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LITHUANIAN SPORTS UNIVERSITY FACULTY OF SPORT EDUCATION PHYSIOTHERAPY STUDY PROGRAMME
PHYSICAL THERAPY STUDY PROGRAM
SANTOSH KUMAR
RELATIONSHIP BETWEEN SPORTS INJURIES, ENDURANCE OF TRUNK MUSCLES AND DYNAMIC BALANCE IN DIFFERENT TEAM SPORTS PLAYERS
FINAL MASTER’S THESIS
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. Supervisor: Assoc.Prof.Dr.Vilma Dudoniene
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KAUNAS 2017
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TABLE OF CONTENTS ABBREVIATION ABSTRACT………………………………………………………………………….….………5 SANTRAUKA………………………………… …………………………………….…….…...7 INTRODUCTION…………………………………………………………………….…...…....8 1. LITERATURE REVIEW 1.1.
……………………………………………………..………...10
Prevalence of sports injuries……………….……….….………………...........….10 1.1.1
Prevalence of sports injuries in ice hockey ………………...............….....14
1.1.2
Prevalence of sports injuries in field hockey …………….………...…….14
1.1.3
Prevalence of sports injuries handball………………….…….….….….…15
1.2.
Relationship between core stability and dynamic stability…………….……..…..16
1.3.
Relationship between core stability and leg injuries ………..........................…...18
1.4.
Core strengthening program ………………………………………………...……20
2. RESEARCH METHODOLOGY ……………………………………..……………….….22 2.1
Participants………………………………………..………………………22
2.2
Methods ……………………………………………………………..……22
2.3
Organization of research ……………………...………………...........…..26
3. RESEARCH RESULTS………………………………………………...………….……….27 4. DISCUSSION…………………………………………………………..……………………36 CONCLUSIONS…………………………………………………………………………...…..38 ACKNOWELEDGMENT …………………………………………………………...……….39 REFERENCE ………………………………………………………………….……...……....40 ANNEX…………………………………………………………………… ……...………...….48
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ABBREVIATION
TEEP -Trunk extensor endurance exercise protocol. TEME- Trunk extensor muscle endurance. IHF - International Handball Federation. TFT- Trunk flexion test. sEMG - Surface electromyography. SEBT- Star Excursion Balance Test. ADIM -Abdominal drawing in manoeuvres. TrA -Transversus abdominis. MTJ - My tendinous junction. CECS - Chronic exertional compartment syndrome. DOMS - Delayed-onset muscle soreness. FOV-Field of view. MTJ-My tendinous junction. PTMO - Posttraumatic myositis ossificans. CSEs -Core stability exercises. NSLBP-Nonspecific mechanical low back pain. SBT- Side bridge test. UQYBT- Upper Quarter Y-Balance Test. UE- Upper extremity. CKC- Closed kinetic chain.
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RELATIONSHIP BETWEEN SPORT INJURIES, ENDURANCE OF TRUNK MUSCLES, AND DYNAMIC BALANCE IN DIFFERENT TEAM SPORT PLAYERS ABSTRACT Keyword: sports injuries, endurance of trunk muscles, dynamic balance. Research object: Effect of Prevalence of Sports Injuries on endurance of trunk muscles and dynamic balance in different team sports players. Research problem: Do strong trunk muscles and good dynamic balance prevent injuries in different team sports players? Study subjects: 61 Male and Women Field hockey, Ice hockey and Handball Players from Lithuania. Aim: To determine difference between different sports team of trunk muscle endurance and dynamic balance. Hypothesis: We think that players who have weak trunk muscles and dynamic balance should have risk of injury. Objectives of the research: 1. To measure endurance of trunk muscles and compare in different sports players. 2. To determine dynamic balance and compare in different sports players. 3. To find correlation between outcome measurements. Method of the Research: This study took 61 male and women field hockey, ice hockey and handball players from Lithuania two methods to measure endurance of trunk muscle (according to McGill, 2007) and to evaluate dynamic balance with Y balance test. Players performed all the routines on four separate days. All the subjects performed were measured and to compare data of man and women handball, ice hockey and field hockey players. Conclusion: 1.
Endurance of back muscle in men field hockey players was significant better to ice hockey players. Endurance of abdominal muscles in women field hockey was significant better to compare men ice hockey and men field hockey.
2.
In Dynamic balance composite score in right and left leg of all players had fewer chances of injuries found. In upper quarter only right hand of man ice hockey had less chance of injuries.
3.
The correlation result found between man and women players groups. There wear men ice hockey players had stronger muscle power than men field hockey players and in women handball players were stronger muscle power compare to women field hockey players.
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SKIRTINGŲ RAUMENŲ TEMPIMO TECHNIKŲ ĮTAKA, FUTBOLO MĖGĖJŲ, PUSGYSLINIO RAUMENS LANKSTUMUI SANTRAUKA Raktiniai žodžiai: sporto traumų, liemens raumenų ištvermę, dinamišką pusiausvyrą. Tyrimo objektas: Poveikis paplitimas sporto traumų ant liemens raumenų ištvermę ir dinamišką pusiausvyrą įvairiose komandos sporto žaidėjų. Tyrimo problema: Ar stiprūs liemens raumenų ir geras dinaminis balansas išvengti traumų skirtingose komandinių sporto šakų žaidėjų? Studijų dalykai: 61 vyrų ir moterų riedulio, Ledo ritulio ir rankininkai iš Lietuvos. Tikslas: Norėdami nustatyti skirtumą tarp skirtingų sporto komanda liemens raumenų ištvermės ir dinamišką pusiausvyrą. Hipotezė: Mes turime galvoti, kad žaidėjai, kurie Silpnas liemens raumenų ir dinamiška pusiausvyra turėtų būti sužeidimo riziką. Tyrimo uždaviniai: 1. Siekiant išmatuoti liemens raumenų ištvermę ir palyginkite skirtingų sporto žaidėjų. 2. Norėdami nustatyti dinaminį balansą ir palyginkite skirtingų sporto žaidėjų. 3. Norėdami sužinoti koreliaciją tarp rezultatų matavimus. Metodas tyrimų: Šis tyrimas užtruko 61 vyrų ir moterų riedulio, ledo ritulį ir rankinį žaidėjų iš Lietuvos du metodus matuoti ištvermę liemens raumenų (pagal McGill, 2007) ir įvertinti dinamišką pusiausvyrą su Y balanso testą. Žaidėjai atliekamas visas kasdienybe keturiais atskirais dienų. Visi tiriamieji atliko buvo matuojamas ir palyginti duomenis vyro ir moterų rankinio, ledo ritulio ir lauko ledo ritulininkų Išvada: 1. Ištvermės nugaros raumenų vyrai Žolės riedulio žaidėjų buvo geriau Reikšmingi ledo ritulininkų. Ištvermės pilvo raumenų moterys Žolės riedulio buvo geriau palyginti vyrams Reikšmingas ledo ritulį, Žolės riedulio ir vyrų. 2. Be dinaminės pusiausvyros sudėtinio partitūros kairę ir į dešinę nuo iš žaidėjų kojos apačioje buvo mažiau galimybių Traumos nerasta. Viršutiniame dešiniajame ketvirtyje Man tik ledo ritulio turėjo mažiau galimybių susižeisti. 3. Rasti koreliaciją tarp vyro ir tenisininkes grupių rezultatai. Ten vyrai dėvi ledo ritulio žaidėjai turėjo stipresnį raumenų jėgą nei vyrai Žolės riedulio grotuvas ir moterų rankinio žaidėjai buvo stipresni raumenų galia, palyginti su moterų riedulio žaidėjų.
