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 will all lower extremity rehabilitation programs.

Individuals with a weak core substitute/compensate 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 stabilizes the kinetic chain during functional movements The core functions primarily to maintain dynamic postural control by keeping the center of gravity over our base of support during dynamic movements.

Pelvic Girdle
29 muscles attach to the core (LPH complex unilaterally)

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

LPH Complex Cont.

Otherwise will get neuromuscular inhibition and CNS will shut down prime movers if LPH not stabilized, thus minimizing the 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 mulidirectional movement
vs unidimentional, low proprioception, all three planes All functional exercises are triplanar (even walking) appears unidirectional but need other planes to stabilize (frontal & transverse). All functional movements required acceleration, deceleration & dynamic stabilization (typically concentrate in concentric and acceleration in rehab)

Definitions:
Functional Strength - ability neuromuscular system to produce dynamic eccentric concentric and dynamic isometric stabilization contraction 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 cannot stabilize or control eccentrically thus increasing stresses in different plane of movement and in different joints (compensation)

Kinetic Chain When it works efficiently:

optimal control distribute force appropriately optimal efficiency during all movements impact absorption/ground reaction forces no excessive comp0ressive transitory force shear in kinetic chain dynamic joint stabilization neuromuscular control

Example: Pelvo-Occular reflex (Janda)

Cervical spine weak: during running fatigue head will go into extension, thus to see straight in from of you the pelvis tips anteriorly This changes length tension ratios of the 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 work synergistically with entire kinetic chain Primary Function: maintain center of gravity over base of support during dynamic movement (Example gait cycle - loss of balance) Stability & control offers more biomechanically correct position for function of entire core and lower extremity muscles

Patho-Kinesiological Model
This is a delicate balance a change in one of these 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 LB comp0laints and hamstring strains (actually attributed to weak abdominals)

Transverse Abdominis and Internal Obliques during functional activity

Only 2 abdominal muscles that attach to the Lspine
Attach thorocolumbar facia (L-spine) via lateral rafia attach to transverse processes Thus when they fire they create a tension affect inherent STABILITY in L-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

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

Transverse Abdominis and Internal Obliques during functional activity

 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 Every single movement we do is the performance paradigm

Basic Concepts of Core Stabilization - Performance Paradigm

Paradigm Shift: NO longer looking to improve strength in one muscle but improvement in multidirectional neuromuscular efficiency (firing patterns in entire kinetic chain with complex motor patterns). The body doesn't just fire one muscle at a time for movement

Basic Concepts of Core Stabilization - Planes of Movement planes are With any movement all three
working together concurrently Even through you may be moving in one plane the other 2 planes must stabilize and work eccentrically for stabilization Example: Posterior Pelvic tilt laying on the floor changes the relationship, thus when standing he relationship again changes the exercises have not been functional and will not work in the altered position. Again it changes when you lift one leg etc.

Basic Concepts of Core Stabilization - Continuum of Function

Movements 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 - Open and Closed Chain

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

Biomechnics: 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

Biomechnics: 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 that thus less time spend in this phase prevent overuse injuries)

Muscle Function Cont.

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

Sheringtons Law of Reciprocal Inhibition: tight muscles will inhibit its functional antagonist. Example:The Psoas (most athletes) inhibit functional antagonists - deep abdominal wall, transverse abdomnis, internal oblique, multifidi, deep transverse spinalis, gluteus maximus. Thus the stabilization and coupli8ng phase will be reduces increasing the movement phase and 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) contract in feed forward mechanism contract 1st before any other muscle (research following back pain the transervse abdominis is inhibited, thus when you move for example an arm, your transverse abdomnis does not stabilize thus the psoas fires - compensation

Muscle Function: Lumbar Spine

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

Muscle Function: Lumbar Spine

Transversal Spinalis Muscles (Rotatories, Multifidi, interspinalis, interanversari) Provide intrisic, intrasegmental stability proprioceptive feedback since constantly under compression and torsinal forces. If these muscles are inhibited, loose the ability to create dynamic stabilization from lack of proprioceptive feedback.

