Ma Bingxiang, Zhang Jiankui, Zheng Hong
[Abstract] In sports, it is increasingly recognized that the main role of the human core is to stabilize the body and to be the basis of muscle power. For children with cerebral palsy, core control is the basis for limb movement and all other activities. This paper introduces the concept of “core stability” training in sports to the treatment of children with cerebral palsy. By explaining the influence of core control on the entire motor ability of children with cerebral palsy from head erection to walking, we hope that more therapists can raise awareness of the importance of core control in children with cerebral palsy and propose corresponding training methods to better promote the rehabilitation of children with cerebral palsy. Zhang Jiankui, Department of Pediatrics, The First Affiliated Hospital of Henan College of Traditional Chinese Medicine
[Keywords] Core stability; cerebral palsy; rehabilitation
“Core stability” theory with the rehabilitation of children with cerebral palsy
MA Bing Xiang ZHANG Jian Kui ZHENG Hong Department of Encephalopathy diagnosis and treatment of pediatric rehabilitation center,The First Affiliated Hospital of Henan University of TCM, 450003
[Abstract [Key words 】 core stability; cerebral palsy; rehabilitation From an anatomical point of view, the core of the human skeleton includes: the spine, the hip, the proximal lower limbs, and the abdominal structures. The core part of the human body muscles is the trunk and pelvis related muscles, whose function is to maintain the stability of the spine and hip, and to help generate and transmit energy from the large joints to the small joints during exercise [1]. also has Correspondence should be addressed to the Pediatrics Department III, First Affiliated Hospital of Henan College of Traditional Chinese Medicine, No. 19 Renmin Road, Zhengzhou, China 450003 First author’s profile: Ma Bingxiang (1963-), male, Han nationality, Zhengzhou City, Henan Province, chief physician, professor, master’s supervisor, research interests: pediatric neurological diseases. Mobile: 13592601575 Tel:0371-66211081 e-mail:[email protected] Full text word count: 5326 Table count: 0 Figure count: 0 Scholars define the core as the area of the body between the diaphragm and the pelvic floor muscles [2], and the muscles located between this area are referred to as the core musculature. In competitive sports, almost all sports involve the application of force to external objects (e.g., balls, ground, water, etc.) through the ends of the limbs to produce movement in the apparatus or body. Therefore, for a long time, in the field of competitive sports training, the focus of strength training has been on the extremities, neglecting or even abandoning the training of muscle strength in the trunk (core) area. In the early 1990s, some European and American scholars began to recognize the important role of the trunk muscles, and they conducted in-depth studies on the trunk from different perspectives, such as mechanics, neurophysiology and rehabilitation, and raised the issue of “core stability (Core Stability)”. The so-called “core stability” refers to the stable posture of the pelvic and trunk muscles during movement, creating fulcrums for upper and lower extremity movements, and coordinating upper and lower extremity force generation, transmission, and control to optimize force [3]. Studies have shown that core stability training can improve the body’s control ability in non-stationary state, enhance balance, better train the body’s deep small muscle groups, coordinate the power output of large and small muscle groups, enhance motor function, and prevent sports injuries [4]. Cerebral palsy is a syndrome caused by non-progressive brain injury and developmental defects during the brain development stage from conception to infancy, mainly manifesting as motor deficits and postural abnormalities [5]. The abnormal movement and posture of children with cerebral palsy are most intuitive and fully expressed in the limbs. Therefore, in the past, rehabilitation training mostly focused on the correction of abnormal posture of limbs, but often neglected the control training of core muscle groups of children with cerebral palsy. We have observed in clinical practice that most children with cerebral palsy have reduced trunk and pelvic control, which directly restricts the child’s motor and balance coordination ability. This paper describes the influence of core muscle group stability on the motor and balance coordination ability of children with cerebral palsy in the order of human body development from head to tail, and proposes corresponding training methods in the hope of drawing more attention from colleagues. I. The relationship between the control of the core and the vertical head Head control is the earliest movement to be completed in motor development and takes about 3 months to complete from birth until the head is raised and stabilized. Although the development of trunk control comes after the development of head control, there is an overlap between the two in the developmental process, and the head can only have free movement after the scapular girdle and trunk begin to have some stability [6]. The reason for poor head control is that in addition to muscle weakness or muscle strength imbalance in the neck, the remnants of primitive reflexes coupled with abnormal distribution of muscle tone and strength in the low back, and limited full extension and gyration of the spine also directly affect the control of the head. For example, in children with tense erector spinae muscles, the coracobrachialis is obvious, and it is difficult for the child to complete the forward flexion of the head; in children with generalized flexion and residual tense vagal reflex, it is difficult to lift the head in the prone position; in children with lumbar and abdominal muscle weakness, the spine control is poor, which directly affects the control of the head and cannot achieve the centered symmetry of the head. For these problems, therapists can break the flexion pattern, promote spinal extension, and suppress back muscle tension through training such as