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To Crunch or Not to Crunch: An Evidence-Based Examination of Spinal Flexion Exercises, Their Potential Risks, and Their Applicability to Program Design

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THE CRUNCH AND ITS MANY VARIATIONS HAVE LONG BEEN CONSIDERED A STAPLE EXERCISE IN FITNESS PROGRAMS. HOWEVER, RECENTLY, SOME FITNESS PROFESSIONALS HAVE QUESTIONED THE WISDOM OF PERFORMING FLEXION-BASED SPINAL EXERCISES, SUCH AS THE CRUNCH. CONCERNS ARE USUALLY PREDICATED ON THE BELIEF THAT THE SPINE HAS A FINITE NUMBER OF BENDING CYCLES AND THAT EXCEEDING THIS LIMIT WILL HASTEN THE ONSET OF VERTEBRAL DEGENERATION. THIS ARTICLE WILL SEEK TO REVIEW THE RESEARCH PERTAINING TO THE RISKS OF PERFORMING DYNAMIC SPINAL FLEXION EXERCISES AND WILL DISCUSS THE APPLICATION OF THESE FINDINGS TO EXERCISE PERFORMANCE.
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To Crunch or Not to Crunch: An Evidence-Based Examination of Spinal Flexion Exercises,
Their Potential Risks, and Their Applicability to Program Design
Bret Contreras, MA, CSCS
Brad Schoenfeld, MSc, CSCS
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The crunch and its many variations have long been considered a staple exercise in fitness
programs. These exercises involve dynamic flexion of the spine in the sagittal plane, and are
performed to increase abdominal strength and development (125), particularly in the rectus
abdominis and obliques musculature. Strength and conditioning coaches frequently include such
exercises as a component of athletic routines designed to enhance sporting performance (45).
Recently, however, some fitness professionals have questioned the wisdom of
performing flexion-based spinal exercises such as the crunch (74; 23; 111). Concerns are usually
predicated on the belief that the spine has a finite number of bending cycles, and that exceeding
this limit will hasten the onset of disc damage (74). Proponents of the theory claim that spinal
flexion therefore should be saved for activities of daily living such as tying one's shoes rather
than "wasted" on crunches and other flexion-based abdominal exercises. Opponents of the theory
counter that an alarming discrepancy exists between laboratory results and what is occurring in
gyms and athletic facilities around the world with respect to total flexion cycles and spinal
injury, and cite a lack of evidence showing any detriments. Therefore, the purpose of this paper
will be threefold: First, to review the relevant research pertaining to the risks of performing
dynamic spinal flexion exercises; second, to explore the potential benefits associated with spinal
flexion exercises; and third, to discuss the application of these findings to exercise program
design.
Overview of Degenerative Disc Disease
The intervertebral discs form cartilaginous joints between adjacent vertebrae, which
stabilize the the spine by anchoring the vertebrae to one another. The discs also facilitate multi-
planar spinal movement and help absorb vertebral shock. Discs are comprised of three distinct
portions: an outer layer annular fibrosus, a central nucleus pulposus, and two hyaline cartilage
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endplates (64). The annulus, which has an inner and outer component, consists of multiple layers
of fibrocartilage, primarily a combination of Type I and Type II collagen (39). The annulus
serves to resist outward pressure, also known as tensile or hoop stresses, during axial
compression and to stabilize the vertebral joint during motion (139). The annulus also serves to
contain the inner nucleus, which is a gel-like structure comprised of a mixture of chondrocytes,
collagen, elastin, and proteoglycans (131). Proteoglycans serve to resist compressive loading due
to their glycosaminoglycan (GAG’s) content (115). GAG’s are long-branch polysaccharides that
attract and bind to water and provide osmotic pressure. The nucleus functions as a "water
pillow," helping to cushion the vertebrae from axial loads and distribute pressures uniformly
over adjacent vertebral endplates (112). The endplates contain primarily type II collagen (55),
are less than 1 mm thick, and contain fibers that extend into the disc (139). In addition to
preventing the nucleus from protruding into adjacent vertebrae, the endplates also help to absorb
hydrostatic pressure caused by spinal loading (26; 81) and allow for nutrient diffusion (132).
Degenerative disc disease is a multifactorial process involving genetic, mechanical,
biological, and environmental factors (59). The first common signs of disc degeneration often
appear between 11-16 years of age, with approximately 20% of teenagers displaying mild disc
degeneration (79). However, minor signs of degeneration such as mild cleft formation and
granular changes to the nucleus appear in disc of 2 year-olds (21). Discs tend to progressively
deteriorate with age, with a majority of discs showing signs of degeneration by the time a person
is 70 years-old (79). Age-related degeneration involves a reduction in proteoglycan and collagen
levels (115), a five-fold reduction in the fixed charge-density a measure of
mechanoelectrochemical strength of GAG’s in the nucleus (60), and a two-fold decrease in
hydration between adolescent discs and 80 year-old discs (130), which diminishes the disc's
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height and load-bearing capabilities (5; 22). Males tend to exhibit more disc degeneration than
females, which is thought to be due to a combination of increased trunk strength, increased
resistance lever arms that heighten spinal forces and stresses, increased heavy-loading, and
increased distance for nutrient-travel (79).
Intervertebral disc degeneration can manifest from a structural disturbance in the annulus,
nucleus, or endplate (8). Aging, apoptosis, collagen abnormalities, vascular ingrowth,
mechanical loading, and proteoglycan abnormalities can all contribute to disc degeneration (71).
As discs degenerate, focal defects arise in the cartilage endplate, the nuclei become increasingly
more consolidated and fibrous, and the number of layers in the annulus diminishes (119). This
has been shown to alter disc height, spinal biomechanics, and load bearing capabilities (99), and
ultimately can lead to spinal stenosis an advanced form of degenerative disc disease that causes
compression of the contents of the spinal canal, particularly the neural structures (93). Endplate
calcification also contributes to disc degeneration by decreasing nutrient diffusion which
interferes with the pH balance and increases inflammatory responses in the nucleus (34). Yet
despite a clear association between degenerative spinal changes and an increased incidence of
lower back pain (LBP) (66), many afflicted individuals are nevertheless asymptomatic (20; 19;
140).
Does Spinal Flexion Cause Disc Injury?
