Integrated

Core
Training
National Academy of Sports Medicine
2
Integrated Core Training
Copyright 2008 National Academy of Sports Medicine
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Author: Dr. Micheal Clark, DPT, MS, PES, CES
3
Integrated Core Training
Introduction
To stay on the cutting edge of research, science, and practical application, the health and tness professional
needs to follow a comprehensive, systematic, and integrated approach when training, reconditioning, or
rehabilitating a client. In order to develop a comprehensive integrated training program, the health and
tness professional must fully understand the functional kinetic chain. An integrated training program
is a comprehensive approach that strives to improve all the components necessary to achieve optimum
performance (strength, balance, exibility, endurance, and power). Since the core is where the human
bodys center of gravity is located and where all movement begins
1,2,3,4
this chapter focuses on the funda-
mental concepts of core stabilization, and how the health and tness professional can design an effective
and dynamic core stabilization program.
5,6,7,8,9,10,11
Section I: Core Stabilization Concepts
Section II: Functional Anatomy of the Core
Section III: Scientic Rationale for Core Stabilization Training
Section IV: Guidelines for Core Stabilization Training
Section V: Core Stabilization Training Program Design
Section VI: Summary
References
Traditionally, training has focused on isolated, absolute strength gains in isolated muscles, utilizing single
planes of motion. However, all functional activities are multi-planar and require acceleration, decelera-
tion, and dynamic stabilization.
10,11,12
Movement may appear to be single-plane dominant, but the other
planes need to be dynamically stabilized to allow for optimum neuromuscular efciency.
13
Understanding
that functional movements require a highly complex, integrated system enables the health and tness
professional to make a paradigm shift. The paradigm shift focuses on training the entire kinetic chain
utilizing all planes of movement, while establishing high levels of functional strength and neuromuscular
efciency.
3,14,15,16,17,18
The paradigm shift also dictates that the health and tness professional train force
reduction, force production, and dynamic stabilization during all kinetic chain activities.
9,19

4
Integrated Core Training
A core stabilization training program (Figure 1) improves dynamic postural control, ensures appropriate
muscular balance and joint arthrokinematics around the lumbo-pelvic-hip complex (LPHC), and allows
for the expression of dynamic functional strength and improved neuromuscular efciency throughout the
entire kinetic chain.
9,10,13,14,15,17,18,19,20,21,22,23,24,25
Figure 1: Benets of Core Training
1. Improve dynamic postural control
2. Ensure appropriate muscular balance and joint arthrokinematics
3. Allow for the expression of functional strength
4. Provide intrinsic stability to the LPHC, which allows for optimum
neuromuscular efciency of the rest of the kinetic chain
5
Integrated Core Training
Section I:
Core Stabilization Concepts
The core is dened as the LPHC.
9,13
There are twenty-nine muscles that attach to the LPHC.
9,26,27,28
An
efcient core allows for the maintenance of optimum length-tension relationships of functional agonists
and antagonists, which makes it possible for the body to maintain optimum force-couple relationships in
the LPHC. Maintaining optimum length-tension relationships and force-couple relationships allows for the
maintenance of optimum joint arthrokinematics in the LPHC during functional kinetic chain movements.
18,25,29

This provides optimum neuromuscular efciency in the entire kinetic chain, and allows for optimum accel-
eration, deceleration, and dynamic stabilization during integrated, dynamic movements.
1,2,3,4,9,11,13,18,25,30

The core operates as an integrated functional unit, enabling the entire kinetic chain to work synergistically
to produce force, reduce force, and dynamically stabilize against abnormal force.
13
In an efcient state,
each structural component distributes weight, absorbs force, and transfers ground reaction forces.
13
This
integrated, interdependent system needs to be appropriately trained to enable it to function efciently
during dynamic activities.
Many individuals have developed functional strength, power, neuromuscular control, and muscular endur-
ance in specic muscles that enable them to perform functional activities.
9,11,13,31
However, few people
develop the muscles required for spinal stabilization.
30,31,32
The bodys stabilization system has to function
optimally to effectively utilize the strength, power, neuromuscular control, and muscular endurance that
it has developed in its prime movers. If the extremity muscles are strong and the core is weak, there will
not be enough force created to produce efcient movements. A weak core is a fundamental problem
inherent to inefcient movement that leads to predictable patterns of injury.
11,30,31,32

The core musculature is an integral component of the protective mechanism that relieves the spine of
deleterious forces that are inherent during functional activities.
14
A properly designed core stabilization
training program helps an individual gain strength, neuromuscular control, power, and muscle endurance of
the LPHC. This integrated approach facilitates balanced muscular functioning of the entire kinetic chain.
13