dip training on the barbell, hand-supported hip compression training, and bridge training; suppress coracobrachialis through ball-holding training in the supine or seated position, hammock rolling training, and the ueda-positive neck method; also through sit-up training, bridge training, abdominal compression method, lumbar compression training, lateral body axis Therefore, the previous rehabilitation training focused on the correction of abnormal limb posture, and the training of gyration, seated body axis gyration, and bending and picking up objects to improve the lumbar and abdominal muscle strength and enhance the trunk control ability of the child [7]. The relationship between core control and turning The normal turning of children, whether in the head-scapular belt-pelvis sequence or the pelvis-scapular belt-head sequence, is inseparable from trunk rotation and active hip flexion and extension, the prerequisite for which is the full extension of the spine, the disappearance of the coracoacromial and tense vagal reflexes and the coordination of trunk and pelvic muscles. For example, children with coracobrachialis are difficult to complete the flexion and twisting of the head, neck and trunk due to the increased tension of the erector spinae muscles; children with tight hip flexion are difficult to complete the conversion from lateral to prone position even if they have completed the conversion from supine to lateral flexion position; some children with weak abdominal or iliopsoas muscles can also complete the turning action, but it is mostly done in the form of lower limb muscle compensation. In this regard, we need to break the abnormal posture or reflexes of the child and improve the strength of the core muscles on this basis, while passive or active turning training can promote trunk rotation and coordination and stability of the core muscles, which are complementary to each other. The therapist can achieve this by shoulder control rollover training or pelvic control rollover training in the supine or prone position of the child. In addition, turning or body axis gyration training can be performed on a barbell, wedge pad or inside a sheet. Third, the relationship between core control and sitting position The sitting position is a position in which the buttocks are on the bed and the body is perpendicular to the floor from the pelvic region upward. The ultimate goal of obtaining a sitting position is to have a stable sitting position with vertical extension of the spine without upper extremity support. The human spine is like an upright bamboo pole, the muscles in the front and back of the spine are like the ropes that hold the pole in place, and the pelvis in the seated position is like the base surface on which the pole is upright, too strong or too weak pulling of the ropes and instability of the base surface will affect the stability of the pole. Children with abnormal lumbar and abdominal muscle strength and tone are mostly used to obtain different sitting positions by means of compensations. For example, children with tense dorsal extension of the trunk in the sitting position to prevent the body from leaning back are more likely to sit on their knees or sit with their hands propped up behind them; children with lumbar muscle weakness in the sitting position are unable to straighten the spine by the strength of the vertical spinal muscles alone, and they may sit with full forward leaning, half full leaning or arching their backs, or use the forward convexity of the spine to shift the center of gravity backward to maintain balance by the pull of the abdominal muscles. For example, in children with tight adductor muscles, the hip joint cannot be fully abducted in sitting position to form a stable basal surface, and the child mostly obtains balance through the support of both hands; in children with tight iliopsoas muscles, the pelvis tilts forward when sitting for a long time, and the center of gravity shifts forward, and in order to maintain the stability of the center of gravity, the child mostly obtains balance through the posterior extension of the scapula and neck; in children with tight N cord muscles, the pelvis tilts backward when sitting for a long time. In order to maintain the balance of the center of gravity, the child mostly sits with an arched back, which often causes kyphosis of the spine. The completion of sitting alone marks the completion of the static balance and dynamic balance of the most basic human movement, sitting. Clinically, through the corresponding training, on the basis of eliminating the abnormal posture of the lower limbs and obtaining normal tone and strength of the trunk and pelvic muscle groups, dynamic balance training in the sitting position should also be performed. The training consists of anterior-posterior-right-left-right dynamic balance training with the help of the therapist and self-dynamic balance training through the child’s own efforts to achieve anterior-posterior-right balance under the therapist’s command. This is a good control of the pelvis can stand, the trunk and pelvis separation movement coordination, the trunk muscle groups of coordinated control and the formation of the sitting balance reflex is very helpful. The completion of sitting alone also requires the perfection of various postures into sitting, which depends on good trunk control and gyration ability and the completion of the postural transition from lying to sitting. The child can ride across the therapist’s legs, the therapist through the double lower limbs up and down height adjustment to promote the child’s sitting trunk stability and rotation; the child or supine on the therapist’s lap, the therapist placed one hand on the child’s abdomen, the other hand to support the child’s shoulders or hips, so that the child’s trunk to produce the body axis of rotation after sitting on the therapist’s lap, to help the child get the feeling of trunk rotation. Children with lumbar muscle weakness can also sit on the barbell, and the therapist induces anterior, posterior and lateral protective stretching through manual techniques to improve trunk stability and coordination in the sitting