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Establishing Core Stability in Rehabilitation. Rehabilitation Techniques for Sports Medicine and Athletic Training William E. Prentice. Core Stabilization. A dynamic core stabilization training program should be key component of all comprehensive functional rehab. programs

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Establishing core stability in rehabilitation

Establishing Core Stability in Rehabilitation

Rehabilitation Techniques for Sports Medicine and Athletic Training

William E. Prentice

Core stabilization
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

What is the core
What is the Core?

  • Core defined as the lumbo-pelvic-hip (LPH) complex

    • 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

What is the core1
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”

Core stabilization training concepts
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

Core stabilization training concepts1
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 fxal movement

      • Lead to compensation and substitution patterns as well as poor posture during fxal activities

      • Increase mechanical stress on contractile and non-contractile tissue thus leading to injury

Review of functional anatomy
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

      • Provide 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 muscles most important in this muscle group

Review of functional anatomy1
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

Review of functional anatomy2
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.

Review of functional anatomy3
Review of Functional Anatomy

  • Key Hip Musculature

    • Psoas

    • Gluteus Medius

    • Gluteus maximus

    • Hamstrings

Review of functional anatomy4
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

        • Extensor mechanism dysfunction during fxal mvmt patterns.

Review of functional anatomy5
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

Review of functional anatomy6
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

Review of functional anatomy7
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

Review of functional anatomy8
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

Review of functional anatomy9
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

Postural considerations
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

Muscular imbalances
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

Neuromuscular considerations
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

Core stabilization training
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

Core stabilization training1
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

Assessment of core
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

Drawing in maneuver
Drawing In Maneuver

  • All core exercises must start with a “drawing in” maneuver, or abdominal brace

    • 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

Specific core stabilization exercises
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

Guidelines for core stabilization program
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