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INTRODUCTION
To determine the intra-tester reliability of clinical measurements those assess five components related to core stability: strength, endurance, flexibility, motor control, and function. Historically, the term “core stability” did not become popular until the 21st century, with the idea developing from the study of spinal stability by individuals, such as Manorah Panjabi. Panjabi was the first to introduce the three physio- logical subsystems responsible for stabilization: passive, active, and neural control. Although lack of core stability has been associated with low back pain and athletic injuries, defining and measuring core stability remains difficult (Waldhelm et al., 2012). Knowledge of load distribution among passive and active components of the human trunk during various occupational and athletic activities is essential both to assess risk of injury and to improve effective prevention, treatment, and rehabilitation of spinal disorders (Arjmand et at., 2006). An athlete often presents to the rehabilitation specialist with either a nonspecific referral, such as “hip pain,” or with a diagnosis of a more specific hip pathology. The highly skilled clinician is trained to look at the “linkage” between the trunk and all parts of the lower extremity (Tyler et al., 2010). The study of the endurance of low back muscles is important to our understanding of how best to manage low back pain. Biering-Sorensenl demonstrated that the time a subject can maintain a horizontal, unsup- ported posture (a measure of mechanical capability and willingness) is a predictor for first-time occurrence of low back pain in men. This test is now known as the Sorensen Test (Larry et al., 1993). A recent focus has been placed on back muscle endurance and its relationship to LBP. Knowledge of the relationship between LBP and isometric back endurance is sparse and somewhat conflicting (Moreau et al., 2001). The muscles of the core help control movements, transfer energy, shift body weight and distribute the stresses of weight-bearing. Balance is the ability to maintain the Canter of Gravity (COG) of a body within the base of support with minimal postural sway. Maintaining balance is coordinated by three systems. The first input is from the vestibular system. The second balance coordinator is the proprioceptive system originating from somatosensory receptors in muscles, tendons, and joints for kinaesthetic sense, body posture and spatial awareness. Finally, the visual system which sends visual signals about bodies position (Amirhossein et al., 2013). Adequate trunk muscle may play an important role in injury free performance among athletes. It has also been also suggested that sufficient trunk muscle endurance contribute to spinal stability over strenuous and prolonged physical task (Kerrie et al., 2007). Risk factors are traditionally divided into two main categories: internal (or intrinsic) athlete related risk factors and external (or extrinsic) environmental risk factors (Bahr et al., 7
2003). Sports participation also entails a considerable risk of injury for elite, as well as recreational, athletes (Bahr et al., 2005). Sports injuries were graded into four categories of severity mild (absence from practice less than 1 week), moderate (absence between 1 and 2 weeks), serious (absence between 2 and 4 weeks), and severe (absence of more than 4 weeks), (Romain et al., 1998). Athletes perform warm-up before any physical activity in the belief that it enhances performance and reduces the risk of injury (Young & Elliott, 2001). There are lots of other benefits that can be achieved through warm-up, for example, increasing range of motion, delaying muscle fatigue, reducing and preventing delayed onset of muscle soreness, improving maximal muscle contraction, increasing the muscle and connective tissue temperature (Alter, 2004).Muscular endurance is the ability of an isolated muscle group to perform repeated contractions over a period of time, assuming the intensity of the activity is moderate. Back extensors are responsible for proper posture of the spine, maintaining the back in a position of lordosis, controlling the rate and magnitude of flexion and attenuating ground reaction forces (Babatunde et al., 2007). Hypothesis: We think that players who have weak trunk muscles and dynamic balance should have risk of injury. Objectives of the research: 1. To measure endurance of trunk muscles and compare in different sports players. 2. To determine dynamic balance and compare in different sports players. 3. To find correlation between outcome measurements.
