Journal of The Korean Society of Physical Medicine, 2013; 8(1): 11-18 Online ISSN: 2287-7215 Print ISSN: 1975-311X Research Article Open Access 다양한자세에따른복부할로잉과브레이싱수축시체간근활성도의차이 문현주 조성학 1 구봉오 22) 부산가톨릭대학교물리치료학과, 1 부산가톨릭대학교물리치료학과, 2 부산가톨릭대학교물리치료학과 Difference of Trunk Muscles Activity during vs Contraction in Various Position Hyun-ju Moon, PT, MS, Sung-hak Cho, PT, MS 1, Bong-oh Goo, PT, PhD 2 Department of Physical Therapy, Busan Catholic University, 1 Department of Physical Therapy, Busan Catholic University, 2 Department of Physical Therapy, Busan Catholic University Received: August 30, 2012 / Revised: October 22, 2012 / Accepted: November 6, 2012 c 2013 Journal of the Korean Society of Physical Medicine Abstract PURPOSE: The purpose of this study was to investigate the difference of trunk muscles activity during abdominal hollowing and bracing contraction in various position. METHODS: This pilot test was carried out in a volunteer sample of normal adults(n=24) without a history of low back pain or injury. 24 subjects were randomly allocated to three groups(n=8) as a contraction method respectively. In hooklying position, trunk muscles activity of subjects was measured using EMG in various bridging position. RESULTS: Abdominal bracing contraction made to more great trunk deep and superficial muscles activity than hollowing contraction.(p<0.00) Especially, Multifidus activity was the biggest.(p<0.00) CONCLUSION: The result from this study showed that abdominal bracing contraction made to more balancing Corresponding Author : wow1300@hanmail.net This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. activity of trunk muscles than abdominal hollowing contraction. Thus, It will good for trunk muscles unbalanced LBP patient to improve lumbar stabilization. Key Words:,, Dynamic Stability Ⅰ. 서론요통을가진환자들에게흔히볼수있는것이체간의불안정성이다 (Panjabi, 2003). 체간근의안정화는요통의강도를감소시키고움직임시다른부위의보상작용을줄이며, 요통의재발율을감소시키는데필수적이다 (Liebenson 등, 2009; Cynn 등, 2006; Suni 등, 2006; Hides 등, 2001). 또한체간근의안정성및유연성이근력, 지구력, 근협응력, 균형감각등의통합과, 효율적이고기능적인운동기술과도연관되므로스포츠에서경기력향상을위한체간안정화운동의중요성이부각되고있다 (Cook, 2001; Kiblar 등, 2006). 따라서요통환자뿐만아니라운동선수들의체간안정성을증진하기위한방법으로복부할로잉 (hollowing) 운동과복부브레이싱 (bracing) 운동등이있다 (Richardson 과 Jull, 1992; McGill과 Karpowicz, 2009).
