Functional Core Stabilization

Chronic Musculoskeletal pain/chronic injuries in the spine and lower extremity are caused or perpetuated by muscle imbalances/weaknesses in the core musculature

Research indicates that 70-85% of all athletes suffer from recurrent low back pain. A comprehensive core stabilization program should be done with all lower extremity rehabilitation programs.

Individuals with a weak core substitute substituting/compensating during dynamic functional movements leading to overuse/chronic injuries both upper and lower extremity

Functional Anatomy: Lumbopelvic-hip Complex

The LPH complex musculature produces force, reduces force, and stabilized the kinetic chain during functional movements 29 muscles attach to the core (LPH complex unilaterally) the core functions primarily to maintain dynamic postural control by keeping the center of gravity over our base of support during dynamic movements.

LPH Complex
Stabilization system (Core system) if not functioning optimally will end neuromuscular substituting to utilize the strength power and neuromuscular control in rest of the body.

LPH Complex Cont.

Otherwise will get neuromuscular inhibition and CNS will shut down prime movers if dont stabilize through LPH complex, thus minimizing kinetic chain. Most athletes have functional strength and control in prime movers but not stabilization in spine (C,T,L)

Definitions:
Function: Integrated proprioceptively enriched multidirectional movement
vs unidimentional, low proprioception, all three planes All functional exercises are triplanar (even walking Saggital plane, appears unidirectional but need to stabilize in other planes ()frontal & transverse) of movement) All functional movements required acceleration, deceleration, & dynamic stabilization (typically concentrate inn concentric and acceleration in rehab)

Definitions:
Functional Strength - ability neuromuscular system to produce dynamic eccentric concentric and dynamic isometric stabilization contractions during all functional movement patterns

Definitions
Neuromuscular efficiency : the ability of your entire kinetic chain to work as an integrated functional movement
this will provide optimal dynamic stabilization at right joint, right time, right plane of movement most athletes can produce the force but more than they can stabilize or control eccentrically thus get increased stress in different planes of movement and in different joint (compensation)

Kinetic Chain When it works efficiently:

optimal control distribute force appropriately optimal efficiency during all movements g\impact absorption/ ground reaction forces no excessive compressive, transitory force, shear in kinetic chain dynamic joint stabilization neuromuscular control

Example: Pelvo- Occular Reflex (Vlatemeir Yanda) Cervical spine weak: during running fatigue head will go into extension, thus to see straight in front of you the pelvis tips anteriorly This changes length tension ration lower extremity, become less efficient, may end up with hamstring injury

Core Stabilization Function

Remember 29 muscles connected to each side of your pelvis. These works synergistically with entire kinetic chain Primary Function: Maintain center of gravity over base of support during dynamic movements (Example gait cycle - loss of balance) Stability & control offers more biomechanically correct position for function of entire core and lower extremity muscles

Patho-Kinisiological Model (Shirley Sarmen)

Human Movement system Kinetic Chain 3 systems
muscular system articular system neural system

Patho-Kinisiological Model
All three must work as integrated unit. If all three work together:
Optimal length tension ratios Thus optimal force coupling Thus control normal arthrokinematics Thus optimal neuromuscular control Thus optimal efficiency of control

Patho-Kinisiological Model
This is a delicate balance a change in one of this can cause injury
Example: articular dysfunction with change length tension ration etc...

Muscle Fatigue:
Ability to generate or maintain decrease ability to require correct muscle Ability to maintain dynamic muscle force decreases Example: fatigue running unable to stabilize core: get shear forces and compressive forces in lumbar spine:
reason why see many LBP complains and hamstring strains (actually attributed to weak abdominal)

 Only 2 abdominal muscles that attach to the L-spine

Attach thorocolumbar facia (l-spine)via latteral rafia attached to transverse processes Thus when they fire they create a tension affect - inherent STABILITY in Lumbar spine these prevent rotational and transnational forces If these muscles are not stabilized the Psoas is used to create a compressive force and mimic stability:

Transverse Abdominis and Internal Obliques during functional activity

Transverse Abdominis and Internal Obliques during functional activity

Actually creates anterior shear force and extension force Leading to reciprocal inhibition of the lower abdominals The pelvis will then tip forward Leading to reciprocal inhibition of the gluteals (extensor mechanism)
This can cause hip internal rotation, knee overuse syndromes etc...