Greater neuromuscular control and stabilization strength provides a more biomechanically efcient posi-
tion for the entire kinetic chain, and thereby allows optimum neuromuscular efciency throughout the
kinetic chain.
6
Integrated Core Training
Neuromuscular efciency is established by the appropriate combination of postural alignment (static/
dynamic) and stability strength, which enables the body to decelerate gravity, ground reaction forces, and
momentum.
10,15,19
If the neuromuscular system is not efcient, it will be unable to respond to the demands
placed on it during functional activities.
13
As the efciency of the neuromuscular system decreases, the
ability of the kinetic chain to maintain appropriate forces and dynamic stabilization decreases signicantly.
This decreased neuromuscular efciency leads to compensation and substitution patterns (synergistic
dominance, altered reciprocal inhibition, arthrokinetic inhibition), as well as poor posture during functional
activities.
18,20,25
This increases mechanical stress on the contractile and non-contractile tissue and leads to
repetitive microtrauma, abnormal biomechanics, and injury.
14,16,20,33
7
Integrated Core Training
Section II:
Functional Anatomy
of the Core
The traditional perception of muscles is that they work concentrically and predominantly in one plane of
motion. However, in order to more effectively understand motion and design efcient training, recondi-
tioning, and rehabilitation programs, it is imperative to view muscles functioning in all planes of motion
and in the full contraction spectrum (eccentrically, stabilization, and concentrically). The following section
will describe the isolated and integrated functions of the major muscles of the kinetic chain.
27,28
Lower Extremity Functional Anatomy
The lower extremity musculature functions synergistically to stabilize the entire kinetic chain during func-
tional movement patterns. The lower extremity also works synergistically to eccentrically decelerate and
concentrically accelerate the entire kinetic chain during functional movement patterns.
27,34
8
Integrated Core Training
Hamstrings
The traditional view of the hamstring is that it assists with hip extension and knee exion. The integrated
view is that it eccentrically decelerates knee extension, hip exion, and internal rotation at heel strike,
eccentrically decelerates iliosacral anterior rotation during functional movements, and dynamically stabi-
lizes the LPHC during functional movement patterns.
Figure 2: Hamstrings
9
Integrated Core Training
Hip Abductors
These include the gluteus medius, gluteus minimus, and tensor fascia latae. The traditional view is that the
hip abductors abduct the femur. The integrated view is that the gluteus medius decelerates hip adduction
and hip internal rotation, and the gluteus minimus and tensor fascia latae decelerate hip adduction. The
tensor fascia latae also assists in decelerating hip extension and hip external rotation. The entire abductor
complex works synergistically as the primary frontal-plane stabilizing mechanism (lateral sub-system).
Figure 3: Hip Abductor Complex
10
Integrated Core Training
Gluteus Maximus
The traditional view is that the gluteus maximus produces hip extension and external rotation. The
integrated view is that it eccentrically decelerates hip exion, hip adduction, and hip internal rotation
during stance phase, decelerates tibial internal rotation via the iliotibial band (ITB), assists in stabilizing
the sacroiliac joint (SIJ) via the sacrotuberous ligament and the lateral knee via the ITB.
Figure 4: Gluteus Maximus
11
Integrated Core Training
Iliopsoas
This consists of the iliacus, psoas major, and psoas minor. The traditional view is that the lliopsoas pro-
duces hip exion. The integrated view is that it eccentrically decelerates femoral internal rotation at heel
strike, eccentrically decelerates hip extension, and assists in stabilizing the lumbar spine during functional
movements.
Figure 5: Iliopsoas
12
Integrated Core Training
Core Functional Anatomy
The core musculature functions synergistically to stabilize, eccentrically decelerate, and concentrically
accelerate the entire kinetic chain during functional movement patterns.
Erector Spinae
This muscle includes the iliocostalis, longissimus, and spinalis. The traditional view is that the erector spinae
extends the trunk. The integrated view is that it eccentrically decelerates exion, rotation, and lateral
exion of the lumbar spine, and dynamically stabilizes the lumbar spine during functional movements.
Figure 6: Erector Spinae
13
Integrated Core Training
Abdominal Complex
This includes the rectus abdominus, external oblique, internal oblique, and transverse abdominus (TVA).
The traditional view of the abdominal complex is that it exes and rotates the trunk. The integrated view
is that the rectus abdominus eccentrically decelerates extension and rotation, dynamically stabilizes the
LPHC, and concentrically exes the spine. The external oblique eccentrically decelerates extension and
rotation, dynamically stabilizes the LPHC, and concentrically posteriorly rotates the pelvis, exes the pelvis
and produces contralateral rotation. The internal oblique eccentrically decelerates extension and rotation,
dynamically stabilizes the LPHC, and concentrically produces exion and ipsilateral rotation. And nally,
the TVA works primarily to dynamically stabilize the LPHC during functional movement patterns.
Figure 7: Addominal Complex
14
Integrated Core Training
Upper Extremity Functional Anatomy
The upper extremity musculature functions synergistically to stabilize, eccentrically decelerate and con-
centrically accelerate the entire kinetic chain during functional movement patterns.
Latissimus Dorsi
The traditional view of the latissimus dorsi is that it adducts, extends, and internally rotates the humerus.
The integrated view is that it eccentrically decelerates exion, abduction, and external rotation of the
upper extremity, assists in dynamic stabilization of the LPHC through the thoracolumbar fascia (TLF)
mechanism, and functions as a bridge between the upper and lower extremity.
Figure 8: Latissimus Dorsi
15
Integrated Core Training
Current Concepts in Functional Anatomy
It has been proposed that there are two distinct yet interdependent muscular systems that enable our
bodies to maintain proper stabilization and ensure efcient distribution of forces for the production of
movement. Crisco and Panjabi
12
have suggested that muscles located more centrally to the spine provide
intersegmental stability (support from vertebrae to vertebrae) while the more lateral muscles support
the spine as a whole. Bergmark
35
has categorized these different systems with relation to the trunk into
local and global muscular systems.
16
Integrated Core Training
Joint Support System
The Inner Unit (Local Muscular System): The local musculature or inner unit consists of muscles that
are predominantly involved in joint support or stabilization.
35,36
Thus we have chosen to refer to the local
muscles as joint support systems. It is important to note, however, that joint support systems are not
conned to the spine and are evident in the peripheral joints as well.
Joint support systems consist of muscles that are not movement specic, but provide stability to allow
movement of a joint. They usually are located in proximity to the joint. They also have a broad spectrum
of attachments to the joints passive elements that make them ideal for increasing joint stiffness and thus
stability.
36
A common example of a peripheral joint support system is the rotator cuff for the glenohu-
meral joint that provides dynamic stabilization for the humeral head in relation to the glenoid fossa during
movement.
37,38
Other joint support systems include the posterior bers of the gluteus medius and the
external rotators of the hip that perform pelvo-femoral stabilization,
39
and the vastus medialis obliquus
that provides patellar stabilization at the knee.
40
The joint support system of the core (LPHC) consists of
muscles that either originate or insert (or both) into the lumbar spine.
4
The major muscles include the
TVA, lumbar multidus, internal oblique, diaphragm and the muscles of the pelvic oor.
35,36,41
This joint
support system has also been referred to as the inner unit.
41

