CORE STABILITY An Introduction

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CORE STABILITY An Introduction
By Donna Sanderson-Hull
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Objectives

• Definitions
• Origins
• Benefits
• Theory/Posture and anatomy
• Research
• Practical

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WHAT IS CORE STABILITY?
The system the body uses to give spinal support
and maintain muscular balance while at the same
time providing a firm base of support from which
other muscles can work to enable the body to
undertake its daily tasks. It is through this
system of joint integrity and support that the
body is able to maintain its posture the
position from which all movement begins and
ends Chek P. 2000
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CORE STABILITY

• The ability to maintain neutral spine using the
  abdominal, back, neck and shoulder girdle muscles
  as stabilisers rather than movers

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Orthopaedic view
That state of muscular and skeletal balance
which protects the supporting structures of the
body against injury or progressive deformity,
irrespective of the attitude in which these
structures are working or resting Academy of
Orthopaedic Surgeons 1947.
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NOT A NEW CONCEPT

• STATIC
• Alexander Technique
• Pilates
• DYNAMIC
• Tai-chi/Karate
• Swiss ball training

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ALEXANDER TECHNIQUE 1869-1955

• PRINCIPLES
• RE-EDUCATION OF KINAESTHETIC SENSE
• QUIETING THE MIND TO FOCUS ON THE MIND/BODY
  CONNECTION
• ESTABLISHING A GOOD HEAD AND NECK POSITION

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JOSEPH PILATES 1880-1967

• PRINCIPLES
• CONCENTRATION
• ALIGNMENT
• BREATHING
• CO-ORDINATION
• STAMINA

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FITNESS PARAMETERS

• CARDIOVASCULAR
• STRENGTH / POWER/SPEED
• ENDURANCE
• FLEXIBILITY
• CORE STABILITY
• PROPRIOCEPTION / NEUROMUSCULAR CONTROL

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Paradigm Shift No longer looking to improve
strength in one muscle but improvement in
multidirectional multidimensional neuromuscular
efficiency (firing patterns in entire kinetic
chain within complex motor patterns).
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The Theories

• Spinal Stability
• The passively supported spine (bone and ligament
  will collapse under 20lb (9kg) of load.
• Muscular components that contribute to
  lumbo-pelvic stability which take up the slack

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Control subsystem (Neural)
Spinal stability
Active subsystem (spinal muscles)
Passive subsystem (spinal column)
Adapted from Panjabi (1992)
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Neutral Zone Concept

• Every joint has a neutral zone or position
• Overall internal stresses and muscular efforts
  are minimal
• A region of intervertebral motion around the
  neutral position where little resistance is
  offered by the passive spinal column (Panjabi
  1992)
• Movement outside this region is limited by the
  ligamentous structures providing restraint

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Control of the Neutral Zone

• Ligaments - support end of range only
• - Can be unstable/over-stretched
• Muscle - Can compensate for instability
• - Increase the stiffness of the
  spine
• - Decrease the neutral zone
• - Form basis for therapeutic
  intervention
• in treatment of spinal stability

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Clinical instability

• A significant decrease in the capacity of the
  stabilising system of the spine to maintain the
  internal neutral zones within physiological
  limits which results in pain and disability
  (Panjabi)

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Patho-Kinesiological model(Shirley Sarhmann)

• Muscular system
• Articular system
• Neural system
• All three must work as an integrated unit
• The movement system requires optimum function of
  the core stabilisers resulting in precise
  arthokinematics and osteokinematics (Sarhmann
  2000)

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Spinal Stability

• Demonstrated that submaximal levels of muscle
  activation adequate to provide effective spinal
  stabilisation
• Continuous submaximal muscle activation crucial
  in maintaining lumbopelvic stability for most
  daily tasks.

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Benefits of Spinal Stability

• Improve Posture and prevent deformities
• More stable Centre of Gravity and control during
  dynamic movements
• contribute to optimal movement patterns
• breathing efficiency
• Distribution of forces and absorption of forces
• Reduce stress on joint surfaces and pain
• Injury prevention and rehabilitation

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Improved PostureRe-education of
stabilisersReduced stress on
jointsReduced injuryIncrease function and
sports performance.
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For Sporting Performance

• Forces transmitted - trunk to the limbs
• Core muscles support the spine to transmit power
  from the trunk.
• Power is transferred for kicking and throwing
  activities
• If the peripheral limbs are too heavy this will
  cause stress on the chassis