A variety of research approaches have been employed to elucidate spinal biomechanics
and their impact on disc pathophysiology, including the use of animal and human in vivo (i.e.
within the living) models, animal and human in vitro models (i.e. within the glass), and
computer-based in silico models (63). In particular, in vitro research has implicated repetitive
lumbar flexion as the primary mechanism of disc herniation (protrusion of disc material beyond
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the confines of the annular lining) and prolapse (a bulging of nucleus pulposus through annulus
fibrosus), as evidence shows that these pathologies proceed progressively from the inside
outwards through nuclear migration toward the weakest region of the annulus the posterolateral
portion (62; 128).
Most in vitro studies on spinal biomechanics that are applicable to the crunch exercise
have used cervical porcine models (30, 35, 124, 36, 70). These models involve mounting spinal
motion segments in custom apparatuses that apply continuous compressive loads combined with
dynamic flexion and extension moments. Total bending cycles have ranged from 4,400 to
86,400, with compression loads equating to approximately 1,500N. Considering that Axler and
McGill (13) found that a basic crunch variation elicited around 2,000N of compression, the
amounts of compression in the various studies is reasonable for making comparisons with the
crunch exercise. In each of the aforementioned studies, a majority of the discs suffered either
complete or partial herniations, particularly to the posterior annulus. This suggests a cause-effect
relationship between spinal flexion and disc damage. The results of the studies are summarized
in Table 1.
TABLE 1
Study
Type of
Spine
# of Subjects
Amount of
Compression
# of Cycles
# of Herniations
Callaghan &
McGill (2001)
Porcine
Cervical
26
260-1,472N
86,400
15
Drake et al.
(2005)
Porcine
Cervical
9
1,472
6,000
7
Tampier et al.
(2007)
Porcine
Cervical
16
1,472N
4,400 14,00
8
Drake &
Callaghan (2009)
Porcine
Cervical
8
1,500N
10,000
8
Marshall &
McGill (2010)
Porcine
Cervical
10
1,500N
6,000
4
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Although the aforementioned studies seem to lend credence to the potential risks of
repeated spinal bending, there are several issues with attempting to extrapolate conclusions from
a laboratory setting to the gym. First and foremost, the studies in question were performed in
vitro, which is limited by the removal of musculature and does not replicate the in vivo response
to the human spine during normal movement (148; 142; 98; 143, 144). As with all living tissue,
the vertebrae and its supporting structures remodel when subjected to applied stress (24).
Consistent with Wolff's and Davis's Laws, deformation of cellular tissues are met by a
corresponding increase in the stiffness of the matrix, which in turn helps to resist future
deformation (103; 102). The vertebrae and intervertebral discs are no exception as they have
been shown to adaptively strengthen when exposed to progressive exercise (92; 65; 1; 24).
Cadaveric tissue does not have the capacity to remodel.
Another important point to consider when interpreting results of in vitro studies involving
cyclic spinal loading is that natural fluid flow is compromised. Van der Veen et al. (133) found
that while porcine lumbar motion segments showed outflow of fluid during loading, inflow failed
to occur during unloading, thereby decreasing disc height and interfering with normal disc
biomechanics.
In vitro comparisons are further complicated by the use of animal models. While animal
models do have structural similarities to the human spine (147; 29), especially the porcine
cervical spine in comparison to the human lumbar spine, numerous anatomical and physiological
variations nevertheless exist (131). Of particular relevance to flexion studies is the fact that the
absolute ranges of motion are smaller in porcine subjects compared to humans (10). These
variations are most prominent in flexion and extension, which may mitigate the ability to draw
applicable conclusions to human dynamic spinal exercise.
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Furthermore, the studies in question attempted to mimic loading patterns of occupational
workers by subjecting spinal segments to thousands of continuous bending cycles, which is far
beyond what is normally performed in the course of a dynamic exercise program. Typical core
strengthening routines employ a limited number of dynamic repetitions, and upon completion of
a set, trainees then rest for a given period of time before performing another set. Thus, total
bending cycles per session ultimately amount to a fraction of those employed in the cited
research protocols and these cycles are performed intermittently rather than continuously.
Rodacki et al. (97) found that despite the moderate values of compression associated with the
traditional crunch; the transient nature of the load (i.e. the short peak period of compressive
spinal force) did not induce fluid loss. In fact, abdominal flexion exercise was actually found to
be superior to the Fowler's position a semi-recumbent position used in therapy to alleviate
pressure on the spine with respect to spinal unloading, presumably mediated by a greater fluid
influx rate than when sustaining a static recumbent posture (97).
It also should be noted that following an exercise bout spinal tissues are allowed to
recuperate until the next training session, thereby alleviating disc stress and affording the
structures time to remodel. Exercise-induced disc damage results when fatigue failure outpaces
the rate of adaptive remodeling, which depends on the intensity of load, the abruptness of its
increase, and the age and health of the trainee (1). Provided that dynamic spinal exercise is
performed in a manner that does not exceed individual disc loading capacity, the evidence would
seem to suggest a positive adaptation of the supporting tissues. In support of this contention,
Videman et al. (136) found that moderate physical loading resulted in the least disc pathology,
with the greatest degeneration seen at extreme levels of activity and inactivity.
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In addition, the role of genetics needs to be taken into consideration. Despite the
commonly held belief that spinal degeneration is most often caused by the wear and tear from
mechanical loading, this appears to play only a minor role in the process (16). Instead, it has
been shown that approximately 74% of the variance is explained by hereditary factors (15).
Battie et al. (16) identified specific gene forms associated with disc degeneration that hasten
degenerative vertebral changes in the absence of repetitive trauma. Hereditary factors such as
size and shape of the spinal structures, and biochemical constituents that build or break down the
disc can highly influence disc pathology, as can gene-environment interactions (16).
In a case-control study involving 45 monozygotic male twin pairs, Battie et al. (17) found
that subjects who spent over five times more hours driving and handled over 1.7 times more
occupational lifting showed no increases in disc degeneration compared to their twin siblings
and, although values did not reach statistical significance, actually displayed fewer lower lumbar
disc herniations. In addition, Varlotta et al. (134) found that the relative risk of lumbar disc
herniation before the age of twenty-one years is approximately five times greater in subjects who
have a positive family history. Furthermore, physically active individuals appear to suffer from
less back pain than sedentary individuals (44; 77).