Figure 9: Inner Unit
17
Integrated Core Training
The Outer Unit (Global Muscular Systems): The global muscles (outer unit) are predominantly respon-
sible for movement and consist of more supercial musculature that attaches from the pelvis to the rib cage
and/or the lower extremities.
35,36,41
The major muscles include the rectus abdominis, external obliques,
erector spinae, hamstrings, gluteus maximus, latissimus dorsi, adductors, hamstrings, and quadriceps. The
outer unit muscles are predominantly larger and are associated with movement of the trunk and limbs and
equalize external loads placed upon the body. They also are important because they transfer and absorb
forces from the upper and lower extremities to the pelvis.
36
The outer unit musculature has been broken
down and described as force couples working in four sub-systems.
42,43,44,45
These sub-systems include the
deep longitudinal, posterior oblique, anterior oblique, and lateral sub-systems. This distinction allows for
an easier description and review of functional anatomy. Its crucial for health and tness professionals to
think of these sub-systems operating as an integrated functional unit. Remember, the central nervous
system is designed to optimize the selection of muscle synergies, not isolated muscles.
46,47,48,49

Figure 10: Outer Unit
18
Integrated Core Training
The Deep Longitudinal Sub-System (DLS): The major contributors to the DLS are the erector spi-
nae, TLF, sacrotuberous ligament, and biceps femoris. Some experts suggest that the DLS provides one
means of a reciprocal force transmission longitudinally from the trunk to the ground.
42,45
As illustrated in
Figure 11, the long head of the biceps femoris attaches to the sacrotuberous ligament at the ischium. The
sacrotuberous ligament in turn attaches from the ischium to the sacrum. The erector spinae attaches
from the sacrum and ilium up to the ribs and cervical spine. Activation of the biceps femoris increases
tension in the sacrotuberous ligament, which transmits force across the sacrum stabilizing the SIJ, and
allows force transference up through the erector spinae to the upper body.
42,45
Figure 11: Deep Longitudinal Sub-System
This transference of force is apparent during the normal gait. Prior to heel strike, the biceps femoris
activates to eccentrically decelerate hip exion and knee extension.
50
Just after heel strike, the biceps
femoris is further loaded through the lower leg via inferior movement of the bula.
51,52
This tension from
the lower leg, up through the biceps femoris, into the sacrotuberous ligament and up the erector spinae
creates a force that assists in stabilizing the SIJ.
42,45
Another force couple not mentioned in the DLS consists of the supercial erector spinae, the psoas and
the inner unit. While the erector spinae and psoas create lumbar extension and an anterior shear force
at L4S1, the inner unit provides inter-segmental stabilization and a posterior shear force (neutralizer)
19
Integrated Core Training
during functional movement.
28,36,41
Dysfunction in any of these structures can lead to SIJ instability and low
back pain (LBP),
45
demonstrating the importance of training these structures as a functional unit.
The Posterior Oblique Sub-System (POS): The POS works synergistically with the DLS. As illustrated
in Figure 12, the gluteus maximus and latissimus dorsi attach to the TLF, which connects to the sacrum.
The ber arrangements of these muscles run perpendicular to the SIJ. Thus, when the contralateral glu-
teus maximus and latissimus dorsi contract, they create a stabilizing force for the SIJ.
45
Just prior to heel
strike, the latissimus dorsi and the contralateral gluteus maximus are eccentrically loaded. At heel strike,
each muscle accelerates (concentric action) its respective limb and creates tension in the TLF. This ten-
sion assists in the stability of the SIJ. In addition, the POS transfers forces that are summated from the
transverse plane orientation of these muscles to propulsion in the sagittal plane when we walk or run.
The POS is also of prime importance for other rotational activities such as swinging a golf club, swinging
a baseball bat, and/or throwing a ball.
42,44,45
Dysfunction of any structure in the POS can lead to SIJ insta-
bility and LBP. The weakening of the gluteus maximus and/or latissimus dorsi may also lead to increased
tension in the hamstring and therefore cause reoccurring hamstring strains.
41,45,53
Figure 12: Posterior Oblique Sub-System Image
The Anterior Oblique Sub-System (AOS): The AOS also functions in a transverse plane orientation
very similarly to the POS only from the anterior portion (front) of the body. Its prime contributors are
the oblique muscles (internal and external) adductor complex, and hip external rotators. Viewing elec-
tromyography (EMG) data on the obliques, adductors, and hip external rotators, it is apparent that they
20
Integrated Core Training
function to aid in the stability and rotation of the pelvis, as well as contributing to leg swing.
27,50
The AOS
is also implicated in the stabilization of the SIJ.
54
As illustrated in Figure 13, when we walk, our pelvis must
rotate in the transverse plane in order to create a swinging motion for the legs.
42
This rotation comes in
part from the POS posteriorly and the AOS anteriorly. One only needs to look at the ber arrangements
of the muscles involved (latissimus dorsi, gluteus maximus, internal and external obliques, adductors, and
hip rotators) to realize this point. The AOS is also necessary for functional activities involving the trunk,
upper and lower extremities. The obliques, in concert with the adductor complex, not only produce
rotational and exion movements, but also are instrumental in stabilizing the LPHC.
44,54
Figure 13: Anterior Oblique Sub-System Image
The Lateral Sub-System (LS): The LS is comprised of the gluteus medius, tensor fascia latae, adductor
complex, and quadratus lumborum. The LS has been implicated in frontal plane stability.
28,53
This system
is responsible for pelvo-femoral stability. Figure 14 illustrates how, during single-leg functional movements
such as in gait, lunges, or stair climbing, the ipsilateral gluteus medius, tensor fascia latae, and adductors
combine with the contralateral quadratus lumborum to control the pelvis and femur in the frontal plane.
28,53

