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CORE STABILITY CORE STABILITY
An IntroductionAn Introduction
By Donna Sanderson-Hull
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ObjectivesObjectives
DefinitionsOriginsBenefitsTheory/Posture and anatomyResearchPractical
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WHAT IS CORE STABILITY?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 STABILITYCORE 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 viewOrthopaedic 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 CONCEPTNOT A NEW CONCEPT
STATIC• Alexander TechniquePilates
DYNAMICTai-chi/KarateSwiss ball training
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ALEXANDER TECHNIQUE ALEXANDER TECHNIQUE 1869-19551869-1955
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 JOSEPH PILATES 1880-19671880-1967
PRINCIPLES
– CONCENTRATION– ALIGNMENT– BREATHING– CO-ORDINATION– STAMINA
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FITNESS PARAMETERSFITNESS PARAMETERS CARDIOVASCULAR STRENGTH / POWER/SPEED ENDURANCE FLEXIBILITY CORE STABILITY PROPRIOCEPTION / NEUROMUSCULAR
CONTROL
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Paradigm Shift: No longer looking to Paradigm Shift: No longer looking to improve strength in one muscle but improve strength in one muscle but
improvement in multidirectional improvement in multidirectional multidimensional neuromuscular multidimensional neuromuscular
efficiency (firing patterns in entire efficiency (firing patterns in entire kinetic chain within complex motor kinetic chain within complex motor
patterns).patterns).
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The TheoriesThe Theories
Spinal StabilityThe 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)
Passive subsystem
(spinal column)
Spinal stability
Active subsystem(spinal muscles)
Adapted from Panjabi (1992)
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Neutral Zone ConceptNeutral 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 ZoneControl 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 instabilityClinical 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 modelPatho-Kinesiological model((Shirley Sarhmann)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 StabilitySpinal 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 StabilityBenefits 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 PostureImproved Posture
Re-education of stabilisersRe-education of stabilisers
Reduced stress on jointsReduced stress on joints
Reduced injuryReduced injury
Increase function and sports performance.Increase function and sports performance.
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For Sporting PerformanceFor 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 OVERVIEWANATOMY OVERVIEWLOCAL 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 MUSCLESSTABILISING CORE MUSCLES
THE INNER CORETransversus abdominusMultifidusPelvic Floor MusclesDiaphragm
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The Outer Core SystemsThe 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 ABDOMINUSTRANSVERSUS ABDOMINUS
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Transversus AbdominusTransversus Abdominus
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FUNCTION TRANSVERSUS FUNCTION TRANSVERSUS ABDOMINUSABDOMINUS
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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MULTIFIDUSMULTIFIDUS
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MultifidusMultifidus
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FUNCTION (MULTIFIDUS)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 StabilisersGluteal 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 MediusGluteus 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 FunctionOptimum Dynamic Function
Integrated proprioceptively enriched multi-directional movement controlled by
an efficient neuromuscular system
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PROPRIOCEPTIONPROPRIOCEPTION
“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 WHY IS PROPRIOCEPTION IMPORTANT?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 WHAT HAPPENS WHEN THE SYSTEM GOES WRONG?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 MOVEMENTSREPEATED MOVEMENTSSUSTAINED POSTURESSUSTAINED 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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POSTURAL DYSFUNCTION
MUSCULAR DYSFUNCTION
STRUCTURAL/SEGMENTAL DYSFUNCTION
PAINPAIN
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POSTURE AND PAINPOSTURE AND PAINPoor 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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Sherington’s 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 Compensations for Weak Glut MedMed
Adaptations EffectsExcessive lateral pelvis tilt O/L of TFL,
SIJ, Lsp
Medial knee drift P/f jt, ITB, Pt, Kn jt
Lateral knee drift Pop, Lat comp’t
Lateral flexion of trunk Facet jts, SIJ
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Lower Cross System Anterior Pelvic Tilt/Increase lumbar Anterior Pelvic Tilt/Increase lumbar
lordosislordosis
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 FatigueMuscle Fatigue
Decreased ability to maintain dynamic muscle force
Fatigue running Unable to stabilise coreShear forces and compressive forces in
lumbar spineHamstring strains
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Pelvo-Occular Reflex Pelvo-Occular Reflex (Vlatemeir Yanda)(Vlatemeir Yanda)
RunningHead Extension (Fatigue or weakness) Visual compromiseCompensation Anterior tilt pelvisChanges of length tension ratio lower limb
muscles
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The CriticsThe CriticsStandaert 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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ASSESSMENTASSESSMENTPosture, ROM, controlAlignmentSingle knee bendForward flexionSeated knee extensionThomas testProne knee bendPost glut medius
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Rules of Stability TrainingRules of Stability TrainingDifferentiate – hypermobility, instability,
normal movement and hypomobilitySafeMust be challenging/multisensoryProgressive – several stagesOffer varietyAll planes of motionIntegration into functional activityMake it fun – not bore stability!
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Progression and VarietyProgression and VarietyFloor 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 trainingProgression 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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BreathingBreathing
Correct inspiration underrated and critical for stability
Allows the diaphragm help stabilise trunk Increased intra-abdo’ pressure Helps to activate Trans Abs (modulates with
resp’n) Inhibits use of external obliques Helps maintain thorax posture Increases breathing efficiency and performance
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Swiss Ball SystemsSwiss Ball Systems
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HYPOTHESIS FOR SWISS HYPOTHESIS FOR SWISS BALL TRAININGBALL 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 environmentDe-stabilising the training environment
Challenges the neuro muscular systemChallenges the neuro muscular system
Improves proprioceptionImproves proprioception
improves equilibrium / co-ordinationimproves equilibrium / co-ordination
Improves functional skillImproves functional skill
Greater sporting performance.Greater sporting performance.
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Swiss BallSwiss 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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BenefitsBenefits
• Proprioception • Postural re-education• Improves balance / co-ordination• Challenges the CNS - improve joint
stability and sports performance
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ReferencesReferences 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 42:930
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