Moreover, the studies in question do not necessarily replicate spinal motion during
dynamic lumbar flexion exercise. For example, the traditional crunch exercise involves flexing
the trunk to approximately 30 degrees of spinal flexion so that only the head and shoulders are
lifted from the floor, making the thoracic spine the region of greatest flexion motion (105; 118).
Further, Adams and Hutton (7) showed that taking a flexed lumbar spine from an end-range of
flexion at 13 degrees to 11 degrees of flexion, a two-degree differential, resulted in a 50%
reduction in resistance to bending moment and therefore a 50% reduction in bending stress to the
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posterior annulus and intervertebral ligaments. Thus, both the location and degree of flexion will
have a significant impact on spinal kinetics.
Finally, although abdominal exercises create compressive forces by way of muscular
contraction, they also increase intra-abdominal pressure (IAP) (32). Three-dimensional
biomechanical models predict reductions in compressive forces of approximately 18% when IAP
is factored into spinal flexion efforts (120). Hence, IAP produced during spinal flexion exercise
may serve to moderate compressive forces, helping to unload the spine and facilitate fluid
absorption in the discs (97). Since in vitro research models to date have not incorporated IAP,
conclusions drawn may be limited with respect to the safety of spinal flexion exercises. It should
be noted, however, that the unloading effects of IAP may be diminished with high levels of
abdominal muscle co-activation (12). Additional research is needed to shed further light on this
topic with particular attention focused on evaluating the effects of IAP on compressive forces in
subjects performing spinal flexion exercise including the crunch.
It also should be noted that some epidemiological studies show an increased risk of spinal
injuries in athletes involved in sporting activities that require repeated spinal flexion. Injuries to
the spinal column, including disc degeneration and herniations, have been found to occur with
greater frequency in gymnasts, rowers, and football players (123; 121; 137; 145). Furthermore,
elite athletes suffer such injuries more frequently than non-elite athletes (121; 88). However, a
cause/effect relationship between spinal flexion and injury in these athletes has not been
established, and the ballistic nature of such sporting activities has little applicability to controlled
dynamic abdominal exercises.
Benefits of Spinal Flexion Exercises
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If dynamic flexion exercises in fact do not pose a significant injury risk in the absence of
spinal pathology, the natural question then is whether performing these movements confers
benefits over and above static-based exercises. The following potential benefits can be identified.
First, spinal motion has been shown to facilitate nutrient delivery to the intervertebral
discs (51; 50). The mechanism of action is theorized to be related to a pumping action that
augments transport and diffusion of molecules into discs. Motion causes more fluid to flow out
of the disc, which is reversed when the spine is unloaded (6). Fluid flow is better at transporting
large molecules, while diffusion is better at transporting smaller molecules (129). This has
particular significance for spinal tissue given that age-related decreases in disc nutritional status
is considered a primary cause of disc degeneration, leading to an accrual of cellular waste
products, degradation of matrix molecules, and a fall in pH levels that further compromise cell
function and possibly initiate apoptosis (52; 27; 71; 131).
Postures involving flexion of the spine are superior to neutral and extended postures in
terms of promoting increased fluid exchange in the disc, especially the nucleus pulposus (6). One
deficiency of neutral posture is that it favors diffusion in the anterior portion of the disc over the
posterior portion. Flexed postures reverse this imbalance by stretching the posterior annulus,
thereby decreasing the distance for nutrients to travel. The posterior region of the disc contains a
region that is deficient of nutrient supplement from all sources (69), and flexion reduces the
thickness of the posterior portion of the disc by 37% which ensures sufficient supply of glucose
to the entire posterior region of the disc (6). Flexion increases diffusion of small solutes and fluid
flow of large solutes. This is important considering that disc degeneration has been linked to
inadequate metabolite transport (51; 83), and that populations adopting flexed postures show less
incidence of disc disease (40). The crunch exercise produces tensile stresses on the posterior
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annulus in flexion the posterior annulus has been shown to extend up to 60% of its original
height (90), and tensile stress has shown to exert a protective effect on disc cells by decreasing
the expression of catabolic mediators during inflammation (107). By enhancing nutrient uptake
and limiting inflammatory-based catabolism, regimented flexion exercise may actually confer a
positive effect on long-term spinal health and promote disc healing in the periphery (9). In fact,
research suggests that spinal flexion and extension exercises can be valuable in reducing low
back pain (96; 38; 43). Although pain or lack of pain is not necessarily an indicator of spinal
health, it nevertheless is interesting to speculate that spinal flexion movements may actually
confer therapeutic benefits provided exercise does not exceed the adaptive capacity of the tissue.
In addition, spinal flexion exercises may help to improve functional spinal flexibility and
thereby reduce the onset of LBP. Multiple studies have found that a lack of sagittal plane spinal
flexibility is associated with an increased incidence of LBP (73; 89; 28; 37). Resistance exercise
has been shown to serve as an active form of flexibility training, helping to improve joint
mobility within a functional range of motion (14; 106; 80), and spinal flexion exercises have
been shown to increase sagittal plane spinal mobility (38). Improved flexibility associated with
resistance training has been attributed to increased connective tissue strength, increased muscular
strength, and improved motor learning and/or neuromuscular coordination (80). At the same
time, dynamic strengthening of the supporting musculature and ligamentous tissue may attenuate
spinal hypermobility in those afflicted, which also has been implicated as a cause of LBP (119).
Hence, a case can be made that a well-designed resistance training program that includes
dynamic spinal flexion may bestow a preventative effect against LBP. It should be noted,
however, that some studies have failed to reveal significant differences in sagittal plane spinal
flexibility between pain free subjects and those with LBP (94), and one study indicated that
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lumbar spinal flexibility is associated with disc degeneration (48). Moreover, we cannot
necessarily determine a cause/effect relationship between an increased risk of injury in those
with poor spinal flexibility. Further research is warranted to draw pertinent conclusions on the
topic.
Finally, flexion-based spinal movements help to optimize hypertrophy of the rectus
abdominis muscle. The crunch exercise and its variations have been shown to target the rectus
abdominis to a much greater extent than the other core muscles. McGill (76) found that a variant
of the crunch activated 50% of maximal voluntary contraction (MVC) of the rectus abdominis,
but only 20%, 10%, 10%, and 10% of MVC of the external obliques, internal obliques,
transverse abdominis, and psoas major, respectively. Given that a direct association has been
noted between muscle cross sectional area and muscle strength (72; 42), muscle hypertrophy has
specific relevance to athletes who require extensive core strength. Moreover, muscle hypertrophy
of the rectus abdominis also is integral to aesthetic appearance of the abdominal musculature and
is therefore highly desired by bodybuilders and other fitness enthusiasts.
