Establishing Core Stability in Rehabilitation
Rehabilitation Techniques for Sports Medicine and Athletic TrainingWilliam E. Prentice
What is the Core?
Core defined as the lumbo-pelvic-hip (LPH) complex– Where our 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
• Also provide proximal stability for efficient upper and lower extremity movements
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
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
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 because not enough trunk stabilization created to produce efficient movements.
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 functional movement
• Lead to compensation and substitution patterns as well as poor posture during functional 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• More muscle spindles, therefore primarily responsible for
providing 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 muscle 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
– Leads to 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 (Table 5-1 pg. 109)– 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