajon denominan )coresets*. Aproximadamente con un 20% de las categorıas de laCIF se podrıa describir hasta un 80% del espectro clınico yfuncional de un grupo de pacientes determinados9,10.

La seleccion de las categorıas de la CIF que constituyenlos )core sets* en las diferentes entidades nosologicas es unproceso que incluye la integracion de evidencia cientıficaobtenida a traves de varios estudios. Puede decirse que setrata de un proceso ambicioso y cuya duracion se estima en

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Funcionescorporales

y estructurascorporales

ParticipaciónActividad

Estado de salud

Factoresambientales

Factorespersonales

Factorescontextuales

Figura 1 Estructura de la Clasificacion internacional delfuncionamiento, de la discapacidad y de la salud. Parte 1.

Funciones corporales Estructuras corporales

CIF

Actividades y participación Factores medioambientales

8

114

323

48

8

56

158

86

9

116

266

5

74

179

Figura 2 Estructura de la Clasificacion internacional del funcionamiento, de la discapacidad y de la salud. Parte 2.

S. Laxe et al154


unos tres anos tras los cuales se obtienen los )core sets*preliminares, que habran de ser validados con posterioridad.

Hasta el momento se han realizado los )core sets*preliminares en otras patologıas cronicas, como la osteoar-tritis, la osteoporosis, la artritis reumatoide, la cardiopatıacronica, la diabetes, la obesidad, la enfermedad pulmonarobstructiva cronica, la depresion, el cancer de mama, elictus o la lesion medular9,11–24.

Aplicaciones practicas de la clasificacioninternacional del funcionamiento, de ladiscapacidad y de la salud en el ambito de laRehabilitacion

Desde una perspectiva clınica, el uso de la CIF y de susherramientas de trabajo puede ser altamente valioso paradescribir el estado de salud de un paciente ası como suevaluacion mediante los calificadores. Tal y como exponıa alinicio de este artıculo, el medico rehabilitador debe poderrealizar una fotografıa del estado de salud de su paciente ysi es posible dentro del modelo amplio biopsicosocial que seha comentado. El uso de las categorıas de la CIF puedepermitir la elaboracion de un codigo de barras para cadapaciente facilmente entendible por diferentes profesionalesy que facilita la obtencion de informacion rapidamente parasu evaluacion.

La creacion de un plan terapeutico por objetivos basando-nos en un lenguaje que todos los miembros del equipomultidisciplinario entenderıan y la asignacion de tareas acada uno de estos miembros son algunas de las oportunidadesque tambien brinda esta clasificacion. Rauch, en su artıculopublicado recientemente, nos invita a hacer uso de la)assessment sheet* y del )rehab cycle* para programar elproceso rehabilitador del paciente, garantizando una mejorobservacion de este y un menor solapamiento de interven-ciones o exploraciones realizadas por diferentes profesiona-les25. De forma similar al uso que hacen otras especialidadesmedicas empleando los diagnosticos de la CIE 10, losrehabilitadores podrıamos comenzar a anadir a nuestrosinformes o a la historia clınica los codigos de la CIF.

Para la investigacion la CIF constituye tambien unaherramienta de trabajo, ya que facilita la categorizacionde pacientes segun su estado funcional, sirviendo como unlenguaje comun que permite comparar estudios o instru-mentos de medida.

Hoy en dıa, ninguna especialidad medica tiene futuro sinun substrato de investigacion que aporte innovaciones y unasolida base cientıfica que la sustente, y la Rehabilitacionigualmente precisa de un empuje en cuanto a la investiga-cion26,27. La presencia de un marco conceptual de trabajoque sea comun y universal ası como la creacion de una seriede redes integrales de trabajo y de intercambio de datos seproponen como retos para la investigacion en esta especia-lidad y la CIF, como paradigma del modelo biopsicosocial, eshoy por hoy el mejor marco para desarrollar conocimiento.