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ANATOMY OVERVIEW

• LOCAL STABILISERS
• Intertransversarii
• Interspinales
• Multifidus
• TrA
• Longissimus thoracis pars lumborum
• Illiocostalis lumborum pars lumborum
• Quadratus lumborum medial fibres
• IO (insertion into TLF)

• GLOBAL STABILISERS
• Longissimus thoracis pars thoracis
• Illiocostalis lumborum pars thoracis
• Quadratus lumborum lateral fibres
• External obliques (Bergmark 1989)

Comerford and Mottram, 2001
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STABILISING CORE MUSCLES

• THE INNER CORE
• Transversus abdominus
• Multifidus
• Pelvic Floor Muscles
• Diaphragm

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The Outer Core Systems

• Anterior Oblique ext and int obliques and
  contralateral hip adductors connected by anterior
  abdominal fascia
• Posterior Oblique Lat Dorsi and contralateral
  Glut Max connected by T/L fascia
• Deep Longitudinal Erector spinae and c/l
  sacrotubrous ligament and biceps femoris
  (connected by T/L fascia)
• Lateral Glut med and min and c/l adductors

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TRANSVERSUS ABDOMINUS
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Transversus Abdominus
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FUNCTION TRANSVERSUS ABDOMINUS

• SUPPORT OF ABDOMINAL CONTENTS VIA CIRCUMFERENTIAL
  ARRANGEMENT
• BILATERAL CONTRACTION CAUSES DRAWING IN OF
  ABDOMINAL WALL
• CAN WORK WITH MULTIFIDUS VIA TENSION OF
  THORACOLUMBAR FASCIA
• CONTRIBUTES TO BOTH SUPPORTING AND TORQUE ROLES
  (JULL, RICHARDSON ET AL 1999)

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MULTIFIDUS
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Multifidus
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FUNCTION (MULTIFIDUS)

• Provides control of shearing forces of
  intervertebral motion segments
• Unique segmental arrangement of multifidus
  suggests capacity for fine control of movement
• Control anterior rotation translation in trunk
  flexion
• Continuously active in upright posture compared
  with recumbency
• Provides anti gravity support
• Active in both ipsilateral and controlateral
  trunk rotation
• Stabiliser rather than prime mover (Richardson,
  Jull et al 1999)

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Gluteal Stabilisers
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• Gluteus medius provides frontal plane
  stabilization, decelerate femoral adduction ,
  assist in deceleration femoral internal rotation
  (during closed chain activity)

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Gluteus Medius

• Provides frontal plane stabilisation in walking
  cycle
• Prevents downward rotation of the pelvis
  (Trendelenburg)
• Allows unsupported leg to swing clear of the
  ground
• Decelerates femoral adduction and internal
  rotation
• Anterior fibres assist the iliotibial tract to
  flex hip and stabilise the extended knee

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Optimum Dynamic Function

• Integrated proprioceptively enriched
  multi-directional movement controlled by an
  efficient neuromuscular system

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PROPRIOCEPTION

• Nerve impulses originating from the joints,
  muscles, tendons and associated deep tissues
  which are then processed in the central nervous
  system to provide information about joint
  position, motion, vibration and pressure.
  (Bruckner Khan 1999)

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WHY IS PROPRIOCEPTION IMPORTANT?

• Sub-cortical systems are not under conscious
  control
• Stabilisation response needs to be second nature.
• Sub-cortical systems act faster - rapid muscle
  reaction times.
• More rapid reaction times can be learnt which may
  lead to increased stability of the lumbar spine.

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• To improve the proprioceptive system in dynamic
  joint stability it must be challenged.
• Pain-free does not mean cured.
• If the proprioceptive deficit has not been
  addressed a complete rehabilitation has not been
  accomplished.
• Mechanically stable joints are not necessarily
  functionally stable ( eg. ACL reconstruction)

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WHAT HAPPENS WHEN THE SYSTEM GOES WRONG?

