CORE STABILITY An Introduction

1. CORE STABILITY An Introduction By Donna Sanderson-Hull

2. Objectives • Definitions • Origins • Benefits • Theory/Posture and anatomy • Research • Practical

3. 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

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

5. 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.

6. NOT A NEW CONCEPT STATIC • Alexander Technique • Pilates DYNAMIC • Tai-chi/Karate • Swiss ball training

7. 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

8. JOSEPH PILATES 1880-1967 • PRINCIPLES • CONCENTRATION • ALIGNMENT • BREATHING • CO-ORDINATION • STAMINA

9. FITNESS PARAMETERS • CARDIOVASCULAR • STRENGTH / POWER/SPEED • ENDURANCE • FLEXIBILITY • CORE STABILITY • PROPRIOCEPTION / NEUROMUSCULAR CONTROL

10. 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).

11. 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

12. Control subsystem (Neural) Spinal stability Active subsystem (spinal muscles) Passive subsystem (spinal column) Adapted from Panjabi (1992)

13. 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

14. 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

15. 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)

16. 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)

17. 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.

18. 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

19. Improved PostureRe-education of stabilisersReduced stress on jointsReduced injuryIncrease function and sports performance.

20. 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

21. 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) ANATOMY OVERVIEW Comerford and Mottram, 2001

22. STABILISING CORE MUSCLES • THE INNER CORE • Transversus abdominus • Multifidus • Pelvic Floor Muscles • Diaphragm

23. 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

24. TRANSVERSUS ABDOMINUS

25. Transversus Abdominus

27. 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)

28. MULTIFIDUS

30. Multifidus

31. 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)

32. Gluteal Stabilisers

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

34. 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

35. Optimum Dynamic Function Integrated proprioceptively enriched multi-directional movement controlled by an efficient neuromuscular system

36. 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)

37. 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.

38. To improvethe 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)

39. WHAT HAPPENS WHEN THE SYSTEM GOES WRONG? The Theories

40. “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)

41. REPEATED MOVEMENTSSUSTAINED POSTURES • ALTERS MUSCLE LENGTH • ALTERS STRENGTH • ALTERS STIFFNESS • ALTERS FLEXIBILITY • ALTERS CARTILAGE AND BONE STRUCTURE – BY OVERLOADING AT COMPENSATORY SITES OF MOVEMENT

42. PAIN MUSCULAR DYSFUNCTION POSTURAL DYSFUNCTION STRUCTURAL/SEGMENTAL DYSFUNCTION

43. 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)

44. 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)

45. Sherington’s Law of Reciprocal Inhibition: • Tight Muscles inhibit the functional antagonist. • Leads to Positive Cross Syndromes of the lower or upper limb

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

47. Poor recruitment in the local stabilisers can lead to over- activity of the global stabilisers to compensate.

48. 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

49. 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

50. 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 comp’t Lateral flexion of trunk Facet jts, SIJ