12 대한물리의학회지제 8 권제 1 호 Hodge와 Richardson(1996) 은요통을가진환자들에게서상지의빠른움직임시복횡근의선행적조절시간이지연되었음을보고하였다. 이를근거로체간안정화를위해심부근인다열근과복횡근만의선택적수축을강조하는할로잉운동기법을제안하였으며, 현재요통환자의치료에있어기초가되는운동으로여겨지고있다. 그러나 Radebold 등 (2000) 은요통환자들은복횡근뿐만아니라체간의전반적인근육의수축지연을보였으며, Hicks 등 (2005) 은로컬근육 (local muscle) 의선택적수축이체간을안정화시킬지에대한직접적인근거는불충분하다고하였다. 또한체간근의최대등척성수축의 2% 정도를차지하던복횡근이사지가움직이는범위나강도가커질수록내복사근의협력근으로서작용해더많은활성화가일어나는것으로볼때 (Juker 등, 1998) 단하나의근육이요부안정성및기능적인움직임을활성화시킬지는의문시되고있다 (Kavcic 등, 2004). 따라서최근연구엔복횡근만의선택적인활성화가오히려전반적인체간안정성의효율을떨어뜨릴수있고이러한이유로전체적인복부근력의발란스를강조하는운동이더좋을수있다고하였다 (Koumantakis 등, 2005). 한편 McGill(2001) 이주장하는브레이싱운동은체간을이루는심부와표층근및엉덩이근육간의잘조화된협응적수축이복부를단단하게만들어서복내압을증진시키고, 이증가된복내압은골반저근을압박해체간의안정성증진뿐만아니라골반부의안정성도증진시킨다고했다. 그근거로는상하지및체간이갑작스런외부적동요 (perturbation) 시에표층의근육들이긴지레팔을가지고있어서, 강한힘과빠른속도, 큰토크로일차적반응을하여척추와골반간의바른정렬을유지함으로써체간의안정성을만들어준다는데있다 (Comerford와 Mottram, 2001). Malik(2009) 의할로잉과브레이싱의비교고찰연구와함께복부할로잉과브레이싱의체간안정성에대한 Vera-Garcia 등 (2007) 의비교연구에서도할로잉은갑작스런움직임에대한동요를감소시키기엔비효율적이라고했으며, 반면에브레이싱은체간의동시수축을증폭시켜요추의전이를감소시킴으로서체간안정성을증진시킨다고했다. 이처 럼정적인자세에서의할로잉과브레이싱운동의비교에관한연구는많이있어왔지만동적인상황에서의브레이싱과할로잉의안정성에관한비교연구는거의없는실정이다. 또한체간안정성증진을위한운동방법이다양하게발달되어왔고스포츠나재활치료분야에서폭넓게이용되고있지만적절한운동의선택에대한정의는아직도불분명하다 (Colado 등, 2008;). 따라서본연구의목적은정상성인을대상으로복부할로잉수축과브레이싱수축을하지의동적인움직임과함께실시했을때, 각움직임에따른체간근의활성도를비교해보고요통을가진환자뿐만아니라기능적움직임을증진하기위한운동처방의기초자료로이용하고자함이다. Ⅱ. 연구방법 1. 연구대상자본연구는파일럿 (pilot) 실험으로써, 연구에동의한 20세이상정상성인남녀24명을대상으로하였다. 대상자의조건은우세다리가오른쪽인사람으로하였으며, 신경또는근골격계적이상및정신적질환이없고정형외과적수술을하지않은것을기준으로하였다. 2. 연구방법본실험에들어가기에앞서대상자에게친숙기간을갖도록 1주일중 2일에걸쳐교각동작과복부할로잉, 브레이싱수축방법을교육시켰다. 교각동작은갈고리누운자세 (hooklying) 에서골반을들어올렸을때, 어깨와골반과무릎이일직선이되도록하였다. 할로잉은갈고리누운자세에서척추만곡과골반과늑골의움직임없이배꼽을내측상방으로당기면서자연스러운호흡을하게하였으며 (Norris, 1995; Richardson과 Jull, 1995; O Sullivan, 2000) 초음파를통해복횡근의수축상태를보면서피드백을하도록하였다. 브레이싱은갈고리누운자세로허리와골반의정렬을맞춘상태에서실시하였다. 누군가배를치려할때반사적으로복부에힘이들어가듯요추를중심으로
다양한자세에따른복부할로잉과브레이싱수축시체간근활성도의차이 13 전, 후, 좌, 우로복부를팽창시킨다는생각을가지면서요골반부를수축하되자연스럽게호흡을유지하도록하였다 (Liebenson, 2007; McGill, 2009). 본실험에서모든대상자는복직근, 외복사근, 다열근, 요부신근의최대등척성수축을하여기준값을정한다음세가지의교각동작을실시하도록하였다. 최대등척성수축은바로누운자세와엎드려누운자세에서실시하였고, 각동작을두번씩시켜그최대값을기준으로정하였다 (Danneels, 2001). 수축시간은 5초간유지하도록하였으며각동작이끝날때마다 2분간휴식을취하게하였다. 대조군에서처음동작의시작자세는무릎을 90도로구부리고발은바닥에닿은갈고리누운자세에서시작했고양팔은팔꿈치를펴서몸통옆에두도록하였다. 대상자가큐신호를듣고곧바로골반을들게하였다. 그다음동작은오른쪽다리의무릎을편체로골반을들게하였으며, 마지막동작은오른쪽다리의무릎을편체로고관절을 45도외전하면서골반을들게하였다. 