Dysfunction in the LS is evident by increased pronation (exion, internal rotation and adduction) of the
knee, hip and/or feet during walking, squats, lunges or climbing stairs. Accessory frontal plane movement
during gait is characterized by decreased strength and neuromuscular control in the LS.
55,56
Keep in mind
that for reasons of explanation, these four sub-systems have been oversimplied and that the human
body simultaneously utilizes all four of these sub-systems during activity. Each sub-system individually and
interdependently contributes to the production of efcient movement by accelerating, decelerating, and
dynamically stabilizing the kinetic chain during motion.
21
Integrated Core Training
Figure 14: Lateral Sub-System
All of these muscles play an integral role in the kinetic chain because they provide dynamic stabilization
and optimum neuromuscular control of the entire LPHC. When isolated, these muscles do not effectively
achieve stabilization of the LPHC. It is the synergistic, interdependent functioning of the entire LPHC that
enhances the stability and neuromuscular control throughout the entire kinetic chain.
Stabilization Mechanisms
The LPHC is stabilized during integrated multi-planar movement by two primary systems, the tho-
racolumbar stabilization mechanism and the intra-abdominal pressure stabilization mechanism (IAP)
(Figure 15).
1,2,3,4,30,31,32,57,58,59,60,61

Figure 15: Stabilization Mechanisms
m
Thoracolumbar Stabilization
m
Intra-abdominal Pressure
22
Integrated Core Training
Thoracolumbar Stabilization Mechanism
The TLF is a fascial network of non-contractile tissue that plays an essential role in the functional stability
of the lumbar spine. The TLF is divided into three layers, the posterior, anterior, and middle. Although the
TLF is non-contractile, it can be engaged dynamically because of the contractile tissue that attaches to it.
The muscles that attach to the TLF include deep erector spinae, multidus, TA, internal oblique, gluteus
maximus, latissimus dorsi, and quadratus lumborum. The TA and the internal oblique are particularly
important for stabilization. They attach to the middle layer of the TLF via the lateral raphe. Contraction
of the TA and the internal oblique creates a traction and tension force on the TLF, which enhances the
regional inter-segmental stability in the LPHC. This preferential contraction decreases translational and
rotational stress at the lumbosacral junction.
30,31,32,60,62,63,64

Figure 16: Thoracolumbar Stabilization Mechanism
23
Integrated Core Training
Intra-abdominal Pressure Mechanism
The second stabilization mechanism is the IAP.
1,2,4,7,65
Increased IAP decreases compressive forces in the
LPHC. As the abdominal muscles contract against the viscera, they push superiorly into the diaphragm
and inferiorly into the pelvic oor. This results in elevation of the diaphragm and contraction of pelvic
oor musculature. This will assist in providing intrinsic stabilization to the LPHC.
Figure 17: Intra-abdominal Pressure Mechanism
Postural Considerations
The core maintains postural alignment and dynamic postural equilibrium during functional activities.
Optimum alignment of each body part is a cornerstone of an integrated training and rehabilitation pro-
gram. Optimum posture and alignment allow for optimum neuromuscular efciency because the normal
length-tension relationship, force-couple relationship, and arthrokinematics are maintained during func-
tional movement patterns.
9,11,14,16,17,18,19,20,25,66,67,68,69
A comprehensive core stabilization program prevents
the development of serial distortion patterns and provides optimum dynamic postural control during
functional movements.
9,11,14,23,24

