core stability an introduction by donna sanderson-hull

CORE STABILITY CORE STABILITY

An IntroductionAn Introduction

By Donna Sanderson-Hull

ObjectivesObjectives

DefinitionsOriginsBenefitsTheory/Posture and anatomyResearchPractical

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

CORE STABILITYCORE STABILITY

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

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.

NOT A NEW CONCEPTNOT A NEW CONCEPT

STATIC• Alexander TechniquePilates

DYNAMICTai-chi/KarateSwiss ball training

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

JOSEPH PILATES JOSEPH PILATES 1880-19671880-1967

PRINCIPLES

– CONCENTRATION– ALIGNMENT– BREATHING– CO-ORDINATION– STAMINA

FITNESS PARAMETERSFITNESS PARAMETERS CARDIOVASCULAR STRENGTH / POWER/SPEED ENDURANCE FLEXIBILITY CORE STABILITY PROPRIOCEPTION / NEUROMUSCULAR

CONTROL

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).

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

Control subsystem

(Neural)

Passive subsystem

(spinal column)

Spinal stability

Active subsystem(spinal muscles)

Adapted from Panjabi (1992)

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

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

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)

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)

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.

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

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.

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

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

STABILISING CORE MUSCLESSTABILISING CORE MUSCLES

THE INNER CORETransversus abdominusMultifidusPelvic Floor MusclesDiaphragm

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

TRANSVERSUS ABDOMINUSTRANSVERSUS ABDOMINUS

Transversus AbdominusTransversus Abdominus

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)

MULTIFIDUSMULTIFIDUS

MultifidusMultifidus

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)

Gluteal StabilisersGluteal Stabilisers

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

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

Optimum Dynamic FunctionOptimum Dynamic Function

Integrated proprioceptively enriched multi-directional movement controlled by

an efficient neuromuscular system

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)

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.

•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)

WHAT HAPPENS WHEN THE WHAT HAPPENS WHEN THE SYSTEM GOES WRONG?SYSTEM GOES WRONG?

The Theories

“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)

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

POSTURAL DYSFUNCTION

MUSCULAR DYSFUNCTION

STRUCTURAL/SEGMENTAL DYSFUNCTION

PAINPAIN

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)

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)

Sherington’s Law of Reciprocal Inhibition:

Tight Muscles inhibit the functional antagonist.

Leads to Positive Cross Syndromes of the lower or upper limb

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

Poor recruitment in the local stabilisers can lead to over-

activity of the global stabilisers to compensate.

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

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

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

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

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

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

Muscle FatigueMuscle Fatigue

Decreased ability to maintain dynamic muscle force

Fatigue running Unable to stabilise coreShear forces and compressive forces in

lumbar spineHamstring strains

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

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

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!)

ASSESSMENTASSESSMENTPosture, ROM, controlAlignmentSingle knee bendForward flexionSeated knee extensionThomas testProne knee bendPost glut medius

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!

Progression and VarietyProgression and VarietyFloor work – Static Floor work – Dynamic

Swiss ball – Static Swiss ball – Dynamic

Cables Medicine Balls,

dumbells Open and closed

chain, speed Standing, kneeling,

lying, one leg etc

Progression of trainingProgression of training

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

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

Swiss Ball SystemsSwiss Ball Systems

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)

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.

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

BenefitsBenefits

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

stability and sports performance

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