Establishing Core Stability in Rehabilitation

Rehabilitation Techniques for Sports Medicine and Athletic TrainingWilliam E. Prentice

Core Stabilization

A dynamic core stabilization training program should be key component of all comprehensive functional rehab. programs– Improve dynamic postural control– Ensure appropriate muscular balance– Affect arthrokinematics (physiology of joint movement: how

one joint moves on another) around lumbo-pelvic-hip (LPH) complex

– Allow dynamic functional strength – Improve neuromuscular efficiency throughout entire kinetic

chain

What is the Core?

Core defined as the lumbo-pelvic-hip (LPH) complex– Center of gravity is located– Where all movement begins– 29 muscles have attachments in this complex

• Maintaining length tension and force-couple relationships will increase neuromuscular efficiency and provide optimal acceleration, deceleration and dynamic stabilization during functional movement

What is the Core?

Allows entire kinetic chain to work synergistically to produce force, reduce force and dynamically stabilize against abnormal force– Each structural component will distribute weight, absorb force

and transfer ground reaction forces

Many terms:– Dynamic lumbar stabilization– Neutral spine control– “Butt and gut”

Core Stabilization Training Concepts

Development of muscles required for spinal stabilization is often neglected– Bodies stabilization system has to be functioning optimally to

effectively use muscle strength, power, endurance, and neuromuscular control developed in S &C programs

– A weak core is a fundamental problem of many inefficient movements that lead to injury

• If extremities are strong, but core is weak optimal movement cannot be obtained

Core Stabilization Training Concepts

Core musculature important for protective mechanism that relieves spine of harmful or unexpected forces– Greater neuromuscular control and stabilization strength

through core program will offer a more biomechanical efficient position for kinetic chain

– If neuromuscular system is not efficient it will be unable to respond to demands placed on it during fxal movement

• Lead to compensation and substitution patterns as well as poor posture during fxal activities

• Increase mechanical stress on contractile and non-contractile tissue thus leading to injury

Review of Functional AnatomyLumbar spine, abdominal and hip musculature– Lumbar spine musculature includes the

transversospinalis (TVS) group (including multifidi), erector spinae, lats, quadratus lumborum

• TVS group: Small and poor mechanical contribution to motion

• Mainly type 1 fibers therefore designed for stabilization• Provide CNS with proprioceptive info.• Compressive and tensile forces during fxal mvmt..

– If trained adequately will allow dynamic postural stab. and optimal neuro-musc. Efficiency

– Multifidus muscles most important in this muscle group

Review of Functional Anatomy

Erector Spinae Muscle– Provides dynamic intersegmental stab. and eccentric

deceleration of trunk flexion and rotation

Quadratus Lumborum– Frontal plane stabilizer that works synergistically with glut

med and TFL

Latissimus Dorsi– Bridge between upper extremity and LPH complex

Review of Functional Anatomy

Abdominal muscles: Rectus abdominus, external and internal obliques & most importantly transverse abdominus (TA)– Offer sagittal, frontal and transversus plane

stabilization by controlling forces in LPH complex– TA: increases intra-abdominal pressure (IAP) thus

providing dynamic stab. against rotational and translational stress in lumbar spine

• Contracts before all limb movement and all other abdominals.

– Active during all trunk movements suggesting important role in dynamic stab.

Review of Functional Anatomy

Key Hip Musculature– Psoas– Gluteus Medius– Gluteus maximus– Hamstrings

Review of Functional Anatomy

Psoas– Common to develop tightness

• Increase shear force and compressive forces at L4-L5 junction

• Lead to reciprocal inhibition of glut maximus, multifidus, deep erector spinae, internal oblique, and TA

– Extensor mechanism dysfunction during fxal mvmt patterns.