24
Integrated Core Training
Neuromuscular Considerations
A strong and stable core can improve optimum neuromuscular efciency by improving dynamic postural
control.
18,25,30,32,63,70,71
Several authors have demonstrated kinetic chain imbalances in individuals with
altered neuromuscular control.
14,15,16,17,18,21,22,23,24,30,31,32,33,60,62,63,67,68,72,73,74,75,76
Research has demonstrated
that people with LBP have an abnormal neuromotor response of the trunk stabilizers accompanying limb
movement.
31,32,76
Additionally, individuals with LBP had signicantly greater postural sway and decreased
limits of stability. Research also demonstrates that approximately 75 to 90% of all individuals suffer from
recurrent episodes of back pain. Furthermore, it has been demonstrated that individuals have decreased
dynamic postural stability in the proximal stabilizers of the LPHC following lower extremity ligamentous
injuries.
14,72,73,74
It has also been demonstrated that joint and ligamentous injury can lead to decreased
muscle activity.
20,29,77,78
Joint and ligament injury can lead to joint effusion, which in turn leads to muscle
inhibition.
77
This alters neuromuscular control in other segments of the kinetic chain secondary to altered
proprioception and kinesthesia.
72,73
Therefore, when an individual has pain and swelling, all of the muscles
that cross that joint can be inhibited.
Research has also demonstrated that muscles can be inhibited from an arthrokinetic reex.
14,22,29,78
This
is referred to as arthrogenic muscle inhibition. Arthrokinetic reexes are reexes that are mediated by
joint receptor activity. If an individual has abnormal arthrokinematics, the muscles that move the joint
will be inhibited. For example, if an individual has a sacral torsion, the multidus and the gluteus medius
can be inhibited.
79
This leads to abnormal movement in the kinetic chain. The tensor fascia latae become
synergistically dominant and become the primary frontal plane stabilizer.
28
This often leads to tightness in
the iliotibial band, which decreases frontal and transverse plane control at the knee. Furthermore, if the
multidus is inhibited,
79
the erector spinae and the psoas become facilitated. This will further inhibit the
inner unit stabilization mechanism (internal oblique and TVA) and the gluteus maximus,
31,32
which also
decreases frontal and transverse plane stability at the knee. As previously mentioned, an efcient core
improves neuromuscular efciency of the entire kinetic chain because it dynamically stabilizes the LPHC
and therefore improves pelvo-femoral biomechanics. This is yet another reason that training programs
should include a comprehensive core stabilization-training program to prevent injury as well as the chain
reactions that are initiated secondary to injury in the kinetic chain.
25
Integrated Core Training
Section III:
Scientic Rationale for
Core Stabilization Training
Most individuals train their core stabilizers inadequately compared to other muscle groups.
13
Although
adequate strength, power, muscle endurance, and neuromuscular control are important for lumbo-pel-
vic-hip stabilization, it is detrimental to perform exercises incorrectly or that are too advanced. Several
authors have found decreased ring of the TVA, internal oblique, multidus, and deep erector spinae in
individuals with chronic LBP.
30,31,32,60,76,80
Research has shown decreased stabilization endurance in individu-
als with chronic LBP.
1,2,5,81
The core stabilizers are primarily type I slow-twitch muscle bers.
1,2,3,4
These
muscles respond best to time under tension. Time under tension is a method of contraction that lasts
for 620 seconds and emphasizes hyper-contractions at end ranges of motion. This method improves
intramuscular coordination, which improves static and dynamic stabilization. To get the appropriate train-
ing stimulus, you must prescribe the appropriate speed of movement for all aspects of exercises.
7,8
Core
strength endurance must be trained appropriately to allow an individual to maintain dynamic postural
control for prolonged periods of time.
65

Performing core training with inhibition of these key stabilizers leads to the development of muscle imbal-
ances and inefcient neuromuscular control in the kinetic chain. Research demonstrates that abdominal
training without proper pelvic stabilization increases intradiscal pressure and compressive forces in the
lumbar spine.
5,30,31,32,60,65,82,83
In fact, maintaining the cervical spine in a neutral position during core training
will improve posture, muscle balance, and stabilization. If, for instance, the head protracts during move-
ment, the sternocleidomastoid is preferentially recruited. This increases the compressive forces at the
C0C1 vertebral junction. This can also lead to pelvic instability and muscle imbalances secondary to the
pelvo-occular reex. This reex is important to maintain the eyes level.
16,22
If the sternocleidomastoid
muscle is hyperactive and extends the upper cervical spine, then the pelvis will rotate anteriorly to realign
the eyes. This can lead to muscle imbalances and decreased pelvic stabilization.
16,22

Additional research demonstrates that hyperextension training without proper pelvic stabilization can
increase intradiscal pressure to dangerous levels, cause buckling of the ligamentum avum, and lead to
narrowing of the intervertebral foramen.
5,65,83
Moreover, the traditional curl-up increases intradiscal pres-
sure and increases compressive forces at L2L3.
5,65,82,83

Increasingly, research has uncovered decreased cross sectional area of the multidi in subjects with LBP.
79

