Chapter 10: Core Stabilization Training in Rehabilitation

1. Chapter 10: Core Stabilization Training in Rehabilitation

2. Function • Integrated, multidimensional movement • Functional Kinetic Chain Rehabilitation • Comprehensive approach to improve all components necessary to allow athlete to function at high level • Must address each link of kinetic chain • Develop functional strength and neuromuscular efficiency • Functional strength • Ability of neuromuscular system to reduce and produce force and dynamically stabilize the kinetic chain during functional movements

3. Neuromuscular efficiency • Ability of CNS to allow agonists, antagonists, synergists, stabilizers and neutralizers to work efficiently and interdependently • Rehabilitation generally focuses on isolated uni-planar strength gains in single muscles • Functional activities are tri-planar requiring acceleration and stabilization • Dynamic stabilization is critical for optimal neuromuscular efficiency • Clinicians must be willing to make paradigm shift • Train the entire kinetic chain on all levels in all planes focusing on functional strength and neuromuscular efficiency

4. Dynamic core stabilization is a key component to this program • Improves postural control • Ensures appropriate muscular balance and joint arthrokinematics (lumbo-pelvic-hip complex) • Allows for expression of dynamic functional performance throughout the entire kinetic chain

5. What is the core? • Lumbo-pelvic-hip complex • Location of center of gravity (CoG) • 29 muscles attach to the core • Efficient core allows for • maintenance of normal length-tension relationships • Maintenance of normal force couples • Maintenance of optimal arthrokinematics • Optimal efficiency in entire kinetic chain during movement • Acceleration, deceleration, dynamic stabilization • Proximal stability for movement of extremities

6. Core functions as an integrated functional unit • Entire kinetic chain operates synergistically • Core efficiency enables structures to operate optimally • Distribution of weight • Absorption of force • Transfer of ground reaction forces • Requires training for optimal functioning

7. Core Stabilization Training Concepts • Spinal stabilization • Must be adequate to effectively utilize strength, power, neuromuscular control and endurance of the “prime movers” • Weak core = decreased force production and efficiency • May result in injury • Protective mechanism for the spine • Facilitates balanced muscular functioning of the entire kinetic chain • Enhanced neuromuscular control provides for more efficient body positioning biomechanically

8. Neuromuscular efficiency • Combination of postural alignment and stability strength • Optimizes body’s ability to generate and adapt to forces • Inefficiency results in body’s inability to respond to demands • Decrease in ability to maintain appropriate forces and dynamic stabilization of the kinetic chain • Results in compensatory actions and increased mechanical stress on contractile and non-contractile tissues • Can result in repetitive microtrauma, faulty biomechanics and injury

9. Review of Functional Anatomy • Lumbar Spine Muscles • Transversospinalis group • Erector spinae • Quadratus lumborum • Latissimus Dorsi

10. Transversospinalis group • Poor mechanical advantage relative to movement production • Primarily Type I muscle fibers with high degree of muscle spindles • Optimal for providing proprioceptive information to CNS • Inter/intra-segmental stabilization • Erector spinae • Provide intersegmental stabilization • Eccentrically decelerate trunk flexion and rotation • Quadratus Lumborum • Frontal plane stabilizer • Works in conjunction with gluteus medius and tensor fascia lata • Latissimus Dorsi • Bridge between upper extremity and core

11. Abdominal Muscles • Rectus abdominus • External obliques • Internal obliques • Transverse abdominus • Work to optimize spinal mechanics • Provide sagittal, frontal and transverse plane stabilization

12. Hip Musculature

13. Psoas • Closed chain vs. open chain functioning • Works with erector spinae, multifidus and deep abdominal wall to balance anterior shear forces of lumbar spine • Can reciprocally inhibit gluteus maximus, multifidus, deep erector spinae, internal oblique and transverse abdominus when tight • Extensor mechanism dysfunction • Synergistic dominance during hip extension • Hamstrings and superficial erector spinae • May alter gluteus maximus function, altering hip rotation, gait cycle

14. Gluteus medius • Frontal plane stabilizer • Weakness increases frontal and transverse plane stresses (patellofemoral stress) • Controls femoral adduction and internal rotation • Weakness results in synergistic dominance of TFL and quadratus lumborum • Gluteus maximus • Hip extension and external rotation during OKC, concentrically • Eccentrically hip flexion and internal rotation • Decelerates tibial internal rotation with TFL • Stabilizes SI joint • Faulty firing results in decreased pelvic stability and neuromuscular control

