1. Anatomy & Function of the “Core” Ellen Casey, MD Assistant Professor Associate Director Sports Medicine Fellowship

2. Disclosures None

3. Objectives Define core stability Review the components of the core Discuss the role of coordination vs. strength in achieving a stable core

5. Functional Spinal Stability Neural Control Spinal Column Spine Stabilit y Muscles Panjabi, 2003

6. Osseoligamentous Structures Lucas & Bresler, 1961

7. Thoracolumbar Fascia 7

8. Core Musculature 8 Hodges 1999

9. Muscles of the Lumbar Spine Global Rectus abdominus External oblique Internal oblique (ant) Iliocostalis (thoracic) Local Multifidi Psoas Transversus abdominis Quadratus lumborum Internal Oblique (post) Iliocostalis Longisimus Akuthota & Nadler, 2004

10. Paraspinals

11. Quadratus Lumborum

12. Psoas major

13. Diaphragm “Ceiling” of the Core Respiration –Reciprocal with pelvic floor –Descends with inspiration Spine stability –Increase IA pressure –Pts with LBP and SIJ  abnormal recruitment O’Sullivan, 2002

14. Pelvic Floor “Floor” of the Core Respiration –Reciprocal with diaphragm Spine Stability –Support lumbopelvis and pelvic organs –Co-activation withTrA (Sapsford 2001) Specialized Functions –Sphincteric control –Sexual function

15. Abdominal Wall Musculature

16. Obliques EXTERNAL Increases IAP Trunk rotation Side bending Controls ant pelvic tilt INTERNAL Increases IAP Trunk rotation Side bending

17. Transversus Abdominis (TrA) 1.Increase Intra-abdominal Pressure  Symmetric  Active in both sagittal flex/ext (Barker 2005) 2.Contributes to control of trunk rotation  Asymmetric  Ipsilateral > Contralateral (Urquhart 2005)  Feed forward/anticipation (Hodges 1996) 3.Different types of activation  Tonic during gait  Phasically active with breathing and heel strike (Saunders 2004)

18. “Core” Controversy HOLLOWING “Drawing in” Selective recruitment of TrA and multifidi (Urquhart 2004) Incr spine stiffness (Hodges 2003) Early in rehabilitation BRACING EO > TrA, multifidi, IO (Urquhart 2004) Greater spine stiffness than hollowing (Grenier 2007) Incr ability to stabilize against trunk perturbations (Vera-Garcia 2006) More functional 18

19. Gender & Abd Wall Nm Control Rho 2013 EO IO TrA MALE FEMALE AT REST CONTRACTION

20. Putting it all together functionally Driver of the kinetic chain Proximal stability  distal mobility Small contraction = big effect (Cholewicki & McGill 1996) –5% MVC for ADLs –10% MVC for vigorous activity Controlled by neural subsystem –Constant feedback –Continued refinement of movement Contribution of each muscle changes based on the demand (Zazulak 2007)

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