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1. LITERATURE REVIEW 1.1. Prevalence of sports injuries In recent years, more focus has been given to sport-related injuries, particularly in lower extremities, which can be attributed to the types of movement, frequency of participation, and intensity of the sports. According to the National Collegiate Athletic Association (NCAA), injury surveillance data for women's basketball indicated the most common sports-related injuries were to the lower extremities. Specifically, more than 60% of all game and practice injuries were to the lower extremity including ankle, knee, and upper leg muscle injuries. In addition, studies pertaining to female soccer players reported that ankle injuries (i.e. ankle sprains) were among the most common impairments at the collegiate level (Abimbola et al., 2012). The importance of core stability for injury prevention and performance enhancement has been popularized during the past decade with minimal supporting evidence. Even though limited evidence exists, the integration of core stabilization exercises into injury prevention programs, particularly for lower extremity, is demonstrating decreased injury rates. A universally accepted definition of core stability is lacking. Generally, core stability comprises the lumbopelvic-hip complex and is the capacity to maintain equilibrium of the vertebral column within its physiologic limits by reducing displacement from perturbations and maintaining structural integrity (Huxel et al., 2013). Recommendations made for preventing sports injuries are, promotion of using protective equipment and adequate warming up before competition or routine prophylaxis program before the start of training sessions or playing competitive games. Since increasingly many youth are involved in sport programs, health and safety are major issues However; participation in sports also entails a risk of injury for all athletes, right from the professional level sport persons down to the amateurs (Kumar et al., 2014). The core plays an important role in stabilizing the peripheral joints and reducing the risk for injury especially during high levels of physical activity. Moreover, core stability has been proven to promote efficient body mechanics, allowing the athlete to maximize force production while minimizing loads placed on proximal joints. This is especially important during complex movements, such as: running, jumping, swimming, throwing, and hitting handball, field hockey (Willard et al.,2007).The core acts through the thoracolumbar fascia, ‘‘nature’s back belt.’’ The transversus abdominis has large attachments to the middle and posterior layers of the thoracolumbar fascia (Bogduk, N. 2005). Additionally, the deep lamina of the posterior layer attaches to the lumbar spinous processes. In essence, the thoracolumbar fascia serves as part of a ‘‘hoop’’ around the trunk (McGill, S. 2010).
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That provides a connection between the lower limb and upper limb (Vleeming et al., 1995). Exercise therapy seems to be an effective treatment to relieve the pain and to improve the functional status of patients with chronic LBP in most clinical practice guidelines. Core stability training has become a popular fitness trend that has begun to be applied in rehabilitation programs and in sports medicine. Many studies have shown that core stability exercise is an important component of rehabilitation for LBP. Core stability training has a powerful theoretical foundation for the prevention and treatment of LBP, as is evidenced by its widespread clinical use. However, there appears to be no consensus agreement that core stability exercise is better than general exercise for chronic LBP (Wang et al., 2012). With contraction of the muscular contents, the thoracolumbar fascia also functions as a proprioceptor, providing feedback about trunk positioning. Two types of muscle fibres comprise the core muscles: slow-twitch and fast-twitch. Slow-twitch fibres make up primarily the local muscle system (the deep muscle layer). These muscles are shorter in length and are suited for controlling intersegmental motion and responding to changes in posture and extrinsic loads. Key local muscles include transversus abdomens, multifidi, internal oblique, deep transversospinalis, and the pelvic floor muscles. Multifidi have been found to atrophy in people with chronic low back pain (LBP) (Hides et al., 1996). The abdominals serve as a particularly vital component of the core. The transversus abdominis has received attention for its stabilizing effects. It has fibres that run horizontally (except for the most inferior fibres, which run parallel to the internal oblique muscle), creating a belt around the abdomen. ‘‘Hollowing in’’ of the abdomen creates isolated activation of the transversus abdominis. The transversus abdominis and multifidi have been shown to contract 30 ms before movement of the shoulder and 110 ms before movement of the leg in healthy people, theoretically to stabilize the lumbar spine (Hodges et al., 1999). However, patients with LBP have delayed contraction of the transversus abdominis and multifidi prior to limb movement (Hodges et al,. 1996). The internal oblique and the transversus abdominis work together to increase the intraabdominal pressure from the hoop created via the thoracolumbar fascia. Increased intraabdominal pressure has been shown to impart stiffness to the spine (McGill, S. (2010).The external oblique, the largest and most superficial abdominal muscle, acts as a check of anterior pelvic tilt. The abdominals (and multifidi) need to engage only to 5%Y10% of their maximal volitional contraction to stiffen spine segments (Cholewicki et al., 1999). The hip musculature is vital to all ambulatory activities, and plays a key role in stabilizing the trunk and pelvis in gait (Lyons et al., 1983). 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 other musculoskeletal conditions such as ankle sprains (Beckman et al., 1995). The psoas is only a 10
feeble flexor of the lumbar spine. However, it does have the potential to exert massive compressive forces on the lumbar disks. In activities that promote maximal psoas contraction, such as full sit-ups, it can exert a compressive load on the L5-S1 disk equal to 100 kg of weight (Bogduk et al., (2005).
Fig 1. Functional core stability. It illustrates the various components and role that interact to achieve functional core stabilization (Huxel et al., 2013).
Core musculature includes the abdominals anteriorly, the Para spinals and gluteal posteriorly, the diaphragm superiorly, and the pelvic floor and hip girdle musculature inferiorly. Within this box are 29 pairs of muscles that help to stabilize the spine, pelvis, and kinetic chain during functional movements. Without these muscles, the spine would become mechanically unstable with compressive forces as little as 90 N, a load much less than the weight of the upper body (Akuthota et al., 2004). Core stability is the capability of lumbar pelvic-hip complex to avoid instability of the spine and return to equilibrium after a perturbation. The core of body can be assumed as a box in which abdominal muscles, Para spinal and gluteal muscles, diaphragm muscle, and thigh muscles are located in the front, back, top, and floor. It has been shown that the muscles in the core of body are activated before the extremities perform a motion. These muscles serve as a bridge between the upper and lower limbs and this way power is produced in the core of body and transferred to organs (Salar et al., 2014).