할로잉군은대조군과같은시작자세에서복부할로 잉수축을먼저만든다음실험자의큐신호와동시에복부할로잉수축을유지한체로대조군과같은세가지교각동작을하도록하였고, 브레이싱군역시대조군과같은시작자세에서복부브레이싱수축을먼저시킨다음복부브레이싱상태를유지하면서대조군과같은세가지교각동작을하도록했다. 각동작들은 5초에걸쳐서하도록하였고각동작이끝날때마다 1분씩쉬게하였으며각동작을 3번씩측정하여그평균값을분석에이용하였다. 세가지의교각동작을실시할때다리가움직이는방향을바꿈으로써점진적으로더어려워지게하였으며실험자는근전도의모니터를보면서외복사근의근활성도를기준으로할로잉군과브레이싱군에게복부수축상태를피드백시켰다. 실험보조자는대상자가정확한자세를하는지지켜보면서다른보상적동작이나타나는지, 통증이있는지등을확인하였다. 모든대상자는오른쪽복직근, 외복사근, 다열근, 요부신근의근활성도를측정하였고, 8일에걸쳐 3명씩측정하였다. Control - MVIC B BLL BLA - MVIC HB HBLL HBLA - MVIC BrB BrBLL BrBLA Fig. 1. Testing procedures. Control; Control Group, ; Group, ; Group, MVIC; Maximal Voluntary Isometric Contraction, B; Bridging, LL; Leg Lift, LA; Leg Abduction, H;, Br; Fig. 2. three bridging exercise
14 대한물리의학회지제 8 권제 1 호 3. 측정방법체간근육들에대한근활성도측정을위해근전도 (Noraxon MyoResearch system, Noraxon Inc, 미국 ) 를사용하였다. 피부를알코올솜으로닦아건조시킨뒤한쌍의 Ag/AgCl blue sensor 전극을오른쪽의다열근 ( 요추 4,5번사이극돌기를중심으로오른쪽 20mm 지점 ) 과요부신전근 ( 요추1,2번의극돌기를중심으로오른쪽 60mm) 그리고외복사근 ( 배꼽높이에서오른쪽으로 150mm 지점 ) 과복직근 ( 배꼽높이에서오른쪽으로 30mm지점 ) 에각근육마다두개씩 20mm 간격으로붙였다 (Arokoski 등 1999; Cholewicki와 McGill, 1996). 쌍으로된 4개의무선활성전극 (active electrode) 을 blue sensor전극위에각각붙였으며, 기준전극 (reference electrode) 은따로붙이진않았다. 표면근전도신호의표본추출률은 1000Hz 로설정하였고, 주파수대역폭은 Noraxon EMG system의측정주파수대역필터인 20 450Hz를사용하였다. 자료의분석을위한소프트웨어프로그램은 MyoResearch verson 4.0으로하였으며, 각동작은큐신호로부터 5초에걸쳐이루어지도록하였으며그 5초중전후 1초씩을끊어낸 3초동안의근전도신호를 RMS(root mean square) 처리하여 MVIC의 % 형태로전환하여분석하였다. 4. 분석방법대상자의일반적인특성은기술통계를하여평균과표준편차를산출하였다. 세군간의근활성도의차이와세가지동작에따른근활성도를알아보기위해 SPSS for 18.0 win 프로그램을이용하여이원배치분산분석 (two-way ANOVA) 으로분석하였다. 측정값은평균과표준편차로나타내고사후분석은 Bonferroni로하였으며유의수준은 α=.05로하였다. Ⅲ. 결과 1. 연구대상의일반적인특성연구대상자는요통이없는 20대남녀 24명중무작위로 8명씩세군으로나누었으며일반적인특성은아래와같다 (Table 1). Table 1. Genral characteristics of subjects (each group n=8) Variable General mean±sd Age(year) 21.41±.56 21.71±.61 22.12±.21 Height(cm) 168.43±1.82 167.98±2.11 167.70±2.04 Weight(kg) 58.25±2.76 59.34±3.12 57.56±4.21 BMI 20.55±.65 20.97±.99 20.29±.57 BMI; Body Mass Index 2. 세군간체간근의활성도비교동일한자세에서군별로근활성도를비교해본결과군간유의한차이가있었다 (p<.05). 