position, self-control ability, and promote protective stretching response in the sitting position. In addition, the chain reaction of the trunk muscles can be improved through supine to long sitting postural transition, prone to long sitting postural transition, and long sitting to transverse sitting postural transition. Fourth, the core control and the relationship between crawling The completion of the four crawls is a sign of normal pediatric crawling maturity. Among the conditions necessary for the development of the four crawling positions and the four crawling movements, the extension of the spine to the lumbar and sacral vertebrae, the stability of the trunk, especially the maturation of the abdominal muscles, can ensure the stability of the trunk; good weight-bearing ability and control of the hip joint is the guarantee of the emergence of the four crawling position balance response. Insufficient support for the pelvis and its surrounding tissues by the hip flexors, extensors and abductors in the interactive movement of the lower limbs can cause the child to sway from side to side when crawling. During the treatment, we can carry out the weight shifting training in the four crawl positions to control the hip: the child takes the kneeling position with hands and knees support, and the therapist places both hands on the hip, slowly presses it vertically to improve its hip weight-bearing capacity, and at the same time exerts force forward and backward, laterally to make its weight move backward and forward, left and right. It is also possible to conduct four-crawl training on a roller to suppress the flexion or extension pattern of the hip joint and improve the control of the hip in preparation for four-crawl. The completion of the four crawls also requires adequate alternate movement of both lower limbs, and children with tense trunk and hip flexion, poor separation movement of the two lower limbs, crawl mostly with two upper limbs forward, lumbar flexion, two lower limbs forward at the same time rabbit hopping-like crawl, or crawl with the belly, two upper limbs pulling the two lower limbs and trunk forward; at this time, we can use the shoulder and pelvis method in Ueda therapy to reduce muscle spasm of the trunk and limbs, and promote two The child can also sit on the barreling ball and alternate movements of the lower extremities, and can also rotate the trunk from side to side to enhance trunk rotation and stability. V. Relationship between core control and knee stance The kneeling position (straight kneeling) is a position in the process of moving from crawling to standing alone, and is the basis for standing and walking movements. Compared with the sitting position, the child’s body center of gravity is raised and the area in contact with the ground is reduced, but the muscle groups involved are more complex, which makes it more difficult for the child to maintain body balance. The completion of straight kneeling, in addition to the participation of trunk muscle groups, more is the stability and coordination of the muscle groups around the hip joint. The most common clinical condition is the anterior pelvic tilt when kneeling straight in children with tight iliopsoas muscles; children with tight adductor muscles cannot maintain kneeling balance when kneeling straight due to the narrowing of the basal plane; children with loose adductor muscles form a “W” sitting posture due to excessive abduction of both hip joints; children with weak gluteus maximus muscles exhibit chest and abdominal protrusion when kneeling straight, with the help of the center of gravity. The child’s center of gravity is shifted backwards to achieve balance. For the above different situations, therapists can relieve the spasm of the child’s adductor muscles and improve the muscle strength of the adductor muscle group through hip-splitting and hip abduction training; promote the release of hip flexion spasm and the normalization of the muscle strength of the posterior extension muscle group by using active hip lift training and swallow hip extension training; also improve the strength of the adductor muscles through active adduction training or adduction resistance training of the adductor muscles. In addition, the therapist can also conduct double knee stance training, single knee stance training and hip self-control training to improve the establishment of static and dynamic balance in the knee stance of the child. The method of hip self-control training is as follows: the child takes a knee-standing position, the therapist faces the child, and pushes or taps the child’s hip and abdomen, with the force acting in the direction of the back or side, and then the child adjusts himself back to the knee-standing position. Six, the core control and standing, walking relationship Standing is the basis for walking, the correct static standing posture is two legs straight, the soles of the feet flat, head in the center, trunk extension, shoulders and hips in the same plane. Dynamic standing posture means that when standing, the head, trunk and limbs can move appropriately at will and still maintain balance. The child can only walk normally if he or she has completed the static and dynamic balance of the position. Compared to the sitting position, children with cerebral palsy often have difficulties in standing upright and perfecting standing balance due to abnormal lower limb muscle tone distribution or poor hip joint control, which is manifested by left and right swaying of the trunk or pelvis in the standing position. After eliminating the abnormal muscle tone of the lower limbs, we can carry out pelvic control training in the supporting position, postural control training in the standing position or passive standing training on the standing promotion board to enhance the control ability of the pelvis and trunk of the child with cerebral palsy. In normal walking it must be the site of weight loading that changes frequently, it requires symmetry of the pelvis and coordination of the left and right sides of the separation movement. Children with poor pelvic separation often have unstable or uncoordinated walking due to the excess effort