Establishing Core Stability in Rehabilitation

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Establishing Core Stability in Rehabilitation

• Rehabilitation Techniques for Sports Medicine and
  Athletic Training
• William E. Prentice

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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

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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

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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

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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.

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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

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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

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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

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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.

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Review of Functional Anatomy

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

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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.

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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

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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

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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

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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

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Review of Functional Anatomy

• LPH complex is like a cylinder
• Inferior wall pelvic floor muscles
• Superior walldiaphragm
• Posterior wallmultifidi
• Anterior and lateral wallsTA
• Must all be activated together and taut for trunk
  stabilization to occur with static and dynamic
  mvmts

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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

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Muscular Imbalances

• Optimal functioning coreprevention 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

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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

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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

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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

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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

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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

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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

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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