Review of Functional Anatomy

Glut medius– During closed chain movements decelerates femoral

adduction and internal rotation– Weak glut medius increase frontal and transversus

plane stress at patella-femoral joint and tibiofemoral joint

• Dominance of TFL and quadratus lumborum tightness in IT band & lumbar spineaffect normal biomechanics of LPH complex and PTF joint

– MUST be addressed after lower extremity injury

Review of Functional Anatomy

Gluteus maximus– Open chain hip ext. and ER– In closed chain eccentrically decelerates hip flexion

and IR• Major dynamic stabilizer of SI joint• Decreased activity can lead to pelvic instability,

decreased neuromuscular control muscular imbalances, poor mvmt patternsinjury

Review of Functional Anatomy

Transverse Abdominus– Deepest abdominal muscle– Primary role in trunk stabilization

• Bilateral contraction of TA assists in intra-abdominal pressure thus enhances spinal stiffness

• Reduces laxity in SI joint• Attachment with thorocolumbar fascia adds tension w/

contraction and assist in trunk stability

Review of Functional Anatomy

Multifidi– Most medial of posterior trunk muscles (closest to

lumbar spine)– Primary stabilizers when trunk is moving from flexion

to extension• High percentage type 1 Muscle fiberspostural control• When TA contracts the multifidi are activated

Review of Functional Anatomy

LPH complex is like a cylinder – Inferior wall = pelvic floor muscles– Superior wall=diaphragm– Posterior wall=multifidi– Anterior and lateral walls=TA

• Must all be activated together and taut for trunk stabilization to occur with static and dynamic mvmts

Postural Considerations

Optimal posture will allow for maximal neuro-muscular efficiency– Normal length tension relationship– Force-couple relationship– Arthrokinematics

• Will be maintained during functional mvmt• Comprehensive core stabilization program will prevent

patterns of dysfunction that will effect postural alignment

Muscular Imbalances

Optimal functioning core=prevention of the development of muscular imbalancesPathologies develop through chain reaction of key links of kinetic chainCompensations and adaptations developIf core is weak normal arthrokinematics are altered Muscle tightness has significant impact on kinetic chain– c

Neuromuscular Considerations

Strong, stable core can improve neuromuscular efficiency throughout entire chain by improving dynamic postural controlOptimal core function will positively affect peripheral joints

Core Stabilization Training

Many individuals train core inadequately, incorrectly or too advanced– Can be detrimental– Abdominal training without proper pelvic stabilization can

increase intradiscal pressure and compressive forces on lumbar spine

– Core strength endurance must be trained appropriately• Allow individual to maintain prolonged dynamic postural

control• **Also important to hold cervical spine in neutral to

improve posture, muscle balance and stabilization

Core Stabilization Training

Time under tension– Improves intramuscular coordination which improves

static and dynamic stabilizationPatient education is key– Must understand and be able to visualize muscle

activation– Muscular activation of deep core stabilizers (TA and

multifidi) w/ normal breathing is foundation of all core exercises

Assessment of Core

Activity based test– SL lowering test using biofeedback Stabilizer

Manual Test– Multifidi & TA

EMG– Surface electrodes

Ultrasound– Reliable tool in determining activation patterns of abdominal

muscles

Drawing In Maneuver

All core exercises must start with a “drawing in” maneuver, or abdominal brace– Different concepts on how to achieve

• Maximal or submaximal contraction• Key is to allow normal breathing, proper muscular

activation cannot be achieved if patient is holding breath• Exercises can start supine or standing in static position,

but should not be abandoned as core exercises become more difficult

Specific Core Stabilization Exercises

Progression of Core Exercises once abdominal bracing is perfected and able to be maintained through exercise– Static– Supine and Prone Exercises– Quadruped Exercises– Comprehensive Core Stabilization Program

• Stabilization• Strength• Power

Guidelines for Core Stabilization Program

Systematic, Progressive and Functional– Manipulate program regularly

• Plane of motion, ROM, resistance or loading parameters, body position, amount of control, speed, duration and frequency

• Progressive functional continuum to allow for optimal adaptations