Researchers found that there was not spontaneous recovery of the multidi following resolution of
26
Integrated Core Training
symptoms.
79
Hence the need for adequate reconditioning of local, intrinsic core musculature. This need
can be addressed through implementing a training regimen that focuses on rst creating core stabilization
(increasing the endurance capacity of local core muscles) by retraining the local muscles with a drawing-in
maneuver. Additional research demonstrates increased EMG activity and increased pelvic stabilization when
an abdominal drawing-in maneuver was performed prior to initiating core training.
5,6,8,60,61,62,63,65,70,84,85
In
fact, recent research by Hides et al. has shown that the technique of drawing-in signicantly increased in
the thickness of the TVA as well as decreased cross-sectional area, theorized to bilaterally contract and
form a corset which will most likely increase the stability of the lumbar spine.
86
A study by Richardson
et al. published in 2002 uncovered decreased joint laxity of the SIJ when a drawing-in maneuver (activat-
ing the TVA with co-contraction of the multidi) was performed.
87
This further supports the notion of
increased core stability when the local core musculature is successfully engaged.
The NASM Stance on Core Training Based on the Research
It seems that much of the debate surrounding core training centers on theories of motor learning and
muscle capacity, not on whether a core training program can help decrease LBP. In fact, many researchers
agree on the integration of some aspect of core training to alleviate LBP in patients. A review of current
core concepts and literature addressing the core revealed a shift in thought about the exercise and appli-
cations of a lumbar stability program (LSP). A review published in the American Journal of Physical Medicine
and Rehabilitation provided some insight into the highly debated and increasingly interesting research of
LSPs. Despite every view, the review found a universal acceptance that exercise may be a vital part of
treatment of nonspecic LBP.
88
The question most researchers are currently xated on is what program
implementation will work best.
89
There are various approaches to training the core. The rationale behind core training seems to fall into
two main categories: the muscle capacity model, which states that exercises are performed because the
demands of trunk control require a restoration of strength and endurance; and the control model, which
states that exercises are performed to gain control and coordination of the trunk musculature.
90
The rst rationale of muscle capacity is based on the Euler model of spinal stability. Eulers model equates
the forces acting on a exible column in order to control buckling forces. This model proposes that the
musculature that surrounds the spine acts as guy wires to help support and stabilize the spine (i.e., stability
is dependent on muscles acting to limit trunk motion). As Eulers theory suggests, devoid of musculature
to stiffen the spine, compressive forces of as little as 90 Newtons (20.23 lbs) could cause the lumbar spine
to buckle. This mode of thought asserts that these muscles keep the spine in a mechanically stable equi-
librium (i.e., neutral spine). These muscles are proposed to control and restrict movement and maintain
27
Integrated Core Training
a stable lumbo-pelvic position (bracing). However, this is a very static analysis of the spine, and theories
have not been tested on a dynamic model. This exercise strategy would require a stable or stiff spine,
with force and load being applied through movement of the extremities.
In the control model of core stability, theorists claim that lumbo-pelvic function and health are dependent
on the accurate interplay of the trunk musculature.
90
In other words, the nervous system must be able
to determine how much stability the spine needs to meet the internal or external demands and recruit
the proper muscles to handle those needs. Feed-forward control dictates that the nervous system can
plan muscle-activation strategies in advance to prepare the spine to handle forces and loads resulting from
movement of an extremity. If the forces are unexpected, the nervous system must be able to respond
accurately and recruit the correct muscles to protect the spine from deleterious forces. Therefore, theo-
rists claim that control of the lumbar spine and pelvis are dependent not only on muscle capacity, but also
on the sensory system that communicates spinal stability, which allows the nervous system to respond
accurately by choosing and implementing the correct muscle strategy.
Studies have shown that people with LBP have changes in motor control. Research has found in LBP suf-
ferers a delayed activity of the TVA and lumbar multidi with quick movements of the extremities.
90,91
Independent of force direction, the local musculature has been shown to be active and activated prior to
movement in healthy participants. Hodges noted in his research that the TVA, when properly activated,
creates tension in the TLF, contributing to spinal stiffness, and compresses the SIJ, increasing stability.
91
The
lumbar multidus, in conjunction with the TVA, can help control movement and translation of vertebrae
by generating an intervertebral compressive force. The global system was found to have little ability to
control the movement of the spine, yet it contributes spinal orientation and helps counter forces. Based
on these ndings, exercise recommendations or program considerations can vary, depending on whether
the individual focus is on control or muscle capacity.
Both strategies should be implemented in a core training program, as research has shown the need for both
retraining motor control of local and global musculature as well as retraining the strength and endurance
of these muscles. Research has upheld the hypothesis that proper function of both the local and global
musculature is needed to maintain efcacy of the spine. For retraining control of core stability, retraining
recruitment strategies of the Central Nervous System would be appropriate. In these cases, the intrinsic
musculature is not functioning appropriately and is often inhibited by the supercial musculature that has
become synergistically dominant or hyperactive.
A core program that incorporates skilled activation of the deep muscles and then progressive integration
of the intrinsic musculature with the supercial musculature is necessary. Once the coordinated activation
28
Integrated Core Training
is accomplished, training in varying environments, at differing speeds, forces, and intensities, is needed to
shift an individual into activities of daily living. The muscle capacity model of core stability exercise tends
to overlap the control model. The muscle capacity model is more aggressive in utilizing supercial trunk
musculature right away, claiming the need for coordination of both groups of muscles to work together
synergistically. In essence, this is a correct observation; however, devoid of proper initial training of the
intrinsic musculature, continual dominance of the supercial muscles could result.
In the end, both theories aim to re-establish the trunk muscles ability to meet the higher demands or
forces placed on them for spinal stability, and the theories, used together, can be a signicant approach
to core stability training.
NASM is continually stressing the integration of both theories of motor relearning and increased capacity
of core muscles. The core stabilization training guidelines require activation and skilled learning of proper
intrinsic muscle recruitment before integration of the supercial musculature.
One starts with what is termed core stabilization training, where the neutral spine is located and retraining
of the inner unit is accomplished. This creates increased lumbo-pelvic-hip stability through the co-contrac-
tion of the TVA and the lumbar multidi, as well as the TLF that is dynamically engaged through muscle
insertions such as the TVA, deep erector spinae, internal obliques, and lumbar multidi. This retraining
also increases neuromuscular efciency, leading to increased muscle capacity as the supercial muscles
are introduced later in training. Performing exercises without proper ring of the inner unit musculature
can lead to muscle imbalances and inefcient neuromuscular control of the entire kinetic chain. This, in
turn, can lead to or propagate already existing injuries, such as LBP.
As mentioned earlier, research has found that lack of proper stabilization leads to increased intradiscal
pressure and compressive forces in the lumbar spine. Once skilled activation is accomplished, movement
of the extremities is added while the client maintains a neutral spine, retraining muscle capacity as the
extremities pose substantial force requirements on the spine. These exercises should be done without
noticeable compensation before integration of supercial muscles into the exercises.
The next level of core training integrates and coordinates activation of the deep musculature with the
supercial muscles of the core. The core strength level of training in NASMs model is intended to
enhance neuromuscular efciency, create a multi-dimensional progression and teach control of eccentric,
isometric, and concentric phases of core activity. Specicity, speed and neural demand are also increased
in this phase. This coincides with both the motor control theory and the muscle capacity theory of core
training. In the NASM core training continuum, both theories are utilized as progressions of one another
and not as differing approaches.
29
Integrated Core Training
Lastly, in the core power stage of training, core stabilization and strength are integrated into the specic
activity, as are speed and neural demand. The speed and forces utilized in this phase are comparable to
those encountered in a clients return to his or her environment. This phase places a high demand on the
coordinated activity of the core musculature as a whole. Each level of core training treats both theories of
core training as valid, and integrates each approach into a systematic progression to restore and increase
function of the core, while avoiding injury.
30
Integrated Core Training
Section IV:
Guidelines for Core
Stabilization Training
Focusing on assessing the local musculature and incorporating exercises that teach proper muscle activa-
tion of the TVA and multidi in patients lacking proper activation may help clinicians begin the process of
rehabilitation. An important key to success in a core training program is the understanding of exibility
and muscle imbalances. Activation of local stabilization musculature is important; however, activation of
these muscles alone may not bridge the gap into functional living. Integration of core stabilization and
strength training is important in keeping clients functioning properly. Teaching proper activation patterns
and increasing the endurance capabilities of both local and global musculature may transition a client safely
from training into everyday movements and activities.
Prior to performing a comprehensive core stabilization program, each individual must undergo a compre-
hensive kinetic chain assessment. All muscle imbalances and arthrokinematic decits need to be corrected
prior to initiating an aggressive core training program. A team approach is the best way to thoroughly
assess each client. Find a competent health care professional in your community with whom you can
establish a referral basis for comprehensive evaluations.
As outlined in Figure 18, a comprehensive core stabilization training program should adhere to specic
guidelines. It should be systematic, progressive, and functional. The program should emphasize the entire
muscle contraction spectrum, focusing on force production (concentric contractions), force reduction
(eccentric contractions), and dynamic stabilization (isometric contractions). The core stabilization program
should begin in the most challenging environment the individual can control.
31
Integrated Core Training
Figure 18: Core Training Guidelines and Program Variables
CORE STABILIZATION TRAINING GUIDELINES
1. Progressive
2. Systematic
3. Activity Specic
4. Integrated
5. Proprioceptively Challenging
6. Based on Current Science
PROGRAM VARIABLES
1. Plane of motion
2. Range of motion
3. Loading parameters (physioball, ball,
Bodyblades, power sports trainer,
weight vest, dumbbell, tubing, etc.)
4. Body position
5. Amount of control
6. Speed of execution
7. Amount of feedback
8. Duration (sets, reps, tempo, time
under tension)
9. Frequency
As outlined in Figures 19 and 20, a progressive continuum of function that adheres to multi-modal loading
parameters should be followed to systematically train the individual. The program should be manipulated
regularly by changing any of the following variables: plane of motion, range of motion, loading parameters
(physioball, ball, bodyblades, power sports trainer, weight vest, dumbbell, tubing, etc.), body position,
amount of control, speed of execution, amount of feedback, duration (sets, reps, tempo, time under ten-
sion), and frequency.
5,6,7,8,9,10,11,13,15,17,18,19,60,61,62,63,71,74,80,83,84,85,92,93,94,95,96,97,98,99,100