The hypertrophic superiority of dynamic movement can be partly attributed to the
eccentric component, which has been shown to have the greatest effect on promoting muscle
development (41; 49, 53, 100). Eccentric exercise has been linked to a preferential recruitment of
fast-twitch muscle fibers (113, 122; 85) and perhaps recruitment of previously inactive motor
units (78; 84). Given that fast twitch fibers have the greatest growth potential, their recruitment
would necessarily contribute to greater increases in muscle cross sectional area.
Eccentric exercise also is associated with greater muscle damage, which has been shown
to mediate a hypertrophic response (78; 109). Muscle damage induced by eccentric exercise
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upregulates MyoD mRNA expression (57) and has been implicated in the release of various
growth factors that regulate satellite cell proliferation and differentiation (127; 138).
In addition, dynamic muscle actions have been shown to induce significantly greater
metabolic stress than static contractions (25). Specifically, the buildup of metabolites such as
lactate, hydrogen ion, and inorganic phosphate has been shown to mediate a hypertrophic
response (101; 110; 117), and some researchers have speculated that metabolic stress may be
more important than high force development in optimizing muscle development (114). The
stress-induced mechanisms theorized to increase muscle hypertrophy include alterations in
hormonal milieu, cell swelling, free radical production, and increased activity of growth-oriented
transcription factors (109). Russ (104) displayed that phosphorylation of Akt, a protein kinase
associated with mTOR pathway signaling and thus regulation of protein synthesis, is
significantly greater in eccentric contractions compared to isometric contractions. This may be
due to heightened metabolic stress, greater muscle damage, or a combination of both.
Practical Applications
Taking all factors into account, it would seem that dynamic flexion exercises provide a
favorable risk/reward ratio provided that trainees have no existing spinal injuries or associated
contraindications such as disc herniation, disc prolapse, and/or flexion intolerance. However,
several caveats need to be taken into consideration in order to maximize spinal health.
First and foremost, since hereditary factors have a tremendous impact on disc
degeneration, it is difficult to know the precise amount of volume, intensity, and frequency
sufficient to stimulate soft-tissue strengthening adaptations without exceeding the recovery
ability of the spine. It has been theorized that a "safe window" of tissue mechanical loading
exists that facilitates healthy maintenance of spinal discs (119). There is evidence supporting this
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theory as it pertains to spinal compression (146), however further research is needed to
determine whether this applies to other types of spinal loading including flexion.
An epidemiological study by Mundt et al. (82) found that participation in sports such as
baseball, softball, golf, swimming, diving, jogging, aerobics, racquet sports, and weight lifting
are not associated with increased risk of lumbar disc herniation, and they even may offer a
protective effect against herniation. Kelsey et al. (58) reported similar findings with respect to
disc prolapse. Many of these sports involve a high frequency of spinal motion including flexion,
which casts doubt on the theory that humans have a limited number of flexion cycles.
Unfortunately, there is no way to determine when an individual's training volume and/or
intensity falls outside this range and thus predispose the spine to localized overload injury.
Given that the spine and core musculature are loaded during non-machine based exercise
performance such as during squats, deadlifts, chin ups, and pushups, most training can be
considered "core training." It is therefore best to err on the side of caution and limit the amount
of lumbar flexion exercise in order to ensure that the tissue remains in "eustress" and doesn't
become "distressed." Based on current data, the authors recommend that a sound core
strengthening routine should not exceed approximately 60 repetitions of lumbar flexion cycles
per training session. Untrained individuals should begin with a substantially lower volume. A
conservative estimate would be to start with 2 sets of 15 repetitions and gradually build up
tolerance over time.
In addition, it is important to allow for sufficient rest between dynamic spinal flexion
sessions. The time course of post-exercise muscle protein synthesis lasts approximately 48 hours
(67). Training a muscle group before protein synthesis has completed its course can impair
muscle development (47) and potentially lead to localized overtraining. Thus, the notion that it is
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optimal to perform dynamic abdominal exercises on a daily basis is misguided. Since the
intervertebral discs are poorly vascularized with low levels of metabolite transport, their rate of
remodeling lags behind that of other skeletal tissues (69; 116), which may necessitate even
greater time for recuperation. Taking all factors into account, a minimum of 48 hours should be
afforded between dynamic spinal flexion exercise sessions, and it may be prudent to allow 72
hours or more depending on individual response.
Although some core training programs include ultra-high repetition sets of crunches, for
example multiple sets of a hundred repetitions or more, this type of protocol has little functional
applicability. After all, when does an individual need to continuously flex the spine in everyday
life? It is therefore recommended that flexion based spinal exercises be reserved for improving
strength and/or hypertrophy of the abdominal musculature as opposed to heightening muscular
endurance. A repetition range of approximately 6 to 15 repetitions is advised for achieving this
goal (109). External resistance should be employed when necessary to elicit an overload
response within this target repetition range. Those seeking improvements in local muscular
endurance would be best served by performing static, neutral posture exercises that are held for
extended periods of time. Specific guidelines will vary dramatically according to the individual’s
needs and abilities, but a general recommendation for untrained individuals would be to perform
3-4 sets of 10-15 seconds holds in multiple planes. Advanced exercisers seeking increases in
static endurance might perform 3-4 sets of 60 seconds or more in multiple planes, whereas
advanced exercisers seeking increases in static power could stick to the 10-15 second holds but
perform more challenging variations or increase external resistance in order to promote further
adaptation. Athletes who engage in sports where spinal flexion exercise or other inherently
dangerous motions for the discs such as spinal rotation is prominent and volumes of flexion
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cycles and training frequencies above our recommendations are exceeded should consider the
possibility of excluding spinal flexion exercise from their routines.