 Stretch/Shortening Cycle (Natural viscoelastic properties of muscles) Every single movement (dynamic functional movement) more efficient the more force can create and absorb)
Efficiency: less wasted movements Example walking

Basic Concepts of Core Stabilization - Performance Paradigm

Every single movement we do is the performance paradigm

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). The body doesnt just fire one muscle at a time for movement

Basic Concepts of Core Stabilization - Planes of Movement With any movement all three planes are working

together concurrently Even though you may be moving in one plane the other 2 plane must stabilize and work eccentrically for stabilization. Example: Posterior Pelvic tilt, laying on the floor changes the relationship, thus when standing the relationship again changes an the exercises have not been functional and will not work in the altered position. Again it changes when you lift one leg etc..

 Movement are not isolated unidirectional Must do movements and exercises in a dynamic systematic program Practically take the athlete from the challenging position they can control in a functional pattern and progress them from there.

Basic Concepts of Core Stabilization - Continuum of Function

 Functional movement is a succession of opening and closing the chain. Functional activity is therefore a timing issue within opening and closing the chain Need core stability to stabilize transition

Basic Concepts of Core Stabilization - Open and Closed Chain

Biomechanics: Three Phases

Pronation - deceleration/force reduction phase (where most injuries occur due to lack of eccentric control)
For rehabilitation need to look at this phase what muscles are decelerating and stabilizing to create a rehabilitation program.

Biomechanics: Three Phases Cont.

Supination - acceleration phase/force production phase (most % time) Coupling - stabilization, ability to change from pronation to supination phase (stronger the core more efficient and thus less time spend in this phase - prevent overuse injuries)

Muscle Function:
Muscles have anatomic individuality but not functional individuality (easier to compartmentalize muscle function for thought process but not practical) Example: Dynamic Movement - tri-planar movement involving muscle strategy & neuromuscular control.

Muscle Function Cont.

Muscles can be placed into two groups: Movement: Prone to develop tightness readily activated during most movement patterns and when an athlete is in a fatigues state or learning new movement patterns, these are the muscles that primarily fire Think about this for injuries the beginning of the season. Gatrocs, Soleus, Hamstring, All Hip flexors, Abdductors, Erector Spinae, Quadratus Lumborum, Pec Major/Minor, Upper Trapezius, Levator, Teres Major, Latissimus, Sternocledomastoid, Scalenes If you would do a flexibility assessment: these are the muscles that are tight

Muscle Function Cont.

Stabilization: Prone to develop weakness and inhibition, less activated during most movement patterns, fatigue easily, primarily function during stabilization movements
Peroneals, anterior tibialis, posterior tibialis, VMO, gluteus medius/maximus, transverse abdominis, int/ext oblique serratus anterior, rhomboids, middle.lower trapezius, deep neck flexors longus coli, longus capitus

Sheringtons Law of Reciprocal Inhibition: Tight Muscle will inhibit its functional antagonist. Example: Thigh Psoas (most athletes) inhibit functional antagonists - deep abdominal wall, transverse abdominis, internal oblique, multifidi, deep transverse spinalis muscles and gluteus maximus. Thus the stabilization and coupling phase will be reduced increasing the movement phase & muscle forces and decreasing efficiency.

Muscle Functions - Abdomen:

Internal Oblique Decelerate transverse plane rotation, frontal plane and transverse plane stability Rectus Abdominis: Decelerate Extension, create pelvic stability during dynamic movement External Oblique Decelerate transverse plane rotation, some extension

Muscle Functions - Abdomen:

Transverse Abdominis - The most important abdominal muscle (attach to lumbar spine) contracts in feed forward mechanism, contracted 1st before any other muscle (research following back pain the transverse abdominis is inhibited, thus when you move for example an arm, your transverse abdominis does not stabilize thus the psoas fires - compensation

Muscle Function: Lumbar Spine

Superficial Erector Spinae: Extends Spine, creates extension force and shear force and L5/S1 works with the Psoas (when Psoas tight it facilitated erector spinae further increasing the shear forces and inhibit posterior muscles) Deep Erector Spine: Posterior translation and L4/L5/S1, if weak or inhibited cannot counterinteract affect of superficial erector and get shearing forces

Muscle Function: Lumbar Spine

Transversal Spinalis Muscles (Rotatories, Multifiti, interspinalis, intertranversari): Provide intrinsic, intrasegmental stability, proprioceptive feeback since constantly under compression and torsinal forces. IF these muscles are inhibited, loose the ability to create dynamic stabilization from lack of proprioceptive feedback.