• The Theories

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MUSCLE PAIN SYNDROMES ARE SELDOM CAUSED BY
ISOLATED PRECITATING FACTORS AND EVENTS BUT ARE
THE CONSEQUENCES OF HABITUAL IMBALANCES IN THE
MOVEMENT SYSTEM (Sahrmann 1993)
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REPEATED MOVEMENTSSUSTAINED POSTURES

• ALTERS MUSCLE LENGTH
• ALTERS STRENGTH
• ALTERS STIFFNESS
• ALTERS FLEXIBILITY
• ALTERS CARTILAGE AND BONE STRUCTURE BY
  OVERLOADING AT COMPENSATORY SITES OF MOVEMENT

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PAIN
MUSCULAR DYSFUNCTION
POSTURAL DYSFUNCTION
STRUCTURAL/SEGMENTAL DYSFUNCTION
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POSTURE AND PAIN

• Poor posture can lead to increased stress on the
  stabilising system of the joints (Chek P 1999)
• Multifidus dysfunction occurs after first episode
  acute unilateral LBP (Hides et al 1994)
• Multifidus dysfunction does not spontaneously
  restore following resolution of pain and
  disability (Hides et al 1996)
• Specific retraining does restore dysfunction
  (Hides et al 1996)

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• TrA contraction is delayed during normal
  movements in subjects with low back pain
  (Richardson et al 1999)
• Mulifidus function can be affected by spinal
  surgery
• Atrophy of multifidus has been shown to be more
  prevalent in post operative patients (Jull, et al
  1999)

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• Sheringtons Law of Reciprocal Inhibition
• Tight Muscles inhibit the functional
  antagonist.
• Leads to Positive Cross Syndromes of the lower
  or upper limb

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• Gluteus Maximus and minimus are inhibited in
  most athletes due to tight psoas (Summer, 1988).

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Poor recruitment in the local stabilisers can
lead to over- activity of the global stabilisers
to compensate.
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Lack of flexibility is often a phenomenon created
by lack of stability in an attempt to stabilize
the body for activity.

• Hamstrings become tight in an attempt to create
  posterior stability of the pelvis
• Instead of focusing on hamstring flexibility,
  work on pelvic stabilization and flexibility will
  return

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• If the glutei's are inhibited or weak
• Lateral pelvic stability reduced
• Femur adducts
• 29 muscles connected to each side of pelvisWork
  synergistically with entire kinetic
  chainMaintain center of gravity over base of
  support during dynamic movements
• gait cycle - loss of balance

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Compensations for Weak Glut Med

• Adaptations
  Effects
• Excessive lateral pelvis tilt
  O/L of TFL, SIJ, Lsp
• Medial knee drift
  P/f jt, ITB, Pt, Kn jt
• Lateral knee drift
  Pop, Lat compt
• Lateral flexion of trunk
  Facet jts, SIJ
  
• 
  

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Lower Cross System Anterior Pelvic Tilt/Increase
lumbar lordosis

• Tight - ES, IP, upper rectus, RF, sartorius,TFL,
  adductors
• Weaker -TA, internal oblique, multifidus,
  erector spinae biceps femoris, glut
  med/max
• Joint dysfunction - sacral rotations, SI,
  L-spine,
• Injury Patterns - plantar faciitis, AKP, Tib Post

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Upper Cross System Rounded Back/Forward Head

• Tight - pec mj/min, lat dorsi, upper trap
  levator, subscap, teres major,
  rnocleidomastoid, rectus capitus and
  scalenes
• Weak - rhomboids, middle trap/lower trap, teres
  minor, infraspinatus, post deltoid, deep neck
  flexors
• Joint Dysfunction - Upper cervical, cervical
  thoracic, SC joint, rotator cuff problems

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Pronation Distortion Syndrome Flat feet

• Tight - Peroneals, lateral gastroc IT-band, Psoas
• Weak - Intrinsic foot muscles, Anterior/posterior
  tibialis, VMO, bicep femoris, piriformis,
  glut medius
• Injury Pattern - muscles that control pronation
  are inhibited and weak causing overuse
  injuries

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Muscle Fatigue

• Decreased ability to maintain dynamic muscle
  force
• Fatigue running
• Unable to stabilise core
• Shear forces and compressive forces in lumbar
  spine
• Hamstring strains

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Pelvo-Occular Reflex (Vlatemeir Yanda)

• Running
• Head Extension (Fatigue or weakness)
• Visual compromise
• Compensation Anterior tilt pelvis
• Changes of length tension ratio lower limb
  muscles

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The Critics

• Standaert et al. review
• Lumbar stabilisation exercises no more
  effective than a less specific exercise
  programme
• Eyal Lederman
• Core stability exercises do not help
  functionality and conflicts with so many areas of
  science in context of research into motor
  control..Offering simple answers to complex
  problems

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• BJSM Transversus Abdominus and Core Stability
  Has the pendulum Swung? Allison et al.
• (VMO and PFPS)
• BJSM Claims for the effectiveness of these
  modalities has been touted well beyond what the
  research has shown Cook Jill
• (isokinetics, reformers, vibration plates,
  kinesiotaping, nintendo wii, wii fit!)