Stucki28 describe la existencia de cinco lıneas basicas parala investigacion en Medicina Fısica y Rehabilitacion funda-mentandose en el modelo de la CIF:

� Ciencias que estudien el funcionamiento humano paracomprenderlo e identificar objetivos para contribuir a la

optimizacion de la funcion y disminuir la experiencia dela discapacidad (epidemiologıa sobre funcion, modelos defuncion, clasificacion y medida de la funcion, etc.).� Biociencias cuyo objetivo sea explicar la lesion corporal y

su reparacion para identificar aquellas intervenciones otratamientos para mejorar la funcion (plasticidad neuro-nal, trasplante de organos, bioprotesis, etc.).� Ciencias integrales de rehabilitacion que estudien la

planificacion de programas de rehabilitacion, estructurasde los centros, evaluacion de polıticas sociales, partici-pacion comunitaria, etc.� Rehabilitacion Medica y Bioingenierıa: uso de medica-

mentos o de material ortoprotesico, desarrollo deestudios clınicos para mejorar la evidencia cientıfica,etc.� Ciencias profesionales de Rehabilitacion para promover

el desarrollo de protocolos en las diferentes entidadesnosologicas, manejo y control de la calidad en losservicios suministrados, evaluacion del equipo terapeu-tico, etc.

A modo de ejemplo, en cuanto al ambito de investigacion,ya han sido varios los estudios publicados en los que empleandola CIF como marco, han servido para comparar variosinstrumentos de medida. Resultados tales como la redundanciade conceptos en las diferentes escalas empleadas y la falta deevaluacion de aspectos relacionados con la participacion y conlos factores medioambientales, son algunas de las conclusionesobtenidas. Del mismo modo, la deteccion de estos aspectospuede servir de base para la creacion y desarrollo de nuevosinstrumentos de medida7,29–32.

Incluso, hay quien va mas lejos e hipotetiza sobre laposibilidad de emplear la CIF como sistema de busqueda deinformacion en bases de datos, tal y como sugiere Sundar ensu estudio empırico, en el que mapea los codigos de la CIFcon los terminos de busqueda en la base de datos electro-nica del CIRRIE33,34.

La Estadıstica y la Epidemiologıa son otras ciencias que sebeneficiarıan de la CIF al poder medir mediante lasdiferentes categorıas el estado de salud de un paciente enterminos de funcionalidad, de estructuras corporales afec-tas, de intervenciones que le han sido practicadas, demedicacion que le sea administrada, de ortesis de ayuda, dedependencia de terceras personas, etc8.

Todas las aplicaciones anteriores sirven para fundamentarla creacion de nuevas estrategias en materia de salud, paraoptimizar los recursos economicos, elaborar planes detratamiento, redactar protocolos para gestion de recursosy ayudas, etc. Prueba de todo ello es el estudio de IngridSchraner de la Facultad de Ciencias Economicas y Finanzasde la Universidad Western Sydney, en el que hace uso de laCIF para la realizacion de un analisis economico sobre el usode sistemas tecnologicos de asistencia35. Este ultimo estudiotambien sirve para ejemplificar que el lenguaje de la CIF esvalido para otros profesionales no sanitarios.

La CIF tambien ha mostrado su utilidad como sistema devaloracion/baremacion a la hora de otorgar prestacionessocioeconomicas por parte de los sistemas de seguridadsocial.

Los sistemas de seguridad social estan bien desarrolladosen Europa y permiten a aquellas personas con unadiscapacidad percibir una prestacion social compensatoria.

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No obstante, aunque estos se fundamentaron sobre unosprincipios similares, existen diferencias importantes encuanto a la evaluacion de la discapacidad en los diferentespaıses europeos. Por esto, la European Union of Medicine inAssurance and Social Security36 (EUMASS), organizacioneuropea que agrupa a expertos en materia de seguridadsocial de 15 paıses, decidio crear a partir de su decimo-quinta asamblea general la realizacion de unos )core sets*basados en la CIF que sirvieran para unificar y homogeneizarlos criterios de evaluacion de la discapacidad y otorgacionde beneficios de la seguridad social en los diferentesestados miembros. Finalmente, este grupo de trabajoha determinado que una seleccion de 20 categorıas deltotal que constituye la CIF deberıa constituir los )core sets*para ser empleados en la seguridad social37. Esteproyecto aun se encuentra en una fase inicial, en la quetodavıa hay que proceder a la validacion y al uso decalificadores.