Joint Dysfunction Example

Joint dysfunction example: lock up SI joint, plant and twist, Multifitus is inhibited complains of low back pain, the erectors will fire and attempt to stabilize (therefore a muscle is doing opposite of its muscle function). This is why pain syndromes are perpetuated

Muscle Function: Hip Musculature:

Gluteus Maximus: decelerate hip flexion, decelerate hip internal rotation during heel strike. Psoas tightness creates inhibition of gluteus maximus (anterior tilt)

Muscle Function: Hip Musculature:

If the gluteus maximus is inhibited or weak will loose ability to control femur, femur will internally rotate:
Microtruma can be created on medial capsule of knee Paltellar tendonitis, non-contact ACL injuries, posterior tibial tendonitis, plantar faciitis

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)

Lack of flexibility is often a phenomenon created by lack of stability in an attempt to stabilize the body for activity.

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

Muscle Function: Hip Musculature:

Gluteus medius: provides frontal plane stabilization, decelerate femoral adduction , assist in deceleration femoral internal rotation (during closed chain activity)
VB/BB with Patellar tendonitis originate from tight psoas and lack of core strength.
Attempting to get triple extension during jumping, couldnt extend through hip using gluteus maximus due to psoas tightness Thus they would hyperextend at the knee and drive the inferior pole of the patella into the fat pad creating the inflammatory response. (Summer, 1988).

Muscle Function: Hip Musculature

Adductors: frontal plane stability Hip External Rotator: Create Pelvo-femoral rhythm,
Gemeli, Obturators, Piriformis help to decelerate femur. If inhibited they become extremely tight because they are attempting to stabilize. Often we attempt to stretch these muscle where a core program would eliminate the origin of the problem.

Force Couples
Saggital Plane: Psoas and superficial erector spinae which create and extension force and shear force in the lumbar spine
counteracted by transverse abdominis internal oblique multifidi, transversal spinalis groups, gluteus maximus. Trend - most athletes the psoas and erector overdeveloped inhibiting stabilizers

Force Couples Cont.

Frontal Plane: Gluteus Medius, ipsilateral adductor and contralateral quadratus lumborum
Example: Weak gluteus medius will cause contralateral LBP, lead into knee pain on opposite side

Force Couples Cont.

Transverse Plane:Left rotation - left internal oblique, left adductor, right external oblique and right external rotators of the hip.
Example: Synergistic dominance Weak transverse abodminis and internal oblique the same side adductor will become tight and inhibit gluteus medius causing anterior knee pain , posterior tib tendonitis etc down the kinetic chain.

Principles of Core Training:

Postural Alignment: Primary Function misalignment will produce predictable stresses, pain, chronic injuries, joint dysfunction

Common Postural Dysfunction

Lower Cross System: Anterior Tilt in most athlete, increase lumbar lordosis
Tight muscles movement group muscles, erector spinae superficial, psoas, upper rectus, rectus femoris, sartorius, tensor facia latae, adductors Weaker muscle/inhibited - stabilizing group deep abdominal wall, transverse abdominis, internal oblique multifidus, deep erector spinae biceps femoris, gluteus medius/maximus muscle that decelerate femoral are inhibited Joint dysfunction: illiosacral rotations, SI, L-spine, Tib-fib joint, subtalar joint Injury Patterns: plantar faciitis, patellar tendonitis, posterior tib tendonitis

Common Postural Dysfunction

Upper Cross System: Rounded Back/Forward Head
Tight muscles pec major/;minor, latisimuss, upper trap levator, subscap, teres major, sternocleidomastoid, rectus capitus and scalenes Weak muscles: rhomboids, middle trap/lower trap, teres minor infraspinatus, posterior deltoid, deep neck flexors Joint dysfunction: Upper cervical, cervical thoracic, SC joint problems (which can cause rotator cuff problems)