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Table1. Common components of injury prevention programs (Huxel et al., 2013)
Core stabilization exercises
Plank Side bridge Supine bridge
Balance exercises
Single-leg stance Single-leg stance partner toss/catch Single-leg stance on wobble board
Jump training/ plyometric exercises
Forward/backward double-leg jumps Forward and backward single-leg jumps Lateral double-leg jumps Lateral single-leg jumps Single-leg zig-zag jumps Bounding
General strengthening exercises
Lunges Body weight squats Nordic hamstring curls
Dynamic balance is defined as the ability of an individual to maintain stability of the centre of mass during movement and an essential component of many sports activities. Dynamic balance is required for activities of daily living, such as walking, running, and stair climbing. Also, it is an important factor associated with lower extremity injury and performance in athletes (OZMEN et al., 2016). Balance is generally defined as the ability to maintain the body’s centre of gravity within its base of support and can be categorized as either static or dynamic balance. Static balance is the ability to sustain the body in static equilibrium or within its base of support. Dynamic balance is believed to be more challenging because it requires the ability to maintain equilibrium during a transition from a dynamic to a static state. Both static and dynamic balance require effective integration of visual, vestibular, and proprioceptive inputs to produce an efferent response to control the body within its base of support (Gioftsidou et al., 2012). Dance performance requires not only lower extremity muscle strength and endurance, but also sufficient core stabilization during dynamic dance movements (Watson et al., 2017) It has non-professional and amateurs to the risk of injury been reported that one of the destructive willingness to be present at the scene of sports effects of urban life was increased mortality due to competitions. Many athletes still are suffering injury even scientists try to drag people to sport stadiums observing all principles related to each sport including Some sports injuries may be and in the professional level . Since the implementation of activities sports because of injury, but also encountering of related to sports have been met always with different problems (Kazemzadeh et al., 2011).
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1.2.1. Prevalence of Sports injuries in Ice hockey Ice hockey is an increasingly popular competitive sport, with participants ranging from youth players to professional athletes. Injuries to the head, shoulder, hip, knee, and ankle and foot are most common, and their mechanisms of injury are unique to the sport. Conceptual work that addresses the prevalence and mechanism of injuries specific to ice hockey is integral to providing the highest quality of care for hockey athletes. Further, rehabilitation protocols, prognosis and prevention of hockey injuries are essential pieces to provide uniform expectations regarding identification of at-risk but uninjured athletes, health/injury status, and anticipated return to play for injured athletes several injury prevention initiatives have been implemented over the years in youth ice hockey with mixed results. While not the focus of this review, head and neck injuries comprise between 20 and 30% of reported youth ice hockey injuries. Mandatory use of face masks with helmets has been a passive prevention that has dramatically reduced the number of facial and eye injuries. (Wolfinger et al., 2016). F
Chronic groin pain is a common entity in ice hockey players and can often be due to a multitude of aetiologies, making it difficult to diagnose and treat. The most common cause of chronic groin pain is an adductor muscle strain. Adductor muscle strains commonly occur in ice hockey due to the strong eccentric contraction of adductor muscles during the skating motion. Proper treatment and rehabilitation can limit the amount of missed playing time and avoid surgical intervention. Restoring a balance between hip abductor and adductor strength with emphasis on strengthening the adductor muscle can also help to prevent these muscle strains in ice hockey players (Popkin et al., 2016). The most common groin much attention has arisen in recent years regarding the condition in high-performance athletes
popularly known as sport’s hernia. The term hernia
sport’s hernia is actually a misnomer in the sense that it does not represent a true herniation of internal contents through the inguinal floor, and this condition is better termed athletic pubalgia or inguinal disruption to more appropriately represent the actual pathophysiology of condition (Brunt et al., 2016). Pubalgia is a general term used to describe severe groin and hip pain in the professional athlete. The ethology of this condition can range from adductor tendon injuries, to hip injuries, to abdominal wall injuries. One of the least understood and most perplexing problems is the sports hernia.
1.1.2. Prevalence of sports injuries in field hockey As progression is made through the initial stages of a core strengthening program, emphasis should be placed on developing balance and coordination while performing a variety of movement patterns in the three cardinal planes of movement: sagittal, frontal, and transverse. Exercises should be performed in a standing position and should mirror functional movements. 13
Functional training typically requires acceleration, deceleration, and dynamic stabilization. An advanced core stabilizing program should train reflexive control and postural regulation (Fredericson et al., 2005). According to the National Collegiate Athletic Association (NCAA), injury surveillance data for women's field hockey and basketball indicated the most common sports-related injuries were to the lower extremities. Specifically, more than 60% of all game and practice injuries were to the lower extremity including ankle, knee, and upper leg muscle injuries (Agel et al., 2007). In addition, studies pertaining to female soccer players reported that ankle injuries (i.e. ankle sprains) were among the most common impairments at the collegiate level (Abimbola et al., 2012). Moreover, co-contractions of trunk muscles are present to stabilise the spine during several sports activities (Granata et al., 2001). This was confirmed by several studies which revealed evidence of increased activities of the trunk muscles due to low back pain (LBP) (Fischer et al., 1985). Several types of methods of testing spinal muscle endurance have been studied. Most commonly, these are (1) measures of isometric, or static, endurance, (2) active measures of endurance within a no fixed range of motion (isotonic), and (3) isokinetic testing that places subjects in a fixed range of motion as well as a fixed rate of joint motion acceleration(Moreau et al., 2001). It has been suggested that the main factors contributing to the stability of the trunk are intrinsic passive stiffness of its structures and the active contraction of the muscles and that these factors are modulated by the neural system (Freddolini et.al, 2014).
1.1.3. Prevalence of sports injuries in handball Handball is a high intensity team sport that is characterized by repetitive accelerations, shots, jumps, changes in direction, goal kicks and involves a high degree of contact between the athletes involved (Habelt et.al, 2011). In general, measures aiming at preventing sport injuries can be roughly divided into four more or less distinct categories, namely into measures focusing on ‘training and physical preparation of handball players’, ‘technical and political approaches’, ‘adaptation of equipment and facilities’, and ‘medical and non-medical measures’. Exercises to improve landing, jumping, cutting and planting technique. In addition, balancing and strengthening exercises are advised (Luig et.al, 2010). Proper technique and discipline is essential and exercises should be supervised by the coaches. Structured warm-up programmes including agility, balance, strength and playing technique exercises, designed to improve knee and ankle control during landing and pivoting movements. It is suggested to start programmes focusing on technique (cutting and landing movements) and balance training (on wobble boards, mats or similar equipment) in players aged 10-12 years and to continue in adolescents and 14
adults. Structured warming-up and mobilisation before training and matches, improving the flexibility, core stability and handball specific coordination, and with due care for appropriate shoes and flooring (Kisser et al., 2012).
Figure 1. Handball injuries (Luig et al., 2010).