32
Integrated Core Training
Figure 19: Functional Continuum
CORE STABILIZATION TRAINING; FUNCTIONAL CONTINUUM
1. Multi-planar (3 planes of motion)
2. Multi-dimensional
3. Utilize the entire muscle contraction spectrum
4. Utilize the entire contraction velocity spectrum
5. Manipulate all acute training variables (sets, reps, intensity, rest intervals,
frequency, duration)
Figure 20: Multi-Modal Loading Parameters
1. Stability Ball
2. Cable (Free motion)
3. Tubing
4. Medicine Ball
5. Power Balls
6. Bodyblades
7. Dumbbells
8. Weight Vests
When designing a core stabilization training program, the health and tness professional should create
a proprioceptively enriched environment and select the appropriate exercises to elicit a maximal train-
ing response. As outlined in Figure 21, the exercises must be safe, be challenging, stress multiple planes,
incorporate a multi-sensory environment, be derived from fundamental movement skills, and be activity
specic.
33
Integrated Core Training
Figure 21: Exercise Selection Criteria
1. Safe
2. Challenging
3. Progressive
4. Systematic (Integrated Functional Continuum)
5. Proprioceptively Enriched
6. Activity Specic
The health and tness professional should follow a progressive and integrated functional continuum like
the one illustrated in Figure 22 to allow optimum adaptations.
9,10,11,84