Exercise tempo is another important consideration. Several studies have shown that
repetitions performed at a speed of one-second elicit greater muscle activation than those
performed more slowly (135), and faster repetitions may selectively recruit the rectus abdominis
(Norris, 2001). Given the principle of specificity, rapid speeds of movement also would tend to
have greater transfer to athletic activities that require dynamic core power such as wrestling
(Iwai et al. 2008), throwing a baseball (56), tennis (33), gymnastics (91), soccer (126),
swimming (68), and track and field (46). However, an increased repetition speed could subject
the spinal tissues to excessive forces that may lead to injury (7; 86). For non-athletic populations,
the risks of faster repetitions would appear to outweigh the potential rewards and thus a slightly
slower tempo of approximately two seconds may be more appropriate with respect to
maintaining spinal health. As for athletic populations, more research is needed to show whether
explosive dynamic core exercises lead to positive adaptations that strengthen tissues and prevent
injury, or whether they subject the athlete to greater risk of injury by adding more stress to the
tissues.
It also is important to consider the effects of diurnal variation on spinal kinetics. During
sleep, loading on the discs is reduced, allowing them to absorb more fluid and increase in volume
(130). Fluid is then expelled throughout the day as normal daily spinal loading ensues. In the
early morning, intradiscal pressure is 240% higher than prior to going to bed (141), and bending
stresses are increased at the discs by 300% and at the ligaments of the neural arch by 80% due to
hydration and absence of creep (2). As the day goes on, discs bulge more, become stiffer in
compression, become more elastic and flexible in bending, affinity for water increases, and the
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risk of disc prolapse decreases (3). After just 30 minutes of waking, discs lose 54% of the loss of
daily disc height and water content and 90% within the first hour (95). For this reason, spinal
flexion exercises should be avoided within at least 1 hour of rising. To be conservative, athletes
may want to allow a minimum of 2 hours or more before engaging in exercises that involve
spinal flexion.
There is some evidence that spinal flexion exercises should also be avoided following
prolonged sitting. It has been shown that discs actually gain height after sitting (11; 61) and
decrease lumbar ROM (31), which reduces slack in the flexion-resisting structures including
ligaments and the posterior annulus while increasing the risk of injury to those structures (2; 18).
However, as noted by Beach et al. (18), individual differences in sitting posture lead to large
variations in tissue response. Some individuals actually gain lumbar ROM from sitting which can
also increase the risk of injury due to viscoelastic creep (75), stress-relaxation (4), or fluid loss
(6), which increases joint laxity (2). Considering that approximately 50% of stiffness is regained
within 2 minutes of rising after 20 minutes of full flexion (75), it seems prudent to allow at least
several minutes to elapse, perhaps 5 or more, before engaging in spinal flexion exercises
following a period of prolonged sitting, and to walk around to facilitate dehydration of the disc.
Conclusion
Based on current research, it is premature to conclude that the human spine has a limited
number of bending cycles. The claim that dynamic flexion exercises are injurious to the spine in
otherwise healthy individuals remains highly speculative and is based largely on extrapolation of
in vitro animal data that is of questionable relevance to in vivo human spinal biomechanics.
While it appears that a large number of continuous bending cycles may ultimately have a
detrimental effect on spinal tissues, no evidence exists that a low volume, strength-based
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exercise routine that includes dynamic spinal flexion movements will hasten the onset of disc
degeneration, and a case can be made that such exercises may in fact produce a beneficial effect
in terms of disc health. Contraindications for spinal flexion movements would only seem
applicable with respect to those with existing spinal pathology such as disc herniation/prolapse
or flexion intolerance.
To date, the authors are not aware of any study that has investigated the effects of spinal
flexion exercise on human spines in vivo. Further research is needed to evaluate both the acute
and chronic effects of dynamic spinal flexion exercises in human subjects in vivo so that more
definitive conclusions can be drawn on the topic. This research should include magnetic
resonance imaging of intervertebral discs to assess disc health preceding and following human
spinal flexion protocols of varying loads, repetitions, tempos, and ranges of motion. Hopefully
this paper will serve to spark new research in this area.
With respect to program design, basic core strength and endurance will be realized
through performance of most non-machine based exercises such as squats, rows, deadlifts, and
push-ups. That said, targeted core exercises may serve to enhance sports performance, functional
capacity, and physique aesthetics. Consistent with the principle of specificity, core program
design should take into account the individual goals and abilities of the exerciser with respect to
their need for muscular hypertrophy, power, strength, and/or endurance, and the types of joint
actions involved in their sport. A variety of abdominal exercises are necessary to sufficiently
work the abdominal musculature and these exercises will differ based on training objectives (13).
Variety in spinal loading is associated with lower risk of spinal pathology (136). A balanced,
multi-planar approach to core training that incorporates a combination of isometric and dynamic
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19
exercises is warranted to prevent any particular spinal segment from accentuated stress and to
ensure proper spine stabilizing biomechanics.
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... In particularly, repeated or prolonged back flexion may be associated with back pain and related risk of injuries (McGill, 2010). A large number of continuous bending cycles may have a detrimental effect on spinal tissues (Contreras and Schoenfeld, 2011). Intradiscal pressure is highest in flexion and lowest in lateral bending (Schmidt et al., 2007). ...
... However, there is no effect of non-machine-based resistance and cardiovascular exercises on trunk muscle morphology (Shahtahmassebi et al., 2014). Core strengthening and stabilization exercises may be also beneficial for disc health (Contreras and Schoenfeld, 2011). There is no evidence that a low volume, strength-based exercise routine that includes dynamic spinal flexion movements hasten the onset of disc degeneration (Contreras and Schoenfeld, 2011). ...
... Core strengthening and stabilization exercises may be also beneficial for disc health (Contreras and Schoenfeld, 2011). There is no evidence that a low volume, strength-based exercise routine that includes dynamic spinal flexion movements hasten the onset of disc degeneration (Contreras and Schoenfeld, 2011). Maintaining proper posture and providing correct exercise techniques may help to prevent exacerbation of back problems. ...