1.2. Relationship between core stability and dynamic stability Core stability (CS) arrived in the latter part of the 1990s.It was largely derived from studies that demonstrated a change in onset timing of the trunk muscles in back injury and chronic low back pain (CLBP) patients (Hodges et al., 1996,1998). The research in trunk control has been in important contribution to the understanding of neuromuscular reorientation in back pain and injury. As long as four decades ago it was show that motor strategies change in injury and pain (Freeman et al., 1965).Those certain muscles are more important for stabilisation of the spine than
other muscles, in particular transversus
abdominis (TrA). That weak core stability leads to back pain. That muscles
strengthening core or trunk
can reduce back pain. That there is unique group of ‘‘core’ ’muscle working
independently of other trunk muscles. That back pain can be i m p r o v e d by normalising the timing of core muscles. That there is a relationship between stability and back pain. Whole industry grew out of these studies with gyms and clinics world-wide teaching the “tummy tuck” and trunk bracing exercise to athletes for prevention of injury and to patients as a cure for low back pain (Lederman et al., 2010). 15
In a sporting environment, core stability is defined as the ability to control the position and motion of the trunk over the pelvis to allow the optimum transfer of energy from the torso to extremities when performing athletic activities, which are often composed of highly loaded movements (Tong et al., 2014). Several types of methods of testing spinal muscle endurance have been studied. Most commonly, these are (1) measures of isometric, or static, endurance, (2) active measures of endurance within a no fixed range of motion (isotonic), and isokinetic testing that places subjects in a fixed range of motion as well as a fixed rate of joint motion acceleration. Isometric endurance testing seems to be cost-effective and requires little equipment for testing. Because of these features, we chose to focus on isometric endurance assessment; we felt that if there was evidence to support it as a clinically useful and valid procedure. (Moreau et al., 2001). The core is particularly important in sports because it provides ‘‘proximal stability for distal mobility’’ (Kibler et al., (2006). Dance performance requires not only lower extremity muscle strength and endurance, but also sufficient core stabilization during dynamic dance movements (Watson et al., 2017). The core plays an important role in stabilizing the lower extremity and knee movement during activity. The core musculature includes the rectus abdomens, transversus abdominis/internal oblique, external oblique, and erector spinae. The rectus abdominis, external oblique, and erector spinae control trunk position relative to its base of support. The transversus abdominis is the first muscle activated during lower body movements (Ambegaonkar at al., 2014). The lateral abdominal muscles, provided greater sacroiliac joint stability (Springer et al., 2006).The belief systems that underpin the current use of CSEs as a treatment of conditions such as nonspecific mechanical low back pain (NSLBP) suggests that focus should be on the lumbar multifidus and transversus abdominal muscles (MacDonald et al., 2006). Some evidence in the literature supports the notion that core stabilization programs may be used to help prevent injury in athletics. Letton and colleagues performed a prospective study looking at 140 male and female intercollegiate basketball and track athletes. They found that injured athletes [injuries included anterior cruciate ligament (ACL) rupture, iliotibial band syndrome, patellofemoral pain, and stress fracture in the lower extremity] had significantly decreased strength in hip abduction and external rotation compared with non-injured athletes. Hip external rotation strength was most useful in predicting injury (Leetun et al., 2004). Some literature supports using neuromuscular training to prevent ACL injuries in athletes. These programs include muscle co-contraction to provide joint stability, balance and perturbation training, and plyometric exercises. Hewitt and colleagues conducted a prospective study comparing injuries in female high school athletes with preseason neuromuscular training, including single-leg functional core stability training, with a control group of female and male athletes without preseason neuromuscular training (Hewett et al., 1999). Specific core stability 16
programs in prevention of athletic injuries have not been well studied. Additionally, core programs have not been proven to enhance athletic performance. Despite these facts, many of these programs have been promoted in lay literature for use in performance enhancement (Akuthota et al., 2008).
1.3. Relationship between core stability and leg injuries prevention In recent year “core “and “core exercise “have become more common word. Core exercise have a positive effect on reducing low back pain (Akuthota et al., 2009), improving upper extremities in breast cancer patients and lower extremities in patents with total hip and knee arthroplasty as well as performance improvement for athletes (Gamble et al., 2007). The core stability is essential to prevent leg injuries and improve performance in athletes. Weak core muscles may be a risk factor for low back pain and lower limb. It has been reported that core muscle fatigue decreased dynamic stability of the trunk and loss of balance control (ozmte et al., 2016). The core muscles transfer force and act as a bridge between the upper and lower extremities. Perhaps more important, the core muscles help passive structures protect and support the spine. Previously, core stability exercises were widely used for the prevention and rehabilitation of leg injuries in sports. (Sandrey et al., 2013). The lack of stability in the core muscles is risk factor for developing low back pain and this problem is associated with neuromuscular deficit and decreased core muscle strength. Beside prevention of low back pain, the strengthening of the stabilizing muscles of the trunk or core is considered of great importance to daily activities and sports. Exercise performed by reducing the base of support increased muscle activity in the stabilizer muscle of the ankle and increased core muscle activity during bridging exercises (Calatayud et al., 2015). The “core” of the torso is described as the lumbopelvic region, and it has been suggested that exercises to facilitate integrity within musculature in this area improve spinal segment stability. However, there is no clinically recognized definition of core stability exercises (CSEs) and therefore no standardized recommend- dation for any specific grouping of exercises. (Aluko et al., 2013).Core stability exercises are said to assist in the activation of the deep fibres of the lumbar multifidus through low loaded isometric activity (Standaert et al., 2008). Emerging evidence suggests that poor core stability is a risk factor for low back and lower extremity injuries in athletes. Core stability is the ability to control trunk position and motion for the purpose of optimal production, transfer, and control of forces to and from the terminal segments during functional activities. Optimal neuromuscular control and muscle capacity (strength and endurance) are critical components of core stability. Frequently used clinical tests to assess core stability include the unilateral hip bridge, trunk extensor endurance, 17