15. Hamstrings • Concentrically flex the knee, extend the hip and rotate the tibia • Eccentrically decelerate knee extension, hip flexion and tibial rotation • Work synergistically with the ACL to stabilize tibial translation • All muscles produce and control forces in multiple planes

16. Postural Considerations • Core functions to maintain postural alignment and dynamic postural equilibrium • Optimal alignment = optimal functional training and rehabilitation • Segmental deficit results in predictable dysfunction • Serial distortion patterns • Structural integrity of body is compromised due to malalignment • Abnormal forces are distributed above and below misaligned segment • Work to maintain alignment

17. Muscular Imbalances • Balanced core = prevention of muscle imbalances and synergistic dominance • Pathology within kinetic chain is part of chain reaction – compensatory reaction of kinetic chain • Muscle tightness and weakness impacts • Length-tension relationship • Force-couples • Arthrokinematics • Reciprocal inhibition – facilitating muscle imbalance

18. Neuromuscular Considerations • Enhance dynamic postural control with strong stable core • Kinetic chain imbalances = deficient neuromuscular control • Impact of low back pain on neuromuscular control • Joint/ligament injury neuromuscular deficits • Arthrokinetic reflex • Reflexes mediated by joint receptor activity • Altered arthrokinetic reflex can result in arthrogenic muscle inhibition • Disrupted muscle function due to altered joint functioning

19. Assessment of the Core • Muscle imbalances • Arthrokinematic deficits • Core • Strength • Endurance • Neuromuscular control • Power • Overall function of lower extremity kinetic chain

20. Straight-Leg Lowering Test for Core Strength

21. Abdominal Neuromuscular Control Test • Athlete performs drawing in maneuver • Lower legs until pressure decreases • Assesses lumbar spine moving into extension • Hip flexors begin to work as stabilizers • Resulting muscle inhibition

22. Core Muscular Endurance and Power • Endurance • Erector spinae performance • Athlete is prone with hands behind head and spine extended 30 degrees • Measure ability to sustain position with goniometer • Utilize axilla and table for frame of reference • Test performed for time • Power • Backwards, overhead medicine ball jump and throw • Assessment of total body power production

23. Lower extremity functional profiles • Isokinetic tests • Balance tests • Jump tests • Power tests • Sports specific functional tests • Kinetic chain assessment must assess all areas of potential deficiency

24. Scientific Rationale for Core Stabilization Training • Must train at an adequate levels • Too much vs. Not enough • Injury can disrupt muscle function (low back pain) • Training with muscle deficits results in altered kinetic chain stabilization • May result in altered segmental function • Appropriate training stimulus must be prescribed • To ensure maintained dynamic postural control endurance training must be incorporated • Utilize time under tension method • Trains hype-contractions at end range of motion

25. Guidelines for Core Stabilization Training • Perform comprehensive evaluation • Muscle imbalances and arthrokinematic deficits must be corrected prior to initiating aggressive training • Program Requirements • Systematic • Progressive • Functional

26. Program should emphasize muscle contraction spectrum • Concentric (force production) • Eccentric (force reduction) • Isometric (dynamic stabilization) • Program must be challenging with progression through function continuum • Variables – must be modified • Plane of motion • range of motion • loading • body position • amount of control and speed • feedback • duration and frequency

27. Specific Guidelines • Proprioceptively rich program • Safe • Challenging • Stress multiple planes • Incorporate multi-sensory environment • Derived from fundamental movement skills • Activity specific • Progressive functional continuum • Slow to fast • Simple to complex • Known to unknown • Low force to high force • Eyes open to eyes closed • Static to dynamic

28. Goal of program should be to develop optimal levels of functional strength and stabilization • Focus on neural adaptations instead of absolute strength gains • Increase proprioceptive demands • Quality not quantity • Poor technique and neuromuscular control results in poor motor patterns and stabilization • Focus on function

29. Core Stabilization Training Program • Level I: Stabilization

30. Level II: Stabilization and Strength

31. Level II: Stabilization and Strength (continued)

32. Level III: Integrated Stabilization Strength

33. Level IV: Explosive Stabilization