Article
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While force-velocity-power characteristics of resistance exercises, such as bench presses and squats, have been well documented, little attention has been paid to load, force, and power-velocity relationships in exercises engaging core muscles. Given that power produced during lifting tasks or trunk rotations plays an important role in most sport-specific and daily life activities, its measurement should represent an important part of the test battery in both athletes and the general population. The aim of this scoping review was 1) to map the literature related to testing methods assessing core muscle strength and stability in sport and rehabilitation, chiefly studies with particular focus on force-velocity-power characteristics of exercises involving the use of core muscles, 2) and to identify gaps in existing studies and suggest further research in this field. The literature search was conducted on Cochrane Library databases, Scopus, Web of Science, PubMed and MEDLINE, which was completed by SpringerLink, Google Scholar and Elsevier. The inclusion criteria were met in 37 articles. Results revealed that among a variety of studies investigating the core stability and core strength in sport and rehabilitation, only few of them analyzed force–velocity–power characteristics of exercises involving the use of core muscles. Most of them evaluated maximal isometric strength of the core and its endurance. However, there are some studies that assessed muscle power during lifting tasks at different loads performed either with free weights or using the Smith machine. Similarly, power and velocity were assessed during trunk rotations performed with different weights when standing or sitting. Nevertheless, there is still scant research investigating the power-velocity and force-velocity relationship during exercises engaging core muscles in able-bodied and para athletes with different demands on stability and strength of the core. Therefore, more research is needed to address this gap in the literature and aim research at assessing strength and power-related measures within cross-sectional and intervention studies. A better understanding of the power-force-velocity profiles during exercises with high demands on the core musculature has implications for designing sport training and rehabilitation programs for enhancement of athletes’ performance and/or decrease their risk of back pain.
... These ideas were in part developed from in vitro studies on porcine spines examining the effect repeated spinal flexionextension has on disc herniation (Callaghan & McGill, 2001). However, the translation of these laboratory findings into human models has been criticized (Contreras & Schoenfeld, 2011). ...
Thesis
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Introduction: Exercises designed to improve the function of the core are a centerpiece of many athletic training programs. Current core stability (CS) ideology, testing protocols, and training methods originated from research into low back pain, yet are commonly applied within the sports performance domain. CS is a controversial concept with significant debate around how effective core stability training (CST) is for athletic populations. The majority of CS exercises and assessments currently emphasize muscular endurance. This exclusive focus may not be appropriate when training or monitoring athletes involved in dynamic sporting activities. To improve our understanding on this topic, the goal of this thesis is to investigate current perspectives and viewpoints, relating to CS and CST, held by practitioners in the sports performance domain. Methods: An online questionnaire and semi-structured interview were performed to gather subjective data from industry experts and professionals working with athletes. Both studies were designed to understand current thoughts and opinions around three key themes; current understanding of CS, how CS is being monitored in practice, and how practitioners are training CS. Results: The online questionnaire was completed by 64 respondents, while 10 industry experts were interviewed. There was a lack of a universal language amongst industry professionals when describing CS and many differing opinions related to key CS concepts. An important finding was that very few practitioners are objectively assessing the core, with little consideration given to monitoring maximal core strength. It was found that nearly all participants implement direct CS exercises, however, opinions on how to best train the core varied significantly. The results of this thesis demonstrate wide ranging viewpoints and opinions related to CS and CST amongst industry professionals, despite over 30 years of related research. Discussion and Practical Implications: The findings from this thesis highlight the extent of divided industry perspectives. Specifically, five key areas were identified to improve our understanding in this area. The alignment of terminology and the development of an evidence-based CST framework are needed to streamline coaching practice. Maximal core strength is an underappreciated area and research exploring its relationship to athletic performance is desperately needed. Moreover, the development of cheap field tests to assess this quality are needed. Finally, longer term intervention studies are also required to substantiate the effectiveness of CS programs. Key Words: Core Stability, Core Stability Training, Trunk, Lumbopelvic Control
... Para finalizar el segundo nivel de dificultad de los ejercicios de fuerza, el press Pallof fue el ejercicio seleccionado para trabajar el CORE ya que integra un componente antirrotacional, una gran transferencia al juego real y una buena activación de la musculatura oblicua al tener que resistir una fuerza rotación, incrementada cuando los brazos se extienden frente al cuerpo (Contreras & Schoenfeld, 2011;Gottschall, Mills & Hastings, 2013). Se realizaron 2 series de 15 repeticiones por cada lado. ...
Article
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El fútbol es un deporte altamente lesivo debido a diversos factores. La lesión disminuye el rendimiento no solo del jugador sino también del equipo, lo que crea la necesidad de establecer programas preventivos para paliar, en la medida de lo posible, la tasa lesional. El objetivo del presente estudio fue diseñar un programa preventivo contextualizado y analizar la reducción lesional derivada de su implementación en jóvenes futbolistas. La muestra estuvo compuesta por 20 futbolistas de la categoría juvenil del Fútbol Club Cartagena, con una media de 6 horas de entrenamiento semanal. Tras una breve valoración inicial, llevaron a cabo un nuevo protocolo de prevención con diferentes ejercicios agrupados en 2 niveles de dificultad. Se realizó un análisis descriptivo de cada una de las variables cuantitativas. Los resultados muestran una disminución del 65% del número total lesiones, entre temporadas, y en gran medida de las graves. La tasa de reducción lesiva obtenida está por encima de diferentes estudios que analizan la eficacia en diversos programas preventivos. Un programa de entrenamiento preventivo basado en la contextualización de los participantes ha resultado en una reducción de la tasa lesiva. Los entrenadores y profesionales del deporte disponen de una herramienta para disminuir el riesgo de lesión.
... El «crujido» llamado en ocasiones «ovillo» (curl-up) (enderezamiento parcial), realizado en decúbito dorsal con las rodillas flexionadas y que consiste en enderezar el tórax de forma dinámica hasta el ángulo inferior del omoplato (con una posible rotación del tronco), sin controlar específicamente la columna lumbar, forma parte de los ejercicios más conocidos para reforzar los músculos abdominales. Sin embargo, no existe un acuerdo común debido a los problemas que origina en el disco intervertebral y en el piso pélvico [62] . Por este motivo, algunos médicos prefieren los crujidos modificados [53] o «abdominales hipopresivos», que requieren más específicamente la participación del transverso abdominal y se realizan sin flexión lumbar. ...