and Y-Balance tests. Recently the trunk control test was developed to clinically assess core stability in a manner that closely resembles a biomechanical method of assessing isolated core stability (Leetun et al., 2004). The most common mechanism of injury of muscles in elite athletes is related to muscle strain (indirect muscle injury), mainly in the lower limbs. Muscles are at risk for disruption during eccentric contraction, as the force of active contraction is added to the passive stretching force applied to the tendinous junction (MTJ). Acute muscle injuries in the lower limbs are associated with both sprinting and stretching activities, mainly affecting the hamstring muscle complex. For these MTJ injuries there is more pronounced loss of function initially but with faster recovery for sprinting related injuries, while for stretching injuries there is less loss of function initially but slower recovery (Guermazi et al., 2017). Blunt trauma is the most common mechanism of direct muscle injury in sports, mainly affecting the lower limbs in sports that may involve collisions as in soccer, football, and rugby. Depending on the dissipation pattern of the blunt force, different degrees of muscle contusion may be observed, usually (but not always) occurring deep in the muscle belly: An intramuscular hematoma may be present (Lee et al., 2014). The core plays an important role in stabilizing the peripheral joints and reducing the risk for injury especially during high levels of physical activity (Abdelraouf et al., 2016). In recent years, fitness practitioners have increasingly recommended core stability exercises in sports conditioning programs. Greater core stability may benefit sports performance by providing a foundation for greater force production in the upper and lower extremities. Traditional resistance exercises have been modified to emphasize core stability. Such modifications have included performing exercises on unstable rather than stable surfaces, performing exercises while standing rather than seated, performing exercises with free weights rather than machines, and performing exercises unilaterally rather than bilaterally (Willard son et al., 2007). Popular core stability exercise programs commonly focus on bracing or activating the trunk muscles that are believed to support the spine. This includes exercises such as: crunches, planks, bird-dog, or those aimed at specifically targeting the transversus abdominis. While it is agreed that core stability/neuromuscular control are needed to perform activities of daily living, only low levels of muscle contraction that occur beyond conscious control are needed to stabilize the spine ( Stilwell et al., 2017). The use of Swiss ball training for core muscle development has been popular for several years (Cosio-Lima et al., 2003). Multiple studies have examined core muscle recruitment during varying types of Swiss ball abdominal exercises (Mori, 2003). McGill et al. reported that males demonstrated significantly greater endurance in the side bridge exercise (a measure of quadratus lumborum function) than females. However, he found no difference in trunk flexor muscle endurance and found that females 18
generally demonstrated greater trunk extension endurance .Nadler et al. reported that female athletes who reported an injury to their lower extremity or low back demonstrated a greater difference in side-to-side hip extension strength symmetry than their male counterparts (Leetun et al., 2004).Dynamic balance was measured on a stabilometer, which records the amount of time a participant maintains an unstable platform within 5" of horizontal (Davlin et al., 2004).
1.4. Core strengthening program Once these activation techniques are mastered and the transversus abdominisis ‘‘awakened,’’ training should be progressed. 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 with alternate arm/leg raises (‘‘bird dog’’). The prone plank and bridging also can be added at this stage (Fredericson et al., 2005). Pelvic bridging is particularly effective for activating the lumbar Para spinals (Arokoski et al., 2004) Initial exercises are done in supine, hook-lying, or quadruped positions. It should be reiterated that the pelvis should not be tilted and the spine should not be flattened, but should maintain a neutral posture. Normal rhythmic diaphragmatic breathing also is emphasized. Once good control is demonstrated with the static core exercises, the individual can advance to exercises using a physio ball. Notably, non-weight-bearing core exercises, such as ones performed on a physio ball, may not translate to improved athletic performance (Stanton et al., 2004). Thus, athletes should quickly advance to more functional exercises in sitting, standing, and walking positions. The gravitational centre in the lumbopelvic region is where all movements are initiated. During activity the centre of gravity is constantly shifting. The musculature that surrounds the centre of gravity plays a vital role in motor function by maintaining a stable base to support the body mass (Wilson et al., 2005). Generally referred to as the core, these global and local muscles are constantly working to maintain posture, absorb loads, protect neural structures, and assist in changing postures and dynamic movements. The core muscles transfer force and act as a bridge between the upper and lower extremities. Perhaps more important, the core muscles help passive structures protect and support the spine. Considering the sensitivity and quantity of nerves that run through the low back, limiting displacement and maintaining the structural integrity of this region is of great importance (Sandrey et al., 2013).
19
Table 2. Example of an evidenced-based core stability program (Akuthota et al., 2008). General
A.
Go over anatomy of the core &
Active participation emphasized. B.
Basic exercises isolate core muscles in
different positions Transversus abdomens (advance if able to
A.
Abdominal bracing
perform 30 reps with 8 s hold)
B.
Bracing with heel slides
C.
Bracing with leg lifts
D.
Bracing with bridging
E.
Bracing in standing
F.
Bracing with standing row
A.
Quadruped arm lifts with bracing
B.
Quadruped leg lifts with bracing
C.
Quadruped alternate arm and legs lifts
Bracing
with
spinals/multifidi
walking (advance
&Para
if
able
to
perform 30 reps with 8 s hold)
with bracing oblique
A.
Side plank with knees flexed
(advance if able to perform 30 reps with 8
B.
Side plank with knees extended
Trunk curl Facilitation techniques if
A.
Progression
necessary
Quadratus
lumborum
and
s hold) )
visualization, substitution
floor
contraction,
B.
Physio ball
palpation,
identifying
C.
Functional
(pelvic
patterns
like
pelvic
tilt,
training
positions
with
activation of core
ultrasound)
Build endurance
A.
Compliance
with
home
exercise
program
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2. METHODS AND METHODOLOGY 2.1. Participants In this correlation study Sixty one male and women athletes were evaluated. Several team sports were represented in this sample, Man field hockey soccer, Man Ice hockey, Women handball, Field hockey. Table 5.Player’s descriptive data of four groups.
Players
Age (Years) Mean ±SD
Weight (Kg) Mean ±SD
Height (cm) Mean ±SD
Man Field Hockey (n=19
19.1±5.83
76.34±13.57
178.57±8.24
Man Ice Hockey (n=4 men)
27.3±1.50
86.8±16.03
184.3±3.10
Women Field Hockey (n=23
19.3±4.3
67±24.18
162±21
20.4±3.03
71.5±5.55
10.87±3.03
men)
men Women Handball (n=15 men
The athletes had no restrictions from participation in their normal practice schedule or other activities during the course of a day. The experimental procedures and the risks involved were explained to all the subjects and a signed informed consent was obtained the protocol was approved by the institutional research ethics committee. All the subjects were handed a research information sheet and given the option to withdraw at any time from the study.