Conclusiones

La Rehabilitacion persigue la maxima optimizacion delfuncionamiento de un individuo en todas sus dimensiones.En nuestra especialidad cobra un interes especial el uso deinstrumentos de medida tanto cualitativos como cuantitativosque permitan una descripcion del estado de salud de nuestrospacientes, que ayuden a elaborar el plan rehabilitador y que,finalmente, nos proporcionen informacion sobre la evaluaciondel proceso. Son innumerables las herramientas de medida delas que se dispone, por eso proponemos el uso de la CIF comometodo unificador y de entendimiento global y neutral desdeun punto de vista etiologico. No obstante, hoy por hoy la granmagnitud de categorıas la hacen poco practica para su uso enla practica clınica, por ello la necesidad de crear herramientaspracticas que posibiliten su uso, como los )core sets*.

En este artıculo hemos descrito algunos ejemplos en losque la CIF demuestra su utilidad en ambitos de conocimientodiferentes.

Dado el gran impacto que la CIF ha supuesto en laRehabilitacion, hecho que se ha manifestado a traves decomunicados por parte de sociedades internacionales, comola ISPRM y la UEMS, el incremento de las publicaciones enrevistas internacionales y de presentaciones en congresos, laformacion sobre la CIF debe ser un campo educacional portener en cuenta en los programas de formacion de residentes.

Uno de los aspectos de mayor relevancia para que laRehabilitacion se desarrolle con exito tanto a nivel de lapractica clınica como de investigacion y su trabajo seareconocido es el empleo de un lenguaje comun, entendibleen diferentes ambitos y niveles, que categorice lasintervenciones terapeuticas en un modelo taxonomicofundamentado en el funcionamiento humano.

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Copyright @ 200 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.7

Core Stability Exercise PrinciplesVenu Akuthota,1 Andrea Ferreiro,1 Tamara Moore,2 and Michael Fredericson3

1Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, CO;2Sports and Orthopedic Leaders Physical Therapy, Oakland, CA; 3Division of Physical Medicine andRehabilitation, Stanford University School of Medicine, Stanford, CA

AKUTHOTA, V., A. FERREIRO, T. MOORE, and M. FREDERICSON. Core stability exercise principles. Curr. Sports Med.Rep., Vol. 7, No. 1, pp. 39Y44, 2008. Core stability is essential for proper load balance within the spine, pelvis, and kinetic chain. Theso-called core is the group of trunk muscles that surround the spine and abdominal viscera. Abdominal, gluteal, hip girdle, paraspinal, andother muscles work in concert to provide spinal stability. Core stability and its motor control have been shown to be imperative for initiationof functional limb movements, as needed in athletics. Sports medicine practitioners use core strengthening techniques to improveperformance and prevent injury. Core strengthening, often called lumbar stabilization, also has been used as a therapeutic exercisetreatment regimen for low back pain conditions. This article summarizes the anatomy of the core, the progression of core strengthening, theavailable evidence for its theoretical construct, and its efficacy in musculoskeletal conditions.

INTRODUCTION

Core stability (or core strengthening) has become a well-known fitness trend that has started to transcend into thesports medicine world. Popular fitness programs, such asPilates, yoga, and Tai Chi, follow core strengtheningprinciples. Broad benefits of core stabilization have beentouted, from improving athletic performance and preventinginjuries, to alleviating low back pain. The purpose of thisarticle is to review the available evidence on the benefits ofcore strengthening, present relevant anatomy, and outlinecore stabilizing exercise principles.