Article
Resumen El tratamiento conservador del paciente con lumbalgia crónica inespecífica debe ser multifactorial. Además del tratamiento de los factores psicosociales, el tratamiento activo se recomienda de manera unánime. Además de las actividades de tipo aeróbico que suelen ofrecerse a estos pacientes, el tratamiento incluye con frecuencia ejercicios de fuerza o resistencia de los músculos del tronco (a veces mediante electroestimulación neuromuscular o aparatos médicos sofisticados que solicitan de forma específica los músculos espinales) y estiramientos (esencialmente de la musculatura espinal) y/o ejercicios de control sensitivomotor. Los ejercicios terapéuticos de tipo Pilates, que incluyen varios componentes, como ejercicios de control sensitivomotor y estiramientos, también parecen utilizarse con frecuencia. La elección y las modalidades de estas técnicas/ejercicios deben ser individualizadas para tener en cuenta las capacidades, necesidades y preferencias del paciente. En efecto, en la actualidad, ningún ejercicio específico parece ser más eficaz que otros. El propósito de este artículo es describir estas técnicas/enfoques para la lumbalgia crónica y sus beneficios basados en la evidencia científica.
... The maximal number of correctly performed SUs in 30 seconds was recorded. Sit-ups, which are also part of the Eurofit test battery, are a widely used measurement of abdominal/core endurance (Tomkinson et al., 2018) and are safe to perform by children and adolescents (Contreras & Schoenfeld, 2011). ...
Article
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Introduction: Recent research data show a significant decline in youth's muscle strength. Purpose: The purpose of the present study was to assess the efficacy of a suspension training intervention during physical education (PE) lessons on strength parameters in adolescents, compared with a control group. Methods: The sample of the study included 321 adolescents (158 boys and 163 girls, M age = 16.54, SD = .91). The intervention group followed a suspension training program twice a week for a total of eight weeks during the PE lesson, while the control group attended the regular PE class throughout the intervention. A pre-intervention, a post-intervention and a detraining test were conducted. Field tests that measure muscle strength and endurance were used to assess lower body, core, upper body and handgrip strength (standing long jump, sit-up, push-up, handgrip). A two-way (2 groups X 3 measurements) analysis of variance (ANOVA) was used to test the efficacy of the intervention. Results: The results showed that students in the intervention group improved performance significantly from pre-to post-intervention in all tests compared to control participants. Regarding retention, the performance of the students in the intervention group, although decreased, remained significantly higher than that of the participants in the control group. Conclusions: These results suggest that suspension training is an effective and feasible resistance training method that can be integrated in PE lessons. Furthermore, due to the promptly observed improvements in strength, the suspension training program could lead to an increase in motivation to participate in the PE lesson and consequently, integrating strength training into the PE lesson throughout the school year could increase the academic learning time.
... The situps test demonstrates high test-retest reliability and low validity (Plowman, 2014) with such low validity coefficients thought to be partially due to the lack of appropriate criterion measures for abdominal/core endurance (Plowman, 2014). Sit-up tests are safe to perform by children and adolescents with no evidence of adverse events (Contreras & Schoenfeld, 2011). ...
Article
We estimated international/national temporal trends in sit-ups performance for children and adolescents, and examined relationships between national trends in sit-ups performance and national trends in health-related/sociodemographic indicators. Data were obtained by systematically searching studies reporting on temporal trends in sit-ups performance for apparently healthy 9–17 year-olds, and by examining nationally representative fitness datasets. Trends at the country-sex-age level were estimated by sample-weighted regression models relating the testing year to mean sit-ups performance. International/national trends were estimated by a post-stratified population-weighting procedure. Pearson’s correlations quantified relationships between national trends in sit-ups performance and national trends in health-related/sociodemographic indicators. A total of 9,939,289 children and adolescents from 31 countries/special administrative regions between 1964 and 2017 collectively showed a large improvement of 38.4% (95% CI: 36.8 to 40.0) or 7.1% per decade (95% CI: 6.8 to 7.4). Large international improvements were experienced by all age and sex groups, with the rate of improvement slowing from 1964 to 2000, stabilizing near zero until 2010, before declining. Trends differed between countries, with national trends in vigorous physical activity a strong, positive correlate of national trends in sit-ups performance. More sit-ups data are needed from low- and middle-income countries to better monitor trends in muscular fitness. PROSPERO registration number CRD42013003657.
... It is important to note that some researchers would argue there is an alternative hypothesis to explain why current training interventions have been ineffective: Spine flexion does not lead to negative outcomes for those without a history of back pain/injury [54]. Some call for an end to movement-based training that targets reductions in spine flexion [55,56]. ...
Article
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Background: Patient handling activities require caregivers to adopt postures that increase the risk of back injury. Training programs relying primarily on didactic methods have been shown to be ineffective in reducing this risk. The use of real-time biofeedback has potential as an alternative training method. Objective: To investigate the effect of real-time biofeedback on time spent by caregivers in end-range lumbar spine flexion. Methods: Novice participants were divided into intervention (n = 10) and control (n = 10) groups and asked to perform a set of simulated care activities eight times on two consecutive days. Individuals in the intervention group watched a training video on safer movement strategies and received real-time auditory feedback from a wearable device (PostureCoach) in four training trials whenever their lumbar spine flexion exceeded a threshold (70% of maximum flexion). Changes in end-range lumbar spine flexion were compared between groups and across trials. Results: Participants in the intervention group saw reductions in end-range lumbar spine flexion during the simulated patient handling tasks at the end of the training compared to their baseline trials while there was no change for the control group. Conclusions: The training program including PostureCoach has the potential to help caregivers learn to use safer postures that reduce the risk of back injury.
Article
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Low back pain may have different causes and one of the cause is anterolisthesis. Anterolisthesis is the anteriorly slippage of a vertebrae onto its caudal one. Its Grading is done using mayerding classification system on a plain radiograph in oblique view. Grade I is identified less than the 25% of slippage, in grade II its 25 to 50%, grade III of 51 to 75%, and grade IV having 76 to 100% of slippage. Sometimes it may be symptomatic as well as asymptomatic; pattern of pain is usually localized and/or referred to the dermatome of slipped vertebrae. Non-operative management is preferred as long as failure of non-operative management and neurological deficit. Case Summary: we presented the case of traumatic anterolisthesis of grade I with the preexisting idiopathic scoliosis. Cases with other conditions have been reported before like spondolysis but not with scoliosis. Case was diagnosed with plain radiography as well as physical examination. The condition was managed with physical therapy. Conclusion: Grade I anterolisthesis can be manageable with non-operative methods such as physical therapy. Cryotherapy is found to provide maximum relive of inflammation based pain than thermotherapy. Early diagnosis and treatment is beneficial to rescue patient from state of kinesophobia.
