1. Establishing Core Stability in Rehabilitation
Rehabilitation Techniques for Sports Medicine and Athletic Training
William E. Prentice

2. What is the Core? Core defined as the lumbo-pelvic-hip (LPH) complex
Where our 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
Also provide proximal stability for efficient upper and lower extremity movements

3. 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”

4. 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

5. 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 because not enough trunk stabilization created to produce efficient movements.

7. 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 functional movement
Lead to compensation and substitution patterns as well as poor posture during functional activities
Increase mechanical stress on contractile and non-contractile tissue thus leading to injury

9. 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
More muscle spindles, therefore primarily responsible for providing 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 muscle most important in this muscle group

10. 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

11. 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.

13. Review of Functional Anatomy
Key Hip Musculature
Psoas
Gluteus Medius
Gluteus maximus
Hamstrings

14. 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
Leads to extensor mechanism dysfunction during fxal mvmt patterns.

15. 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

16. 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

17. 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

18. 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

19. Review of Functional Anatomy
LPH complex is like a cylinder
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

20. Postural Considerations
Optimal posture will allow for maximal neuro-muscular 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

24. 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 c

25. 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

26. 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

30. 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

32. Assessment of Core Activity based test Manual Test EMG Ultrasound
SL lowering test using biofeedback Stabilizer
Manual Test
Multifidi & TA
EMG
Surface electrodes
Ultrasound
Reliable tool in determining activation patterns of abdominal muscles

33. Drawing In Maneuver
All core exercises must start with a “drawing in” maneuver, or abdominal brace (Table 5-1 pg. 109)
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

34. Specific Core Stabilization Exercises
Progression of Core Exercises once abdominal bracing is perfected and able to be maintained through exercise
Static
Supine and Prone Exercises
Quadruped Exercises
Comprehensive Core Stabilization Program
Stabilization
Strength
Power

35. 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