SPINE MUSCLES
Heads

1.Iliocastalis Lumborum Thoracis Cervicis 2.Longissimus Thoracis Cervicis Capitis 3.Spinalis Thoracis Cervicis Capitis

ANATOMY Macro anatomy. Multifidus (MF) is the largest and most medial of the lumbar paraspinal muscles. Each muscle consists of five separate, overlapping bands that form a triangle as these bands run caudo laterally from the midline. Insertion: spinous process at caudal tip. Origin: transverse process at mamillary process, iliac crest, and sacrum (polysegmental: 2-4 segments below insertion at spinous process).

Joint Dysfunction Example

Joint dysfunction example: lock up SI joint plant and twist, Multifitus is inhibited complains for 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 wak will loose ability to control femur, femur will internally rotate:
Microtruma can be created on medial capsule of knee Patellar tendonitis non-contact ACL injuries posterior tibial tendonitis, plantar facitis 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

Gluteus 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 maxiumus due to thigh psoas Thus they 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 int he lumbar spine
counteracted by transverse abdominis, internal oblique multifidi, transversal spinalis groups, gluteus maximums Trend - most athletes the psoas and erector overdeveloped inhibiting stabilizers

Frontal Plane: Gluteus Medius, ipsilateral adductor and contralateral quadratus lumborum
Example: weak gluteaus medius will cause contralateral LBP, 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 abdominis and internal oblique the same side adductor will become tight and inhibit gluteus medius causing anterior knee pain, posteior tib tendonitis etc. Down the kinetic chain.

Principle 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 athletes increase lumbar lordosis
tight muscles movement groups muscles erector spinae superifical 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 gluteaus medius/maximus
muscle that decelerate femur are inhibited

Joint dysfunction illiosacral rotations, S1, L-spine, Tibfib joint, subtalar joint Injury patterns: plantar faciiitis, patellar tendonis, posterior tib tendonitis

Common Postural Dysfunction

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

Common Postural Dysfunction

Pronation Distortion Syndrome: Flat feet
tight muscles: peroneals, lateral gastroc IT band, Psoas Weak muscles: intrinsic foot muscles, anterior/post tibialis, VMO, bicep femoris, piriformis, glut medius
muscles that control pronation are inhibited and weak causing overuse injuries

Pronation Distortion Syndrome

Joint dysfunction: 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 the core chain into movements of the extremity). The same can occur with sprain ankle and lock tibotalar joint

Through 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 chains 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 o inefficient movement which leads to injury

Low Back Pain & Rehabilitations

Transerve abdominis, multifitus, internal oblique are inhibited in someone with LBP Decrease in stabilization endurance can perform the movement until fatigue. OK for 3x20 but once start functional movement revert back to previous positions Increase interdisck pressure and compressive forces with lack of pelvic stabilization Think about athletes that lift and then have LBP cause may not be 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-couple relationships The path of instantaneous center of 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:

Sport Demand Analysis
Demands of the individual sport 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 etc.) Plane of motion Body position, floor standing, one leg etc..) speed of movement duration frequency

Abdominal Bracing Key

Transverse Abdominis - draw belly-button into spine Make self skinny)
Pelvis tilts work rectus abdominis avoid anchoring feet so as not to activate hip flexors or psoas Full ROM]Exercise profession 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

SPINE MUSCLES
Heads

1.Iliocastalis Lumborum Thoracis Cervicis 2.Longissimus Thoracis Cervicis Capitis 3.Spinalis Thoracis Cervicis Capitis

ANATOMY Macro anatomy. Multifidus (MF) is the largest and most medial of the lumbar paraspinal muscles. Each muscle consists of five separate, overlapping bands that form a triangle as these bands run caudo laterally from the midline. Insertion: spinous process at caudal tip. Origin: transverse process at mamillary process, iliac crest, and sacrum (polysegmental: 2-4 segments below insertion at spinous process).