of the other lower limb when stepping, and children with hemiplegia have a special gait due to the loss of pelvic laterality. Therefore, on the basis of the child’s balance in the upright position, the therapist should also carry out the postural transition ability in the upright position and the weight-bearing separation ability of the pelvis. The lunge stance training and control of the pelvic girdle are commonly used to assist in training. The therapist can also help the child’s pelvic rotation and body weight shift with hand force to drive the lower extremities forward with the pelvic rotation, thus allowing the child to feel the sensation of alternating walking and alternating weight bearing. From the above, we can see that the core control of children with cerebral palsy is very different from the core stability of athletes. The core stability of athletes is to improve the energy output from the core to the limbs and other muscle groups during exercise under normal muscle strength and motor function to increase the speed of rotation of force and improve the efficacy of technical movements and the efficiency of coordination between upper and lower limbs and movements; whereas the core stability of children with cerebral palsy is mainly to break the abnormal The child’s posture and movement pattern should be normal, and normal muscle tone and normal movement pattern should be achieved. We also found in the clinic that with the intervention of early detection and early rehabilitation training for children with cerebral palsy, the muscle tone and abnormal reflexes of many children improved significantly, but the children still could not achieve good control of the spine and pelvis, and there may be two reasons for this: 1. lack of training for the deep core muscles, according to the core stability theory, the muscles of the spine can be stabilizing muscles and motor muscles [2] two categories. The stabilizing muscles are usually located deep in the spine and originate from the vertebrae, such as the sacrospinous, transverse spine, intertransverse spine, interspinous, and multifidus muscles. These muscles control the cone activity and have static holding capacity through centrifugal contraction, controlling the curvature of the spine and maintaining the mechanical stability of the spine. The motor muscles are usually located in the superficial layer around the spine, in the shape of a shuttle, such as the latissimus dorsi, external abdominal oblique, erector spinae, lumbaris major, and thigh and hip muscles. These muscle contractions usually produce greater force to control the movement of the cone through centripetal contractions. While traditional lumbar and abdominal strength training focuses on the motor muscle groups, core stability training involves the muscles of the entire trunk and pelvis, with a particular focus on the small muscle groups located deep within. Training in unstable conditions allows more small muscle groups, especially the periarticular auxiliary muscles, to be involved in the movement. According to this theory, we can enhance the ability of the child with cerebral palsy to stabilize the joints and control the center of gravity during movement with the help of rehabilitation equipment such as barre balls, balance boards and round rolls, such as knee standing, sitting, four crawling and standing training on balance boards.2. Poor muscle co-contraction ability: According to the neurodevelopmental theory [8], muscle co-contraction ability mainly refers to the co-contraction of active and antagonistic muscles to complete the normal To maintain the posture and stability of the body and joints. If the balance of synergy is broken, then the quality of movement decreases. For example, in children with cerebral palsy due to excessive opposite inhibition of involuntary movement and dyscalculia, the movement will induce immediate and excessive relaxation of the antagonist muscles, so that the antagonist muscles do not play the role of motor stop, which is manifested as excessive motility; in children with spastic cerebral palsy, due to excessive and simultaneous contraction of the antagonist muscles of the active muscles, the antagonist muscles in movement cannot relax, forming a state of postural tension hyperactivity. These children even in passive training muscle tone is reduced, muscle coordination is still poor, as shown by the start of the movement of the antagonist muscle diastolic too slow, resulting in difficulties in starting movement, and at the end of the movement antagonist muscle tension too slow, the movement can not be stopped in time. For the above-mentioned cases, we can use compression percussion to make the active, antagonistic and synergistic muscles work at the same time; we can also use alternating percussion to ensure the intermediate position of the child by alternating percussion on different parts of the child’s body in opposite directions. The stability of the core of a child with cerebral palsy is inseparable from the stability of the limbs and head and neck, and the two exist in a complementary relationship. The stability of the core is the guarantee of the completion of normal movement of the head, neck and limbs, while the normal strength and tone of the head and neck muscles of the limbs is the basis of core stability. Such as the disappearance of the abnormal posture of both lower limbs and good weight-bearing ability is a prerequisite for the human core to achieve balance in the upright position, while the core’s wobbliness directly affects the realization of the upright position. Advocating core stability does not mean neglecting the limb muscle groups, but on the contrary, it is to better promote the achievement of limb movement. The movement disorder of children with cerebral palsy is rarely a problem of a single muscle group or a single limb, but only the severity of the problem differs in each part of the body. This requires that we should not focus on the local area during the training, but start from the whole area and correct the weak links according to the law of human development, so as to better promote the recovery of children with cerebral palsy.