2.2. Methods 1. Aged between 13 to 40 years. 2. Healthy Man and Women Ice hockey, Field hockey, and Handball Players. 3. All participants were healthy and had no injuries on testing day. 4. Volunteers signed the consent form to become participants.
21
Static and Dynamic Balance Static balance is the ability to maintain a base of support with minimal movement. Dynamic Balance may be considered the ability to perform a task while maintaining or regaining a stable position (winter et al., 1990).This study was designed to investigate the effects of static and dynamic balance compare between different sports players Muscle Endurance of Back extensors , Abdominal and Side flexors muscles on Women handball, field hockey , Men Ice hockey and field hockey and also to determine the effects of muscle for by measuring McGill and Dynamic Y-Balance technique. Trunk Flexor Endurance The Trunk Flexor Endurance Test was used to assess the endurance of the trunk and hip flexor muscles. Subjects were placed in a sit-up position on a treatment table/plinth. A padded belt was used to secure the subject at the proximal ankles. Subjects were required to maintain a 45 degree flexed position of the trunk for as long as possible. The test was terminated when the subject was unable to maintain position after one warning or 240 seconds (actual test not to exceed 240 seconds). (West rick et al., 2012). Lateral Trunk Endurance Test (Side Bridge) The Lateral Trunk Endurance Test (LTET) was included to assess the endurance of the shoulder and lateral trunk musculature. The subjects were positioned side-lying with their legs extended. The top foot was placed in front of the lower foot for support and the free hand was placed on the shoulder of the stance limb with the arm across the chest. Subjects lifted their hips off the surface to maintain a straight line over their body while supporting themselves with the stance limb and the sides of the feet. The test was terminated when the subject was no longer able to maintain position after one warning or 240 seconds (actual test not to exceed 240 seconds).(West rick et al., 2012). Trunk Extensor Endurance Test The Trunk Extensor Endurance Test was used to assess the endurance of the trunk extensor muscles. Subjects were positioned prone with their torso off the edge of a treatment table/plinth. The anterior superior iliac spine (ASIS) was positioned as close to the edge of the plinth as possible but still supported by the plinth. A 6” foam bolster was placed under subjects’ ankles for comfort and 2 padded belts were used to secure the subject at the mid-thigh and midleg. Subjects were required to maintain a horizontal position of the torso for as long as possible. The test was terminated when the subject was unable to maintain position after one warning or 240 seconds (actual test not to exceed 240 seconds) (West rick et al., 2012).
22
A
B
C Figure 4.Core Endurance tests of McGill. A. Flexor endurance test, B.Side plank, D. Extensor endurance test
Upper Quarter Y-Balance Test component The subject performed maximal effort reaches with the free hand in three directions (medial, super lateral, and inferolateral) named in relation to the stationary hand (Figure 1). The distance reached in each direction was recorded. Each subject was allowed 3 practice trials prior to testing. The average of 3 trials was used for analysis. The sum of the 3 reach directions was calculated for a total excursion score. To normalize for limb length, a composite score was calculated taking the total excursion distance and dividing it by 3 times the upper limb length (Westrick et al., 2012). The greatest reach of the three trials in each direction is recorded and the following formula is used to calculate the ‘Composite Score’
(Medial + Superolateral + Inferolateral ) × 100 3x Limbe Length
23
A
B
C
Figure 5. Upper Quarter Y-Balance Test. A) Medial Reach Directions. B) Inferior lateral Reached Direction C) Superior Lateral Reach Direction
Lower Quarter Y-Balance test components The lower quarter Y-balance test (YBT-LQ) has been recommended as a measure of dynamic postural control in the clinical setting; however, information about the relationship between performance on the YBT-LQ and joint kinematics is limited. Thus, the kinematic predictors responsible for performance on the YBT-LQ need to be identified for accurate evaluation of dynamic postural control (Kang et al., 2015). The patient stands on the canter footplate, with the distal aspect of the right foot at the starting line. While maintaining single leg stance on the right leg, the patient reaches with the free limb (left leg) in the anterior, posteromedial, and posterolateral directions in relation to the stance foot by pushing the indicator box as far as possible. Participants complete 3 consecutive trials for each reach direction and to reduce fatigue subjects alternate limbs between each direction. Attempts are discarded and repeated if: The subject fails to maintain unilateral stance on the platform, Fails to maintain reach foot contact with the reach indicator on the target area while the reach indicator is in motion, Uses the reach indicator for stance support, or Fails to return the reach foot to the starting position under control The greatest reach of the three trials in each direction is recorded and the following formula is used to calculate the ‘Composite Score’ (Fritz et al., 2001).
24
B
A
C
Figure 6. Lower Quarter Y-Balance test. A) Anterior Reach Direction. B) Posteromedial reach direction C) Posterolateral reach direction
2.3. Organization of the research 1. Field hockey players - Vilnius Tauras ,Siauliai Sports School track and field riding hall. 2. Ice hockey Players - Kaunas light Manezh. 3. Handball players - Kaunas "ACME-Žalgiriz" team The subjects reported to the exercise 4 separate days for all 4 groups. On the day of testing, all the subjects were asked to perform static and Dynamic Balance test for at their own comfort and self-strength. Statistical Analyses All Quantitative variables follow normal distraction wear expressed as mean ± standard deviation (SD). Differences in baseline characteristics between the two groups were assessed using T-test. All subjects completed the study, so no adjustments were needed for drop-outs. Difference across groups and were considered statistically significant when P < 0, 0.05.
25
1. RESEARCH RESULTS 1. Trunk muscle endurance of all players There were (figures 7) the descriptive data of the subjects are put, for each sport separately. The results of one-way variance analysis showed that the static balance among different groups has meaningful difference. The results of T- test showed that comparisons between all players static and dynamic group of muscles. The comparison between man field hockey and man ice hockey back muscle groups was significant ( p0, 0.5).
