CORE STABILITY EXERCISES DPT 9th Semester IPM&R (KMU) MUJEEB UR RAHMAN ASSISTANT PROFESSOR IPM&R KMU

Core stability “The ability to control the position and motion of the trunk over the pelvis and leg to allow optimum production, transfer and control of force and motion to the terminal segment in integrated kinetic chain activities” Core is also known as lumbo-pelvic-hip complex.

Functional anatomy of the core: 29 muscles attach to core Lumbar Spine Muscles Transversospinalis group Rotators Interspinalis Intertransversarii Semispinalis Multifidus Erector spinae Iliocostalis Longissimus Spinalis Quadratus lumborum Latissimus Dorsi

Abdominal Muscles Rectus abdominis External oblique Internal oblique Transversus abdominis

Hip musculature Psoas Gluteus medius Gluteus maximus Hamstrings

Hip Musculature 6

Core can be divided into : 1-Inner core(local postural muscles) 2-Outer core(global dynamic muscles)

Inner core/local postural muscles The inner core is comprised of muscles that link directly to the spinal cord. These muscles include: Transversus abdominis Lumbar multifidus Pelvic floor muscles Diaphragm

The inner core muscles often go neglected as they are not visible and have no aesthetic appearance like the muscles of the outer core.

Outer Core/global dynamic muscles: The outer core includes muscles that attach from the pelvis to the spine, and from the spine and pelvis to the body’s extremities. The outer core muscles are more commonly seen and exercised and include: Internal obliques External obliques Erector spinae(Longissimus and iliocostalis) Rectus abdominus

Functions Of The Core Efficient core allows for Maintenance of normal length-tension relationships Maintenance of normal force couples Maintenance of optimal arthrokinematics Optimal efficiency in entire kinetic chain during movement Acceleration, deceleration, dynamic stabilization Proximal stability for movement of extremities

Functions of the Core Provide spinal stability and coordinate the movement of the arms, legs, and spine stabilize the person's thorax and pelvis during dynamic movement. Shock absorber. reduce stress during rotational and flexion movements . keep the body balanced, to reduce stress and injury, and to protect the spinal column.

The muscles of the core are also responsible for movement. They provide stability, torque, and momentum for movements such as: leg swing and arm swing in walking or running. weight transfer in stepping, walking and running. momentum shifts in movements like swinging, throwing, or pitching.

The core is used to stabilize the thorax and the pelvis during dynamic movement and it also provides internal pressure to expel substances (vomit, feces,giving birth etc). Valsalva maneuver Continence Pregnancy Valsalva maneuver: Core muscles are very important in the Valsalva maneuver, which is when a person's thorax tightens while holding their breath. This normally involuntary action can be induced by linking one's hands in front of the chest while standing, and then pulling against the hands without letting go. The Valsalva maneuver assists in lifting, excretion, pushing, and birthing. Continence: Continence is the ability to withhold bowel movements, and urinary stress incontinence (the lack of bladder control due to pelvic floor dysfunction) can result from weak core musculature. Pragnancy: Women use their core muscles, specifically the transversus abdominis, during labor and delivery.

Rehabilitation steps 1-The first step is motor skill learning (i.e. learning how to Isolate and activate the core muscles to train them, to contract them) 2- The second step is strengthening/endurance of core muscles. 3-The final step is functional progression i-e to co-contract the entire core and use this connection in functional activities.

For sports player the final step is sports specific training (i. e For sports player the final step is sports specific training (i.e. progressing these exercises into drills which replicate sport)

No matter what core exercise you are doing your aim should be for maximal control and stability with minimal use of the global stabilizers. If an exercise is too difficult go back and master a simpler exercise and then progress.

Transversus abdominis training

Step 1: Isolation of Transversus Abdominis Lie on your back or side with your spine in a neutral posture. Identify transversus abdominis by : Putting fingers on lower part of abdomin,gently close the muscles around your rectum and then connect the rectum to the back of the pubic symphysis.You will feel a light, deep tension under your fingertips, not a contraction that pushes the fingers out.

Draw in muscles and hold the contraction for 10 seconds without becoming rigid, and continue to breathe. AVOID: movement of the hip,spine. Posterior tilting of the pelvis Bulging of the abdomen Depression of the rib cage Breath holding Fingertips being pressed out by a strong muscular contraction (internal oblique)

Once you can isolate the transversus abdominis, practice this isolation in many different positions - i.e. sitting, standing, bending over etc. Once you can turn the muscle on in different positions easily you can progress to stage 2.