Common Postural Dysfunction

Pronation Distortion Syndrome: Flat feet
Tight muscles: Peroneals, lateral gastroc ITband, Psoas Weak muscles: intrinsic foot muscles, Anterior/posterior tibialis, VMO, bicep femoris, piriformis, glut medius
muscle that control pronation are inhibited and weak causing overuse injuries

Postural Dysfunction
Pronation Distortion Syndrome
Joint dysfunctions: 1st MTB joint (EX: cause anterior shoulder pain: stub toe and then lack normal passive extension, shorten stride, internal rotation of the femur, causing pain up chain though spine into movements of the upper extremity due to core inhibition). The same can occur with sprain ankle and lock tibotalar jiont

Though the kinetic chain, muscle problems can lead to joint problems and joint problems can lead to muscle problems.

Postural Considerations
Many individuals have well developed muscle strength and power to perform specific activities, however, few have developed stabilization systems optimally Optimal alignment of each segment in the kinetic chain is a cornerstone for all functional rehabilitation programs.

Postural Considerations
If one segment in the kinetic chain is out of alignment, then predictable patterns of dysfunction will develop in other parts of the kinetic chain A weak core is a fundamental problem of inefficient movements which leads to injury

Low Back Pain & Rehabilitation

Transverse abdominis , multifitus, internal oblique are inhibited in someone with LPB Decrease in stabilization endurance: Can perform the movement until the become fatigue. Ok for 3x20 but once start functional movements revert back to previous positions. Increase interdisk pressure and compressive forces with lack of pelvic stabilization Think about athletes that lift and then have LBP cause may be not stabilizing and can perpetuate muscle imbalances creating hamstring dysfunction etc. Address through unstable ball training

Hiltons Law: any muscle that crosses that joint will be inhibited. With injuries the individual will have a lot of joint substitutions and muscle imbalances

Muscle Imbalances
An optimal functioning core helps to prevent the development of muscle imbalances Optimal core neuromuscular efficiency allows for the maintenance of the normal: length-tension relationships force coupe relationships the path of instantaneous center or rotation A strong stable core can improve neuromuscular efficiency throughout the kinetic chain by improving dynamic postural control

Assessment of the Core:

Core strength can be assessed using the straight leg lowering test Core power can be assessed using the overhead medicine ball throw Core muscle endurance can be assessed using back extension

Core Stabilization to create program:

Abdominal strength functional assessment: assessment (Hodges, stabilization endurance P.) Sports Demand muscle imbalance Analysis assessment demands of the joint assessment individual sport Baseball vs basketball lower extremity etc.) profile assessment demands of the athlete (Grey,G.) (player vs non-player) functional assessment: demands of the stabilization endurance position/specialty

Core Stabilization to create program:

Sports Demand Analysis
demands of the individual sport Baseball vs basketball etc.) demands of the athlete (player vs non-player) demands of the position/specialty

Guidelines for Core Training:

A comprehensive core stabilization training program should:
progress from slow to fast simple to complex known to unknown low force to high force static to dynamic

Guidelines for Core Training

Exercises should be safe, challenging, stress multiple planes, incorporate a multi-sensory environment, and activity specific. Put each athlete in the most challenging environment they can control

Guidelines for Core Training

Change program often
ROM Loading (cable, tubing, dumbbells, body plane) plane of motion body position (floor, standing, ball, one leg, knees )

speed of movement (core slow twitch time under tension but change with dynamic patterns) duration (how long train) frequency (in-season, out-of-season, injury status)

Abdominal Bracing Key

Transverse Abdominis - draw belly-button into spine make self skinny)
Pelvic tilts work rectus abdominis avoid anchoring feet so as not to activate hip flexors or psoas Full ROM Exercise Progression Stretch antagonists between sets to prevent inhibition (if working abdominal stretch hip flexors between sets)

Exercise Progression
Stage I: Learning Abdominal Bracing
maintain stability change duration and frequency

Stage II:
Educate on daily use Increase ROM and instability mainly uniplanar, change body position

Exercise Progression
Stage III: Instability
Maximize the use of functional activities with abdominal bracing Maximize multidirectional patterns and unstable positions Maximize frequency and duration changes

Stage IV:
Challenge the individual with high intensity strength and power