Article
Riassunto Il trattamento conservativo del paziente affetto da lombalgia cronica non specifica deve essere multifattoriale. Accanto alla gestione dei fattori psicosociali, è unanimemente raccomandata una gestione attiva. Oltre alle attività di tipo aerobico spesso proposte a questi pazienti, il trattamento prevede spesso l⬢uso di esercizi di forza o di resistenza dei muscoli del tronco (a volte, mediante elettrostimolazione neuromuscolare o sofisticati dispositivi medici che solleciterebbero più specificamente i muscoli spinali) e stretching (essenzialmente della muscolatura spinale) e/o esercizi di controllo sensorimotorio. Anche gli esercizi terapeutici tipo Pilates, che includono diverse componenti, tra cui esercizi di controllo sensorimotorio e di stretching, sembrano essere usati frequentemente. La scelta e le modalità di queste tecniche/esercizi devono essere individualizzate per tenere conto delle capacità, dei bisogni e delle preferenze dei pazienti. In effetti, al momento, nessun esercizio specifico sembra essere più efficace di altri. Questo articolo mira a descrivere queste tecniche/approcci per la lombalgia cronica e i loro benefici sulla base di prove scientifiche.
Book
Low back pain (LBP) is a very common health problem worldwide and one of the major causes of disability that affect work performances. The prevalence of LBP among women is alarmingly high due to hormonal and reproductive factors such as irregular or prolonged menstrual cycle and hysterectomy. It is commonly believed that exercise plays an important role in the treatment of LBP. The most important types of exercise for preventing LBP are exercises for abdominal muscles, gluteal muscles, and multifidus muscles. The female subjects examined in this study underwent a five-week training intervention programme. The stabilisation training programme examined in this study is effective in improving the muscle activations of the subjects. The results of the current study are expected to be useful for the rehabilitation experts in determining the best training exercise programme for females suffering from LBP.
Article
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Using data from 16 published reports, the authors correlated macroscopic disc degeneration grades with age, sex, and spine level In 600 lumbar Intervertebral discs from 273 cadavers (ages: 0-96 years). Male discs were more degenerated than female discs at most ages; significantly so In the second, fifth, sixth, and seventh decades. On average, L4-L5 and L3-L4 level discs showed more degeneration than discs at other lumbar levels. These macroscopic findings corroborate radio-graphic data from epldemlologlc studies. The calculations suggest that higher mechanical stress, perhaps combined with longer nutritional pathways, may be responsible for the earlier degeneration of male discs.
Article
The thoracolumbar spine was examined by magnetic resonance imaging (MRI) and the history of back pain was analyzed in 24 male elite gymnasts (age range, 19-29 years) and in 16 male nonathletes (age range, 23-36 years). Disc degeneration, defined as reduced disc signal intensity, was significantly more common in athletes (75%) than in nonathletes (31%). The gymnasts also had a higher incidence of other abnormalities of the thoracolumbar spine, and there was a significant correlation between reduced disc signal intensity and the other abnormalities among the gymnasts. There were also significant correlations between back pain and reduced disc signal intensity and abnormal vertebral configuration when the gymnasts and the nonathletes were pooled. Male elite gymnasts run a high risk of developing severe abnormalities of the thoracolumbar spine, and they often have a history of back pain.
Article
The collagen content, proportion of Types I and II collagen, and the relative concentrations of the reducible crosslinks of human lumbar intervertebral discs have been found to vary with age and location and to be highly dependent on the topography of the tissue. From adolescence to mature adulthood, the most significant change is an increase in the content of Type I collagen at the expense of genetically distinct Type II collagen in the outer lamella of the posterior quadrant, while just the reverse is true of the anterior quadrant. These changes are accompanied by similar but smaller alterations in the total collagen content and in the crosslink hydroxylysinohydroxynorleucine. The same differences in the distribution of Types I and II collagens occur in the annull on the concave and convex sides of scollotic curves. Together, these data establish that active cellular activity and tissue remodelling occur in the annull fibrosl and suggest that these specific changes are initiated in response to overall increases in compressive loading on the concave side and tensile loading on the convex side of the spine and the subsequent changes they induce in the magnitude and distribution of internal stresses within the annull. In its most general formulation, the biological behavior of annull fibrosl to mechanical forces appears to follow Wolff's Law.
Article
Study design: This study investigated the influence of five different muscle groups on the monosegmental motion (L4-L5) during pure flexion/extension, lateral bending, and axial rotation moments. Objectives. The results showed and compared the effect of different muscle groups acting in different directions on the stability of a single motion segment to find loading conditions of in vitro experiments that simulate more physiologically reasonable loads. Summary of Background Data. In spine biomechanics research, most in vitro experiments have been carried out without applying muscle forces, even though these forces stabilize the spinal column in vivo. Methods. Seven human lumbosacral spines were tested in a spine tester that allows simulation of up to five symmetrical muscle forces. Changing pure flexion/extention, lateral binding, and axial rotation moments up to +/-3.75 Nm were applied without muscle forces, with different muscle groups and combinations. The three-dimensional monosegmental motion was determined using an instrumented spatial linkage system. Results. Simulated muscle forces were found to strongly influence load-deformation characteristics. Muscle action generally increased the range of motion and the natural zone of the motion segments. This was most evident for flexion and extension. After five pairs of symmetrical, constant muscle forces were applied (80 N per pair) the range of motion decreased about 93% in flexion and 85% in extension. The total natural zone for flexion and extension was decreased by 83% muscle action. The multifluids muscle group had the strongest influence. Conclusion. This experiment showed the important of including at least some of the most important muscle groups in invitro experiments in lumbar spine specimens.
Article
In order to study the type and number of CAT scan abnormalities of the lumbar spine that occur in asymptomatic people, 52 studies from a control population with no history of back trouble were mixed randomly with six scans from patients with surgically proven spinal disease, and all were interpreted by three neuroradiologists in a blinded fashion. Irrespective of age, 35.4% (26.6%, 51.0%, and 31.3%) were found to be abnormal. Spinal disease was identified in an average of 19.5% (23.8%, 22.7%, and 12.5%) of the under 40-year-olds, and it was a herniated nucleus pulposus in every instance. In the over 40-year-old age group, there was an average of 50% (29.2%, 81.5%, and 48.1%) abnormal findings, with diagnoses of herniated disc, facet degeneration, and stenosis occurring most frequently.