Step 2-strenthening and endurance exercises for transversus abdominis

LEVEL 1:- Stabilize one leg.(left) Other leg will fall out.(right)

LEVEL 2:- Stabilize one leg (left) Perform following 3 activities on other leg (right) A-lift bend leg with 90 degree hip flexion. B-slide heel to extend knee. C-lift straight leg to 45 degrees

Level 3: Hold one leg at 90 degrees of hip flexion with upper extremity assistance. perform following activities on other leg : A-lift bend leg with 90 degree hip flexion. B-slide heel to extend knee. C-lift straight leg to 45 degrees

Level 4:- Hold one leg at 90 degrees of hip flexion with out upper extremity assistance. perform following activities on other leg : A-lift bend leg with 90 degree hip flexion. B-slide heel to extend knee. C-lift straight leg to 45 degrees

Level 5: Bilateral lower limb activity i-e A-lift both legs with 90 degree hip flexion. B-slide both heels to extend knee. C-lift both legs straight to 45 degrees

Instructions Begin each exercise with drawingin maneuver to activate core muscles. For endurance, decrease limb loading and perform repetitive motion for 1 minute or longer. For strength, progress load.

With all these exercises maintain the leg lift for 10 seconds and build 3 sets of 10 reps

Advanced dynamic strengthening exercises for abdominal muscles

Curl up exercise

Bilateral leg raising

Standing trunk flexion against elastic material.

Curl ups on unstable surface

Step 3: Incorporate into Other Activities The final step is to remember to use the core during regular life activities. Such as: -Getting out of chair -Bending -lifting -Reaching etc .

Rehabilitation of multifidis

Step 1: Isolation of Multifidus: Lie on your side with your spine in a neutral posture Palpate the multifidus you are trying to isolate, (find the spine bone and then fall off into the gutter just sideways from the bone)

Breathe in and out and contract the multifidus under the fingers. The contraction of the multifidus should feel like a slow, firm, 'swelling' under your fingers . You should not feel a rapid contraction. No actual movement of the hip, pelvis or spine should occur. Hold the contraction without becoming rigid, and continue to breathe.

Step 2: strengthening of multifidis: Once you can isolate the multifidus, practice this isolation in many different positions - i.e. sitting, standing, bending over etc. Once you can turn the muscle on easily you can progress to the following exercises.

Level 1: Quadruped position. Flex one upper extremity.

Level 2: Quadruped position Extend one lower extremity by sliding it along the exercise mat.

Level 3: Quadruped position Extend one lower extremity and lift 6-8 inches off the mat.

Level 4: Quadruped position Flex one UE and extend contralateral LE.

Level 5: Prone position. Extend one LE.

Level 6 and 7 : Level 6:-extend both LE Level 7:-extend both LE and lift head and arms off table.

Instructions:- Patient position quadruped or prone Patient assumes spine . Perform drawing in maneuver. Moves extrimities . Motions are repeated or alternated from side to side .

Advanced dynamic strengthening exercises for back extensors.

Back extension against resistance

Superman exercise

Elastic resistance/weight pulleys

Step 3: Incorporate into Other Activities The final step is to remember to use the core during daily life activities.

Pelvic floor muscles rehabilitation

Step 1: Isolation of the Pelvic Floor Muscles Lie on your back or side or sit with the spine in a neutral posture. Firmly palpate your abdomen 1-2 inches inside of your hip bones. Imaginary stop the urine and fecal flow. The muscles you use to stop the flow of urine and feces are the same muscles you will be squeezing when doing the Kegel's exercises.

When you isolate your pelvic floor muscles you should feel a deep tension in your abdomen (under your fingers), you should NOT feel your buttocks tighten, legs rotate out or movement of your spine or pelvis. If you feel a muscle pushing your fingers out of your abdomen, butt gripping or spinal movement then you are not being successful in connecting to your pelvic floor muscles. A correct contraction should result in a very gentle tension deep in the abdomen (often very hard to feel initially).

KEGEL’S IN SUPINE

Step 2: Learning to Co-contract the Pelvic Floor with Transversus Abdominis and Relax the Deep Posterior Pelvic Muscles(ischiococcygeus and piriformis) Begin by sitting on a firm chair. Find your neutral spine position Squeeze the muscles in your buttock and turn your hips out . feel the muscles in the deep posterior pelvis contract. draw your Ischial bones together. Now complete relax these muscles

maintain the relaxation and gently and slowly contract the pelvic floor muscles Repeat this few times. palpate the transversus abdominis just inside your anterior hip bones. As you contract your anterior pelvic floor you should feel a light, deep tensioning in the lower abdomen. Keep your buttocks relaxed, maintain your neutral spine position and repeat this gentle contraction a few times while focusing on relaxed breathing.