Statical endurance ( s)
300 250 200 150
Man Field Hockey 100
Women Handball
50 0
Back
Abdomen Muscles group
Figure 15. Mean standard deviation back and abdomen muscle of man field hockey and women handball.
30
10. Man ice hockey vs women field hockey (Back, abdomen, Right and left side) There wear (figure 16) Statistics difference man ice hockey between women field hockey there were only abdomen muscles wear significant (p> 0.05).
Static endurance ( s)
400.0
*
Man Ice Hockey
350.0
Women Field Hockey
300.0 250.0 200.0 150.0 100.0 50.0 0.0
Back
Abdomen
Right Side
Left side
Muscles Group Figure 16. Man ice hockey vs women field hockey abdomen muscles - *p>0, 05
10. Man ice hockey vs women handball players (Back, abdomen, Right and left side). There was (figure 17) ) statistics difference between back , abdomen, right and left side core muscles of man ice hockey and women handball wear non-significant(p>0,0.5).
Statical endurance ( s )
300.0 Man Ice Hockey
250.0
Women Handball
200.0 150.0 100.0 50.0
0.0 Back
Abdomen
Right Side
Left side
Muscles Group
Figure 17. Mean, standard deviation man ice hockey and women handball players back, abdomen right and left side.
31
12. Composite score of man, women right and left leg The Composite score (figure18) all players had less chance of injuries because they have more than 100 composite score. In women field hockey had better composite score compare to others team players.
180
▪ ▪
Composite Score
160
Right leg Left leg
140 120 100 80 60 40 20 0 Man Field Hockey
Man Ice Hockey
Women Field Hockey Women Handball
Muscle groups
Figure18.Composite score of dynamic balance standing on right and left leg
12. Composite score of man, and women on right and left arm The Composite (figure19) of man ice hockey had less chance of injuries because composite score was more than (100) and other players had more chances of injuries because composite score was less than (100).
250
Composite Score
200 150 100
Right arm Left arm
50 0 Man Field Hockey
Man Ice Hockey Women Field Hockey
Women Handball
Muscles group
Figure19.Composite Score of right and left arm muscles of all players. 32
13. Man field hockey correlation In (figure 20) Dynamic balance of right and left arm was stronger (r= 0.76) than right and left leg (r= 0.03). Right and left side core muscle (r = 0.72) of man field hockey was stronger than back and abdomen (r= 0.12).
Man field hockey Right & left Arm Right & left Leg Right and left side Back and abdomen 0
0.1
0.2
Back and abdomen 0.12
Man field hockey
0.3
0.4
Right and left side 0.72
0.5
0.6
Right & left Leg 0.03
0.7
0.8
Right & left Arm 0.76
Figure 20. Correlation of man field hockey. 14. Man ice hockey correlation In (figure 21) Dynamic balance of right and left leg was stronger (r= 0.98) than right and left arm (r= 0.04). Right and left side core muscles (r = 0.99) of man field hockey was stronger than back and abdomen (r= 0.9).
Man Ice hockey Right & left Arm Right & left Leg Right and left side Back and abdomen 0
Man Ice hockey
0.2 Back and abdomen 0.9
0.4
0.6
Right and left side 0.99
0.8 Right & left Leg 0.98
1
1.2
Right & left Arm 0.04
Figure 21. Correlation of man ice hockey player.
33
15. Women field hockey correlation In (figure 22) Dynamic balance of right and left arm (r= 0.16) was better than right and left leg (r= 0.04). Right and left side core muscles (r = 0.68) of women field hockey was stronger than back and abdomen muscles (r= 0.19).
Women field hockey Right & left Arm Right & left Leg Right and left side Back and abdomen 0
0.1
0.2
Back and abdomen 0.19
Women field hockey
0.3
0.4
0.5
0.6
Right and left Right & left side Leg 0.68 0.04
0.7
0.8
Right & left Arm 0.16
Figure 22. Correlation of women field hockey player. 16. Women handball player correlation In (figure 23) Dynamic balance right and left arm (r= 0.8) was stronger than right and left leg (r= 0.49). Right and left side core muscles (r = 0.87) of women handball was stronger than back and abdomen muscles (r= 0.32).
Women Handball Right & left Arm Right & left Leg Right and left side Back and abdomen 0
Women Handball
0.2 Back and abdomen 0.32
0.4 Right and left side 0.87
0.6 Right & left Leg 0.49
0.8
1
Right & left Arm 0.8
Figure 22. Correlation of women handball player.
34
4. DISCUSSION
The primary purpose of this study was to determine the relationships between core muscle endurance and Dynamic balance that subsequently affect functional movement and performance. In the posture and balance context, back, abdomen, left and right side has been the main focus for study and therapeutic intervention. The literature unanimously shows negative effects of trunk muscle fatigue on balance. In 2010, Helbostad et al demonstrated the consequences of lower extremity and trunk muscle fatigue on balance and functional tasks (Helbostad et al., 2010). The core becomes activated before gross body movements as part of the postural control system. Since the core is responsible for postural control, assessments of dynamic balance are alternatives to assess core stabilization. The current study used a variety of corestabilization training methods that included using unstable surfaces, using limb movement to challenge the postural-control system, and performing some exercises in a weight bearing position, which may be why reach distances improved. In addition, the core-stabilizationtraining program did not specifically train for postural control and dynamic stability in a standing position. While postural control and dynamic stability were challenged throughout the training program, only 3 of the positions involved standing. Most often the subject was positioned in supine, prone, side-lying, or other like positions (Sandrey et al., 2013) Endurance of trunk muscles and dynamic balance of Y-Balance test and Determine compare between different sports players with, Upper and Lower Quarter Y-Balance. In this research wear also determine prevalence of sports injuries in different players. .Following the Assessment of core endurance and dynamic Y- Balance test in 4 groups, Group Man Field Hockey(n=19, Man Ice Hockey(n=4),Women Field Hockey(n=23),Women Handball(n=15). First of all, I would like to discuss results that were gotten for evaluation. The comparison static and dynamic back muscle of men field hockey, men ice hockey, women field hockey and women handball players were significant (p