The core can be described as a muscular box with theabdominals in the front, paraspinals and gluteals in the back,the diaphragm as the roof, and the pelvic floor and hip girdlemusculature as the bottom (1). Within this box are 29 pairsof muscles that help to stabilize the spine, pelvis, and kineticchain during functional movements. Without these muscles,the spine would become mechanically unstable with com-pressive forces as little as 90 N, a load much less than theweight of the upper body (2). When the system works as itshould, the result is proper force distribution and maximumforce generation with minimal compressive, translational, or

shearing forces at the joints of the kinetic chain (3). Thecore is particularly important in sports because it provides‘‘proximal stability for distal mobility’’ (4).

Ipso facto, core stability exercises appear to be especiallyimportant in cases of spinal instability. Gross spinal insta-bility is an obvious radiographic displacement of vertebrae,often with associated neurologic deficit and deformity.However, functional or clinical instability is not as easilydefined. Panjabi describes ‘‘clinical instability as the loss ofthe spine’s ability to maintain its patterns of displacementunder physiologic loads so there is no initial or additionalneurologic deficit, no major deformity, and no incapacitatingpain’’ (5). The spine stability system consists of the followinginteracting elements:

& Neuromuscular control (neural elements)& Passive subsystem (osseous and ligamentous elements)& Active subsystem (muscular elements)

In other words, stability of the spine is not only dependenton muscular strength, but also proper sensory input thatalerts the central nervous system about interaction betweenthe body and the environment, providing constant feedbackand allowing refinement of movement (6). Thus a completecore stabilizing program would consider sensory and motorcomponents related to these systems for optimal spinalstabilization. Recently, the Queensland physiotherapy groupproduced research drawing a great deal of attention to thedeep core musculature, specifically the transversus abdominisand multifidi, for core stability (1). However, McGilland other biomechanists emphasize larger ‘‘prime mover’’muscles, such as the abdominal obliques and quadratus

39

SPINE CONDITIONS

Address for correspondence: Venu Akuthota, M.D., Department of Physical Medi-cine and Rehabilitation, University of Colorado School of Medicine, Aurora, CO80309 (E-mail: [email protected]).

1537-890X/0701/39Y44Current Sports Medicine ReportsCopyright * 2008 by the American College of Sports Medicine


lumborum, in providing stability (7). It appears a coordi-nated contraction of all deep and superficial core muscles isneeded for optimal spinal stabilization (8).

ANATOMY

The core acts through the thoracolumbar fascia, ‘‘nature’sback belt.’’ The transversus abdominis has large attachmentsto the middle and posterior layers of the thoracolumbar fascia(9). Additionally, the deep lamina of the posterior layerattaches to the lumbarspinous processes. In essence, thethoracolumbar fascia serves as part of a ‘‘hoop’’ around thetrunk (7) that provides a connection between the lower limband the upper limb (10). With contraction of the muscularcontents, the thoracolumbar fascia also functions as aproprioceptor, providing feedback about trunk positioning.Two types of muscle fibers comprise the core muscles:

slow-twitch and fast-twitch. Slow-twitch fibers make upprimarily the local muscle system (the deep muscle layer).These muscles are shorter in length and are suited forcontrolling intersegmental motion and responding tochanges in posture and extrinsic loads. Key local musclesinclude transversus abdominus, multifidi, internal oblique,deep transversospinalis, and the pelvic floor muscles. Multi-fidi have been found to atrophy in people with chronic lowback pain (LBP) (11). On the other hand, fast-twitch fiberscomprise the global muscle system (the superficial musclelayer). These muscles are long and possess large lever arms,allowing them to produce large amounts of torque and grossmovements. Key global muscles include erector spinae,external oblique, rectus abdominis muscles, and quadratuslumborum (which McGill states is a major stabilizer of thespine) (12).The abdominals serve as a particularly vital component of

