Transcript Establishing Core Stability in Rehabilitation

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
– 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?
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 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
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 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
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 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 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 Anatomy
Key Hip Musculature
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Psoas
Gluteus Medius
Gluteus maximus
Hamstrings
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 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 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 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 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 Anatomy
LPH complex is like a cylinder
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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
Optimal posture will allow for maximal neuromuscular 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
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
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
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 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
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
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
Progression of Core Exercises once abdominal bracing
is perfected and able to be maintained through exercise
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Static
Supine and Prone Exercises
Quadruped Exercises
Comprehensive Core Stabilization Program
• Stabilization
• Strength
• Power
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