Establishing Core Stability in Rehabilitation

1. Establishing Core Stability in Rehabilitation Rehabilitation Techniques for Sports Medicine and Athletic Training William E. Prentice

2. 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

3. 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”

4. 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

5. 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.

7. 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

9. Review of Functional Anatomy • Lumbar 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

10. 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

11. 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.

13. Review of Functional Anatomy • Key Hip Musculature • Psoas • Gluteus Medius • Gluteus maximus • Hamstrings

14. 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.

15. 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 spineaffect normal biomechanics of LPH complex and PTF joint • MUST be addressed after lower extremity injury

16. 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 patternsinjury

17. 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

18. 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 fiberspostural control • When TA contracts the multifidi are activated

19. 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

20. 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

24. Muscular Imbalances • Optimal functioning core=prevention of the development of muscular imbalances • Pathologies develop through chain reaction of key links of kinetic chain • Compensations and adaptations develop • If core is weak normal arthrokinematics are altered • Muscle tightness has significant impact on kinetic chain • c

25. Neuromuscular Considerations • Strong, stable core can improve neuromuscular efficiency throughout entire chain by improving dynamic postural control • Optimal core function will positively affect peripheral joints

26. 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

30. Core Stabilization Training • Time under tension • Improves intramuscular coordination which improves static and dynamic stabilization • Patient 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

32. 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

33. 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

34. 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

35. 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