the core. The transversus abdominis has received attentionfor its stabilizing effects. It has fibers that run horizontally(except for the most inferior fibers, which run parallel to theinternal oblique muscle), creating a belt around the abdo-men. ‘‘Hollowing in’’ of the abdomen creates isolatedactivation of the transversus abdominis. The transversusabdominis and multifidi have been shown to contract 30 msbefore movement of the shoulder and 110 ms beforemovement of the leg in healthy people, theoretically tostabilize the lumbar spine (13,14). However, patients withLBP have delayed contraction of the transversus abdominisand multifidi prior to limb movement (14). The internaloblique and the transversus abdominis work together toincrease the intra-abdominal pressure from the hoop createdvia the thoracolumbar fascia. Increased intra-abdominalpressure has been shown to impart stiffness to the spine(7). The external oblique, the largest and most superficialabdominal muscle, acts as a check of anterior pelvic tilt. Theabdominals (and multifidi) need to engage only to 5%Y10%of their maximal volitional contraction to stiffen spinesegments (15).The hip musculature is vital to all ambulatory activities,

and plays a key role in stabilizing the trunk and pelvis in gait(16). Poor endurance and delayed firing of the hip extensor(gluteus maximus) and abductor (gluteus medius) muscles

have previously been noted in people with LBP and othermusculoskeletal conditions such as ankle sprains (17). Thepsoas is only a feeble flexor of the lumbar spine (9).However, it does have the potential to exert massive com-pressive forces on the lumbar disks. In activities that pro-mote maximal psoas contraction, such as full sit-ups, itcan exert a compressive load on the L5-S1 disk equal to100 kg of weight (9). Tightness of the hip flexor (psoas)can cause LBP by increasing compressive loads to the lum-bar disks.

The diaphragm serves as the roof of the ‘‘muscular box’’ ofthe core, and the pelvic floor serves as the floor. Contractionof the diaphragm increases intra-abdominal pressure, thusadding to spinal stability. Pelvic floor musculature iscoactivated with transversus abdominis contraction (18).Recent studies (19) have indicated that people withsacroiliac pain have impaired recruitment of the diaphragmand pelvic floor. Thus diaphragmatic breathing techniquesand pelvic floor activation may be an important part ofa core-strengthening program.

MEASURING CORE STABILITY

Research on core stability exercises has been hampered bya lack of consensus on how to measure core strength. If coreinstability and core weakness can be measured, outcomes canbe followed and a proper emphasis can be placed upon corestrengthening in certain individuals. Delitto and others

Figure 1. Prone instability test: In this test, the patient is prone, withlegs off the table and feet on the floor. The clinician applies posterior-anterior pressure over the lumbar spine and assesses for pain. The patientthen engages extensors and lifts feet off the floor. The test is positive ifpain is elicited with pressure and relieved with active extension, as this isthought to indicate temporary pain relief through stabilization of thespine (22).

40 Current Sports Medicine Reports www.acsm-csmr.org


have proposed that stabilization exercises would work best inindividuals who are young, with increased flexibility (post-partum, generalized ligamentous laxity), or with examfindings suggesting an interspinal segment with increasedpainful movement (20,21). The prone instability test is anexample of a physical exam maneuver testing for clinicalinstability (22) (Fig. 1). Measures can include triplanar,weight-bearing evaluation of the global core as well asisolated measures of particular muscles (4) (Fig. 2 Table 1).

DEVELOPING A CORE EXERCISE PROGRAM

Exercise of the core musculature is more than trunkstrengthening. Lack of sufficient coordination in coremusculature can lead to decreased efficiency of movementand compensatory patterns, causing strain and overuseinjuries. Thus motor relearning of inhibited muscles may bemore important than strengthening in patients with LBP andother musculoskeletal injuries.

A core exercise program should be done in stages withgradual progression. It should start with restoration of normalmuscle length and mobility to correct any existing muscleimbalances. Adequate muscle length and flexibility arenecessary for proper joint function and efficiency of move-ment. Muscle imbalances can occur where agonist musclesbecome dominant and short while antagonists would becomeinhibited and weak. One example of a muscle imbalancepattern includes tightness and over-activity of the primaryhip flexor (iliopsoas), which in turn causes reciprocalinhibition of the primary hip extensor (gluteus maximus).