사후분석결과복직근과다열근은군별로유의한차이가있었고, 외복사근은대조군과할로잉군사이에유의한차이가없었으며 (p<.08), 요부신근도대조군과브레이싱군사이에유의한차이가없었다 (p<.31). Table 2. Comparision of trunk muscles activity in three group Group Muscle Mean±SD(%) F p post-hoc Control Control Control Control RA EO MF ES 10.35±4.44 8.35±3.87 21.45±5.15 17.87±6.55 15.67±6.42 24.96±5.08 40.25±6.82 34.05±5.42 39.64±4.61 30.08±4.35 26.80±6.15 28.63±4.74 134.13.00* b<c 30.37.00* a,b<c 38.78.00* b<c 4.89.01 b<c Control; Bridging Group, ; Group, ; Group, RA:; Rectus Abdominis, EO:; External Oblique, MF; Multifidus, ES;: Erector Spinae 3. 세자세간체간근의활성도비교동일한군내에서동작별로각근육의활성도를비교했을때다리외전하면서교각동작, 다리들면서교각동작, 단순교각동작순으로활성도가높았고, 동작별로유의한차이가있었다 (P<.05). 사후분석결과복직근
다양한자세에따른복부할로잉과브레이싱수축시체간근활성도의차이 15 과요부신근은각동작마다유의한차이가있었고, 다열근 (p<.36) 과외복사근 (p<.21) 은다리드는동작과다리외전하는동작간에유의한차이가없었다. Table 3. Comparision of trunk muscles activity in various position Position Bridging only Bridging leg lift Bridging leg abduction Bridging only Bridging leg lift Bridging leg abduction Bridging only Bridging leg lift Bridging leg abduction Bridging only Bridging leg lift Bridging leg abduction Muscle Mean±SD (%) RA EO MF ES F p post-hoc 9.45±6.62 13.07±6.14 45.25.00* a<b<c 17.63±6.97 13.78±5.56 23.14±5.19 32.44.00* a<b,c 21.58±6.97 34.83±5.31 41.50±6.10 42.61±7.11 25.55±3.63 28.16±4.87 32.17±3.04 4.04.00 a<b,c 1.16.00 a<b<c RA:; Rectus Abdominis, EO:; External Oblique, MF; Multifidus, ES;: Erector Spinae Ⅳ. 고찰 본연구에서는복부할로잉군과브레이싱군그리고대조군에게세가지의동적인교각동작을각각실시하여체간근의활성도를비교해보았다. 연구결과브레이싱군이할로잉군보다표층근과심층근모두근활성도가유의하게높게나타났으며전반적인근육의활성도를비교해볼때, 세군중브레이싱군이가장높았고할로잉군이가장낮았다. 이는복횡근과다열근의선택적수축을유도하는할로잉이외복사근과복직근같은다른체간근들의활동성을상대적으로억제함으로써, 체간의표층과심층근의협응적수축을유도하는브레이싱군보다전반적인근활성도가떨어진것으로보인다. McGill 과 Karpowicz(2009) 는복부할로잉을유지한상태로크런치 (crunch) 나다른운동을하는것보다일반적인크런치를할때척추가외부적부하를견디는힘이오히려더좋았다는연구결과를얻었다. 이는전반적인근육의수축을유도하는크런치에할로잉을추가하여움직이다보니할로잉에필요한단지몇개의근육만이활성화되므로써원래의크런치운동을할때일어나던근활성도보다전반적인근육의활성도가떨어진것으로보인다. 따라서몇개의근육만선택적으로강화한다면체간의안정성은감소될것이라고 McGill과 Karpowicz(2009) 는말하였다. Kavcic 등 (2004) 역시복횡근만선택적인조절을하는훈련을받은환자들은복직근과내, 외복사근의활동성이억제되는결과를가져왔다고했다. 본연구결과도할로잉군이다른군들과비교하여외복사근과복직근등이유의하게낮은근활성도를보인것으로보아할로잉을한체로동적인동작을해서표층근들의근활성도가떨어지는결과를가져온것으로사료된다. 그리고본연구에서는체간의표층근과심층근의활성도의비율을비교해보았다. 심층근인다열근이표층근외복사근보다높은활성도를보였는데, 다열근을기준으로했을때외복사근의활성도비율은브레이싱군은 61%, 할로잉군은 44% 로써브레이싱군이심층근과표층근간의활성도편차가적었다. 또한할로잉군과브레이싱군사이에서심층근인다열근만비교해보면, 할로잉이심층근의선택적인근수축을유도하는수축방법임에도불구하고오히려브레이싱수축시다열근의활성도가더높게나타났다. Critchley(2002) 이정상성인을대상으로할로잉운동을실시했을때보다골반저근을함께수축시키면서할로잉운동을했을때복횡근의두께가유의하게커졌다는연구결과를볼때도다른근육들의협력수축이복횡근만선택적으로수축시키는것보다활동성을더증진시킨다는결과가있었다. 또최근에는발목배측굴곡에저항을주어방사 (irradiation) 를통해복근을강화하는실험연구가있었다 (Chon 등, 2010). 이연구에서는건강한성인과요통이있는성인두그룹으로나눠할로잉만실시한그룹과발목배측굴곡과함께할로잉을