Figure 22: Integrated Functional Continuum

lNTEGRATED FUNCTlONAL CONTlNUUM
Power
5trength
5tabiIization
M8 Potat|ona| C|est Pass
Cab|e C|o
Draw|ngln Maneuver Dur|ng
lntegrateo Act|v|t|es
In addition, the health and tness professional should follow an exercise progression continuum similar
to the one outlined in Figure 23.
34
Integrated Core Training
Figure 23: Exercise Progression Continuum
m
Slow to Fast
m
Simple to Complex
m
Known to Unknown
m
Stable to Unstable
These concepts are critical for a proper exercise progression: slow to fast, simple to complex,
known to unknown, low force to high force, static to dynamic, correct execution to increased reps/
sets/intensity.
7,8,9,10,11,84

The goal of core training is to develop optimal levels of functional strength and dynamic stabilization.
5,13

Neural adaptations become the focus of the program instead of striving for absolute strength gains.
9,14,15,30,62

Increasing proprioceptive demand by utilizing a multi-sensory, multi-modal environment becomes more
important than increasing the external resistance. Quality of movement is stressed over quantity. The
focus of the program must be on function.
9,10,11

35
Integrated Core Training
Section V:
Core Stabilization
Training Program
The following is an example of an integrated core training program. As mentioned earlier, the individual
begins at the highest level at which he or she is able to maintain stability and optimum neuromuscular
control. He/she is progressed through the program when he/she achieves mastery of the exercises in the
previous level.
1,2,5,6,7,8,9,10,11,13,14,15,17,19,30,34,60,62,65,71,74,83,92,93,94,99,100,101,102,103,104,105

Figure 24: OPT

Model
36
Integrated Core Training
Core Stabilization
In core stabilization (phase 1 of the OPT

model), exercises involve little motion through the spine and

pelvis. These exercises are designed to improve the functional capacity of the stabilization system.

Marching Prone Iso-Abs Side Iso Abs

Iso Abs w/Hip Extension Floor Bridge 1 Floor Bridge 2

Floor Cobra 1 Floor Cobra 2 Arm/Opposite Leg Raise
37
Integrated Core Training
Core Strength
In core strength training (phases 2, 3, and 4 of the OPT

model), the exercises involve more dynamic

eccentric and concentric movements of the spine through a full range of motion. The specicity, speed, and
neural demand are also progressed in this level. These exercises are designed to improve dynamic stabiliza-
tion, concentric strength, eccentric strength, and neuromuscular efciency of the entire kinetic chain.

Ball Crunch 1 Ball Crunch 2 Ball Crunch Ball Crunch
w/Rotation 1 w/Rotation 2

Back Extension 1 Back Extension 2 Reverse Crunch 1

Reverse Crunch 2 Knee Ups 1 Knee Ups 2
38
Integrated Core Training

Cable Lift 1 Cable Lift 2 Cable Chop 1 Cable Chop 2
Core Power
In core power training (phase 5 of the OPT

model), exercises are designed to improve the rate of force

production of the core musculature. These forms of exercise prepare an individual to dynamically stabilize
and generate force at more functionally applicable speeds.

Ball MB Pullover Throw 1 Ball MB Pullover Throw 2 Woodchop Throw 1 Woodchop Throw 2
39
Integrated Core Training

MB Scoop Toss 1 MB Scoop Toss 2 Rotational Chest Rotational Chest
Pass 1 Pass 2
Integrated Core Training Program Design
OPT

Level Phase Example Core Exercises Sets/Reps Rest

Stabilization
Strength
Power
1
2, 3, 4
5
14 Core Stabilization
2Leg Floor Bridge
Prone Iso-Abs
Prone Cobra
*04 Core Strength
Back Extensions
Ball Crunches
Cable PNF
Knee-ups
**02 Core Power
Medicine Ball Rotational Chest Pass
Ball Medicine Ball Pullover
13 x 1220
23 x 810
24 x 510
0 90 s
0 60 s
0 60 s
Table 1 Integrated Core Training Program Design
*For the goal of muscle hypertrophy and maximal strength, it may be optional (although recommended) for individuals.
**Because core exercises are performed in the dynamic warm-up portion of this program and core power exercises are included
in the resistance training portion of the program, separate core training may not be necessary in this phase of training.
40
Integrated Core Training
Section VI:
Summary
This type of training should be included in all integrated training programs. A core training program enables
an individual to gain optimum neuromuscular control of the LPHC and to achieve optimum performance.
To choose the proper exercises when designing a program, follow the progression of the OPT

model.
In the stabilization level, choose one to four core stabilization exercises. In the strength level, select from
zero to four core strength exercises. In the power level, pick from zero to two core power exercises.
41
Integrated Core Training
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