Further up the kinetic chain, this particular muscle imbal-ance leads to increased lumbar extension, with excessiveforce on the posterior elements of the spine. In addition,postural muscles have a tendency to become tight due toconstant activity in order to fight the forces of gravity.

Then, activation of the deep core musculature should betaught through lumbo-pelvic stability exercises. When thishas been mastered, more advanced lumbo-pelvic stabilityexercises on the physioball can be added. Finally, thereshould be transitioning to the standing position, facilitatingfunctional movement exercises that promote balance andcoordination of precise movement. The goal of advancedcore stabilization is to train functional movements ratherthan individual muscles (3).

BEGINNING A CORE STRENGTHENING PROGRAM

Warm-up can include the ‘‘cat’’ and ‘‘camel’’ stretches anda short aerobic program. A core stability exercise programbegins with recognition of the neutral spine position (mid-range between lumbar flexion and extension), touted to bethe position of power and balance for optimal athleticperformance in many sports (8).

The first stage of core stability training begins with learn-ing to activate the abdominal wall musculature. Individualswho are not adept at volitionally activating motor pathwaysor individuals with chronic low back pain and fear-avoidancebehavior may require extra time and instruction to learn torecruit muscles in isolation or with motor patterns (23).Cueing individuals on abdominal hollowing, which mayactivate the transversus abdominis, as well as abdominalbracing, which activates many muscles including the trans-versus abdomin is, external obliques, and internal obliques, isan important beginning step. One study showed thatperforming abdominal hollowing and bracing prior toperforming abdominal curls facilitated activation of thetransversus abdominis and internal obliques throughout theabdominal curling activity (22,24).

Grenier and McGill, however, found little utility of theabdominal hollowing to cue the transversus abdominis into

Figure 2. Advanced functional training techniques for core stability.Transverse plane core exercises in standing position. This resistive,dynamic trunk pattern challenges the core in the transverse plane. Thisrequires strict bracing of the abdominals and locking the ribs and pelvistogether to avoid unnecessary spinal torsion. The athlete activates theabdominal brace before movement. It is important to emphasize posturalalignment with scapulae retracted and depressed. The athlete shouldmaintain neutral spine angles throughout movement. Progression caninvolve greater resistance or weight.

TABLE 1. Measuring core stability: the core score

1. Prone instability test

2. Prone extension endurance test (Biering-Sorenson paraspinalendurance strength)

3. Side bridge endurance test (quadratus lumborum endurance strength)

4. Pelvic bridging

5. Leg lowering test (lower abdominal strength)

6. Trunk curl

7. Hip external rotation strength

8. Modified Trendelenburg test (single leg squat with observationinfrontal plane)

9. Single leg squat in sagittal plane

10. Single leg squat in transverse plane

Volume 7 ● Number 1 ● January/February 2008 Core Stability Exercise Principles 41


improving core stability and place more emphasis onabdominal bracing (25).

PROGRESSING A CORE STRENGTHENING PROGRAM

Once these activation techniques are mastered and thetransversus abdominisis ‘‘awakened,’’ training should beprogressed. The beginner can then incorporate the ‘‘big 3’’exercises as described by McGill. These include the curl-up,side bridge (side plank), and quadruped position withalternate arm/leg raises (‘‘bird dog’’). The prone plank andbridging also can be added at this stage (3). Pelvic bridgingis particularly effective for activating the lumbar para-spinals (26).Initial exercises are done in supine, hook-lying, or

quadruped positions. It should be reiterated that the pelvisshould not be tilted and the spine should not be flattened,but should maintain a neutral posture. Normal rhythmicdiaphragmatic breathing also is emphasized. Once goodcontrol is demonstrated with the static core exercises, theindividual can advance to exercises using a physioball.Notably, non-weight-bearing core exercises, such as onesperformed on a physioball, may not translate to improvedathletic performance (27). Thus, athletes should quicklyadvance to more functional exercises in sitting, standing, andwalking positions.