16 대한물리의학회지제 8 권제 1 호 실시한그룹중어느그룹이복근의활성도가더증진되는가를알아보았는데, 그결과발목배측굴곡과함께할로잉한그룹이훨씬복횡근과내복사근의활성도가컸으며요통도유의하게감소되었다. 이는본연구에서도심층근과표층근이다같이협응적수축을하는브레이싱군에서단순할로잉군보다다열근의활성도가더높게나온것과일치하는결과라생각된다. 따라서요통환자뿐만아니라운동선수들에게체간안정성증진을목적으로운동을시킬때, 특정근육의수축을목적으로하지않는다면굳이할로잉을하지않고브레이싱수축을훈련시킴으로서신경근조절의촉진과균형있는근력을동시에발생시킬수있을것이라생각된다. 또할로잉운동이신경근조절력을증진시킬지라도그것만으로척추를안정화시킨다고볼수는없고모든근육이척추안정성에중요한역할을하며그것이조화롭게협응되어야만진정한척추의안정성을만들수있다고본다. 그런점에서복부브레이싱은척추를바르게정렬함과동시에체간의표층근과심층근심지어길항근의협응까지유발시켜척추의안정성을증진시킬것으로생각된다. 또한본연구에서세가지의교각동작을제시한목적은각동작시체간근의활동성도에어떤차이가있는지를알기위해서였다. 다리를드는동작과외전시키는동작은동적인움직임을만들어줌과동시에근육의활동성요구도와실행의난이도를조절할수있다고가정하여좀더세부적으로다리를움직이는방향을나누어실험해본것이다. Hodges(1999) 의연구에따르면팔을드는방향에따른복횡근활성도와근개시시간 (onset time) 을측정한연구에서팔을외전했을때복횡근활성도가가장컸고, Saliba 등 (2010) 에따르면요통환자들을바닥이불안정한지면과안정된지면에서복부할로잉을유지한상태로다리를굴곡, 외전했을때, 외전시에복횡근의활성도가유의하게높게나타났다고했다. 이처럼상, 하지모두외전시에활성도가높게나온연구결과와마찬가지로, 본연구에서도자세별로근활성도를측정해본결과다리를외전했을때근활성도가유의하게높았다. 이는척추에직접붙어있지않는외복사근과복직근같은표층근 이다리를외전할때골반의토크 (torque) 를발생시켜요골반부의바른정렬을유지할수있도록함으로써전반적인근활성도가다른자세에비해증가된것으로사료된다 (Bergmark, 1989). 다른군에비해브레이싱군에서한쪽다리외전시에복직근과외복사근의근활성도가가장높게나타났으며브레이싱군을기준으로할로잉군의복직근과외복사근의근활성도의평균은각각 38% 와 62% 밖에미치지못했다. 이는브레이싱군이할로잉군에비해서외복사근과복직근이등척성수축을하여척추의비틀림 (torsion) 을제거하고, 골반과늑곽을잠궈주는 (locking) 작용이강조되는운동이기때문인것으로생각된다 (McGill과 Karpowicz, 2009). 따라서 Faries와 Greenwood(2007) 는복횡근과다열근의선택적수축을시키는할로잉은동적인움직임을하는동안다른근육들의정상적인활동을감소시키며다른체간안정성근육들의자연스러운협응을막을수도있다고했으며, 복횡근만을선택적으로강화하는것은운동조절력을향상하기위한수단이나정적인자세에서이뤄지는운동이므로동적안정성이필요함에도불구하고, 복횡근외의다른근육들의수축이억제됨으로써동적인체간의안정성을만드는것은부족할지모른다고하였고, 따라서할로잉은동적인환경에서의업무수행보다국소근육의정적인운동에더적합하다고하였다. Grenier와 McGill(2007) 의연구에따르면 4가지동적인자세에서복횡근은, 척추에가해지는동요에반응할때힘의효율성면에서떨어진다고했고, 특히체간안정성증진을목적으로할로잉운동을하는것은역학적으로비합리적이라고했다. 게다가단지복횡근과다열근두개의근육에초점을맞춘것은동적안정성의개념에비추어볼때지나치게단순화된접근방법이라하였다. 또한 Allison과 Morris(2008) 에의해할로잉이체간안정성에정말효과적인지아닌지에대한의문이증폭되기도했는데복횡근의선택적수축이비록임상적으로요통을완화하는유용성을보여줄지라도그것이척추의안정성에직접적으로큰역할을하는지의추정은아직불명확하다고하였다. 따라서본연구의결과는세군중에서브레이싱군이할로잉군에비해체간의표층과심층근모두균형적인근활성도를
다양한자세에따른복부할로잉과브레이싱수축시체간근활성도의차이 17 보였으며, 다리를외전하는동작시에근활성도가가장컸다. 요통환자가아닌정상성인을대상으로연구를한만큼요통환자와운동선수에게있어운동조절력과체간근강화를위해서운동을적용할때, 본연구결과를토대로운동적용방법의기초자료로써의가치가있을것이다. 다만본연구에서의제한점은일반인을대상으로하였으므로각수축을했을때통증의경감도를알지는못했다. 따라서할로잉운동과브레이싱운동시통증의경감유무를비교해본경우는적기때문에앞으로요통환자들을대상으로두운동법이통증에미치는영향에대해비교하는연구를해보고치료에적용한다면더유익하지않을까생각된다. Ⅴ. 결론본연구에서복부할로잉과브레이싱수축을세가지동작에서실시했을때근활성도를비교해본결과할로잉군보다브레이싱군에서체간의표층과심층근모두근활성도가높았다. 