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ASSESSMENT

• Posture, ROM, control
• Alignment
• Single knee bend
• Forward flexion
• Seated knee extension
• Thomas test
• Prone knee bend
• Post glut medius

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Rules of Stability Training

• Differentiate hypermobility, instability,
  normal movement and hypomobility
• Safe
• Must be challenging/multisensory
• Progressive several stages
• Offer variety
• All planes of motion
• Integration into functional activity
• Make it fun not bore stability!

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Progression and Variety

• Floor work Static
• Floor work Dynamic

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• Swiss ball Static
• Swiss ball Dynamic

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• Cables
• Medicine Balls, dumbells
• Open and closed chain, speed
• Standing, kneeling, lying, one leg etc

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Progression of training

• progress from slow to fast
• simple to complex
• known to unknown
• low force to high force
• static to dynamic

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Breathing

• Correct inspiration underrated and critical for
  stability
• Allows the diaphragm help stabilise trunk
• Increased intra-abdo pressure
• Helps to activate Trans Abs (modulates with
  respn)
• Inhibits use of external obliques
• Helps maintain thorax posture
• Increases breathing efficiency and performance

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Swiss Ball Systems
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HYPOTHESIS FOR SWISS BALL TRAINING

• Reactive training with a Swiss Ball may encourage
  activation of the spinal stabilisers. Carrier B
  (1998)
• Swiss ball exercises may help to re-educate TrA
  and multifidus due to the unstable environment.
  Carrier B (1998)
• Multifidus is very difficult to activate
  voluntarily. Janda V (1996)
• Sub-cortical control of stabilisation can be
  learnt through proprioceptive exercises on labile
  surfaces such as exercise balls. Saxton et al
  (1993), Saal Saal (1998)

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De-stabilising the training environmentChallen
ges the neuro muscular systemImproves
proprioceptionimproves equilibrium /
co-ordinationImproves functional
skillGreater sporting performance.
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Swiss Ball

• Optimal dynamic stabilisation at right joint,
  right time, right plane of movement
• With any movement all three planes are working
  together concurrently
• Producing force in one plane whilst stabilising
  or controlling in other 2 planes eccentrically

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Benefits

• Proprioception
• Postural re-education
• Improves balance / co-ordination
• Challenges the CNS - improve joint stability and
  sports performance

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References

• Shirley Sahrmann (2002) Treatment and Diagnosis
  of Movement Impairment Syndromes. Mosby St.
  Louis
• Diane Lee (2000) The Pelvic Girdle An approach
  to the examination and treatment of the
  lumbo-pelvic-hip region. Churchill Livingstone
  Edinburgh
• M.J Comerford and S.L Mottram (2001) Functional
  Stability Retraining Principles and strategies
  for Managing Mechanical Dysfunction. Manual
  Therapy 6(1) 3-14
• Hides, Julie A. Richardson, Carolyn A. Jull,
  Gwendolen A (1996).. Multifidus Muscle Recovery
  Is Not Automatic After Resolution of Acute,
  First-Episode Low Back Pain Spine.
  21(23)2763-2769 1996
• Richardson, Carolyn A. Snijders, Chris J.
  Hides, Julie A. Damen, Léonie Pas, Martijn S.
  Storm, Joop. (2002). The Relation Between the
  Transversus Abdominis Muscles, Sacroiliac Joint
  Mechanics, and Low Back Pain Spine. 27(4)399-405
  
• Standaert et al. (2008). Evidence-informed
  management of chronic low back pain with lumbar
  stabilization exercises. The Spine Journal 8(1)
  114.
• Allison et al. (2008) Transversus Abdominus and
  Core Stability Has the pendulum swung? British
  Journal of Sports Medicine 42930
• Lederman. E The myth of core stability. www.
  Cpdo.net/myth_of_core_stabiity.doc
• Cook (2008) Jumping on bandwagons taking the
  right clinical message from research. British
  Journal of Sports Medicine 42 (11) 563
• Goldby et al. (2006) A randomized control led
  trial investigating the efficiency of
  musculoskeletal physiotherapy for chronic low
  back disorder. Spine 31 1083
• Cairns, Mindy C. Foster, Nadine E. Wright,
  Chris (2006) Randomized Controlled Trial of
  Specific Spinal Stabilization Exercises and
  Conventional Physiotherapy for Recurrent Low Back
  Pain Spine. 31(19)E670-E681
• Trueland. J (2009) Core Values Frontline 15 6