ADVANCED CORE STRENGTHENING: CHALLENGINGBALANCE AND MOTOR CONTOL

As progression is made through the initial stages of a corestrengthening program, emphasis should be placed ondeveloping balance and coordination while performing avariety of movement patterns in the three cardinal planes ofmovement: sagittal, frontal, and transverse. Exercises shouldbe performed in a standing position and should mirrorfunctional movements. Functional training typically requiresacceleration, deceleration, and dynamic stabilization. Anadvanced core stabilizing program should train reflexivecontrol and postural regulation (3).Various unstable surfaces can be used to further challenge

balance and coordination and assist with training movementpatterns. These include the balance board (a whole sphereunderneath the board, which creates multiplanar instability),the rocker board (a curved surface underneath the board,which allows single-plane motion), the Bosu BalanceTrainer, and the Dyna Disk (the latter two, both of whichare air-filled plastic discs, can be used interchangeably) (3).The abdominal bracing technique should be initiated

before performing any of the standing exercises. Initial gaittraining is important, emphasizing control of heel strike in thesupinated position on the lateral edge of the foot, moving topronation onto the medial foot with flexion of the firstmetatarsal head and toes. From there, exercises can beprogressed to a controlled falling lunge onto an unstablesurface, emphasizing control and spinal alignment. Multi-directional lunges can be done on the floor in multiple planesof movement. Progress can be made to jumps on one or two

legs, which stimulates cerebellar activity and helps createautomatic postural control (3). An example of an evidence-based core stability program is provided in Table 2 (28,29).

CREATING MORE HARM THAN GOOD: PRACTICESTO AVOID

Some traditional progressive resistance strengthening ofthe core muscles may be unsafe to the back. Specifically,heavy resistance training of the lumbar extensors is notrecommended. Roman chair exercises or back extensorstrengthening machines require at least torso mass forresistance, which is a load that is often injurious to thelumbar spine (8). Traditional sit-ups also may be unsafebecause they create excessive compressive forces in thelumbar spine (9,30). Caution should be used with full spinalflexion or repetitive torsion, as risk of lumbar injury isgreatest with these positions (31). In addition, spinal exerciseshould not be done in the first hour after rising in the

TABLE 2. Example of an evidenced-based core stability program

General

& Go over anatomy of the core

& Active participation emphasized

Basic exercises Y isolate core muscles in different positions

& Transversus abdominus (advance if able to perform 30 reps with8 s hold)

) Abdominal bracing

) Bracing with heel slides

) Bracing with leg lifts

) Bracing with bridging

) Bracing in standing

) Bracing with standing row

) Bracing with walking

& Paraspinals/multifidi (advance if able to perform 30 reps with 8 s hold)

) Quadruped arm lifts with bracing

) Quadruped leg lifts with bracing

) Quadruped alternate arm and legs lifts with bracing

& Quadratus lumborum and obliques (advance if able to perform 30 repswith 8 s hold)

) Side plank with knees flexed

) Side plank with knees extended

& Trunk curl

Facilitation techniques if necessary (pelvic floor contraction, visualization,palpation, identifying substitution patterns like pelvic tilt, ultrasound)

Progression

& Physioball

& Functional training positions with activation of core

& Build endurance

Compliance with home exercise program



morning. This is due to the fact that hydrostatic pressure inthe disk is increased during that time (32).

WHO SHOULD HAVE CORE STABILITY PRESCRIBED?

Certain predictors can be used to determine whichpatients will be more likely to benefit from lumbar stabiliza-tion programs. One study (28) found the following factorscould be used to assess which patients would be likely torespond favorably to core stabilization:

& Younger age (G40)& Greater general flexibility (hamstring length greaterthan 90-, postpartum)

& Positive prone instability test& Presence of aberrant movement during spinal range ofmotion (painful arc of motion, abnormal lumbopelvicrhythm, and using arms on thighs for support)

Stuge et al. also proposed the following physical maneu-vers as predicting a good response from stabilization exercisein postpartum women (33):