이는할로잉이체간심층근만의선택적수축을유도하는것과달리브레이싱은체간의심층과표층근이협응을하여특정근육에편중되지않고고르게근활성도를증가시킨것으로보인다. 특히심층근인다열근이할로잉군보다브레이싱군에서근활성도가더높은것으로볼때, 체간안정성을위해브레이싱수축을훈련시킴으로서신경근조절력과체간의균형있는근력을함께발달시킬수있을것이라생각된다. 더불어다리를움직이는방향에따른체간근의활성도의차이를통해임상가들이요통환자들에게또는운동선수들에게적절한운동을적용하는데있어서기초자료로활용할수있을것으로사료된다. 참고문헌 Allison GT, Morris SL. Transversus abdominis and core stability: has the pendulum swung? Br J Sports Med. 2008;42(11):930-1. Arokoski JP, Kankaanpaa M, Valta T et al. Back and hip extensor muscle function during therapeutic exercises. Arch Phys Med Rehabil. 1999;80(7):842-50. Bergmark A. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand Suppl. 1989;230: 1-54. Cook G. Base-line sports-fitness testing. In: high performance sports conditioning. B Foran ed. Champaign IL. human kinetics Inc. 2001. Chon SC, Chang KY, You SH. Effect of the abdominal draw in maneuver in combination with ankle dorsiflexion in strengthening transverse abdominal muscle in healthy young adults: A preliminary, randomized, controlled study. Physiotherapy. 2010;96(2):130-6. Comerford MJ, Mottram SL. Movement and stability dysfunction-contemporary developments. Man Ther. 2001;6(1):15-26. Critchley D. Instructing pelvic floor contraction facilitates transversus abdominis thickness increase during low-abdominal hollowing. Physiother Res Int. 2002; 7(2):65-75. Cholewicki J, McGill SM. Mechanical stability of the in vivo lumbar spine: implications for injury and chronic low back pain. Clin Biomech. 1996;11(1):1-15. Cynn HS, Oh JS, kwon OY et al. Effects of lumbar stabilization using a pressure biofeedback unit on muscle activity and lateral pelvic tilt during hip abduction in sidelying. Arch Phys Med Rehabil. 2006;87(11):1454-8. Danneels LA, Vanderstraeten GG, Cambier DC et al. A functional subdivision of hip, abdominal, and back muscles during asymmetric lifting. Spine. 2001;26(6): E114-21. Faries MD, Greenwood M. Core training: stabilizing the confusion. Strength Condition J. 2007;29(2):1025. Grenier S, McGill S. Quantification of lumbar stability by using 2 different abdominal activation strategies. Arch Phys Med Rehabil. 2007;88(1):54-62. Hides JA, Jull GA, Richardson CA. Long-term effects of specific
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