& Positive posterior pelvic pain provocation (P4) test (alsocalled thigh thrust test)

& Positive active straight leg raise& Positive pain provocation (persists greater than 5 s afterpalpation) with palpation of PSIS region (long dorsalsacroiliac ligament)

& Positive pain provocation (persists greater than 5 s afterpalpation) with palpation of pubic symphysis

& Positive Trendelenburg sign

EFFICACY OF CORE-STRENGTHENING EXERCISE FORTREATMENT OF BACK PAIN

There is ample evidence that individuals with chronicLBP and sacroiliac pain lack proper recruitment of coremuscles and exhibit core weakness (6,11,14,26,34,35). Therealso is evidence of increased fatigability, decreased crosssection, and fatty infiltration of paraspinal muscles inpatients with chronic LBP (6). Even high-level athletesshow signs of core instability, and this may set them up formore musculoskeletal injuries (4,36Y39). Female athletesmay be particularly susceptible to injury to the anteriorcruciate ligament if core weakness is found (36Y38). Inaddition, these patients seem to have increased difficultywith balance and decreased ability to compensate forunexpected trunk perturbation. Patients with back pain alsoseem to over-activate superficial global muscles whereascontrol and activation of the deep spinal muscles is impaired.Thus core stability exercises have strong theoretical basis forprevention of different musculoskeletal conditions and thetreatment of spinal disorders.

Level 1 evidence for stabilization exercises is mixed andmainly comes from studies on LBP. To our knowledge, therehave been five randomized trials that have supportedstabilization exercises for LBP (33,40Y43). However, thereare some methodological flaws in some of these studies,

including lack of true controls, significant attrition rate,and statistical vagaries (21,44). Two other randomized trialsfurther question the superiority of stabilization exercises(29,45). The control groups in both of these studies includedgeneralized strengthening components in addition to otherfeatures (21). Systemic reviews also have come to theconclusion that stabilization is helpful for spinal disordersbut may not be superior to other therapeutic exerciseregimens (46Y48).

CORE STRENGTHENING AND INJURY PREVENTION

Some evidence in the literature supports the notion thatcore stabilization programs may be used to help preventinjury in athletics. Leeton and colleagues (36) performed aprospective study looking at 140 male and female intercolle-giate basketball and track athletes. They found that injuredathletes [injuries included anterior cruciate ligament (ACL)rupture, iliotibial band syndrome, patellofemoral pain, andstress fracture in the lower extremity] had significantlydecreased strength in hip abduction and external rotationcompared with non-injured athletes. Hip external rotationstrength was most useful in predicting injury (36).

Some literature supports using neuromuscular training toprevent ACL injuries in athletes. These programs includemuscle co-contraction to provide joint stability, balance andperturbation training, and plyometric exercises. Hewitt andcolleagues conducted a prospective study comparing injuriesin female high school athletes with preseason neuromusculartraining, including single-leg functional core stability train-ing, with a control group of female and male athletes withoutpreseason neuromuscular training (37). Non-contact ACLinjury risk was significantly less in the group of femaleathletes with neuromuscular training. In a similar study,Heidt and colleagues found that preseason neuromusculartraining in female high school soccer players led to sig-nificantly fewer injuries overall, but no difference in ACLinjuries between groups (39).

Specific core stability programs in prevention of athleticinjuries have not been well studied. Additionally, coreprograms have not been proven to enhance athletic per-formance. Despite these facts, many of these programshave been promoted in lay literature for use in performanceenhancement.

CONCLUSIONS

Core strengthening has a strong theoretical basis intreatment and prevention of LBP, as well as other muscu-loskeletal afflictions, as is evidenced by its widespreadclinical use. Studies have shown that these programs mayhelp decrease pain and improve function in patients withLBP. However studies are limited, and some show conflictingresults. Future studies are needed to elucidate precise corestrengthening programs and their effects on treatment andprevention of LBP, in comparison with other exercisetraining programs.

Volume 7 ● Number 1 ● January/February 2008 Core Stability Exercise Principles 43


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