CORE STABILIZATION TRAINING IN REHABILITATION

KINETIC CHAIN REHABILITATION DEFINITIONS Functional kinetic chain rehabilitation: “a comprehensive approach that strives to improve all components necessary to allow a patient to return to a high level of function.” While caring for the affected area remains the foremost ,clinicians have developed interventions to treat the whole as well as the part. Functional training starting from the ground up

KINETIC CHAIN REHABILITATION DEFINITIONS Functional strength: “Is the ability of the neuromuscular system to reduce force, produce force, and dynamically stabilize the kinetic chain during functional movements, upon demand, in a smooth, coordinated fashion.” Kinetic chain starts at the feet and moves up Moving in a controlled fashion

KINETIC CHAIN REHABILITATION DEFINITIONS Neuromuscular efficiency: “ is the ability of the CNS to allow agonists, antagonists, synergists, stabilizers and neutralizers to work efficiently and interdependently during dynamic kinetic chain activities” Muscles work together and independently in order to complete open and closed chain activities

KINETIC CHAIN REHABILITATION SO: BY TRAINING THE “CORE”: Improve dynamic postural control Ensure appropriate muscular balance Ensure appropriate joint arthrokinematics at the hip/pelvis/lumbar spine Allow for dynamic functional strength Improve neuromuscular efficiency throughout kinetic chain. Muscle balance – proper length, proper tension Ensure appropriate joint arthrokinematics at the hip/pelvis/lumbar spine – ensure all the muscles are working properly in order to have proper function of the joint. If everything is lined up properly we will have better neuromuscular efficiency and best muscular function

WHAT IS THE “CORE”? CORE: The lumbo-pelvic-hip complex CoG is located Beginning point for all movement 29 muscles that attach to the lumbo-pelvic-hip complex Works as an integrated functional unit

CORE STABILIZATION TRAINING CONCEPTS “core” of body similar to foundation of a house. Connects kinetic chain (lower to upper body) therefore, strong, efficient movements

CORE STABILIZATION TRAINING CONCEPTS benefits of strong core musculature Protective of spine Gain strength, power, endurance and neuromuscular control If extremities are strong and core is weak , there will not be enough force created to produce efficient movements A weak core is a fundamental cause of inefficient movements that may lead to injury Gain strength, power, endurance and neuromuscular control throughout the whole body Balance muscle function will allow all the bodies muscles at all points (med/lateral, ant/post)

FUNCTIONAL ANATOMY POSTERIOR MUSCLES ANTERIOR MUSCLES HIP MUSCLES

FUNCTIONAL ANATOMY POSTERIOR MUSCLES ERECTOR SPINAE QUADRATUS LUMBORUM Dynamic intersegmental stabilization Eccentrically decelerates forward flexion & rotation QUADRATUS LUMBORUM stabilizer Erector Spinae Concentrically extend your back Eccentrically decelerate forward flexion Concentrically and eccentrically involved in rotation Quadratus Lumborum Helps prevent forward flexion

FUNCTIONAL ANATOMY POSTERIOR MUSCLES LATISSIMUS DORSI Is bridge between upper and lumbo-pelvic-hip complex Starts around L2, 3, 4 and attaches around the humerus

FUNCTIONAL ANATOMY ANTERIOR MUSCLES/ ABDOMINALS RECTUS ABDOMINUS EXTERNAL OBLIQUES INTERNAL OBLIQUES TRANSVERSE ABDOMINUS Abdominals operate as an integrated functional unit When functioning efficiently , they offer sagittal, frontal and transverse plane stabilization

FUNCTIONAL ANATOMY RECTUS ABDOMINUS “6 pack” Eccentrically decelerates trunk extension and lateral flexion Dynamically stabilizes trunk in functional movements Rectus Ab – “the six pack” Not the most important functional muscle to work on

FUNCTIONAL ANATOMY EXTERNAL OBLIQUES Concentric opposite side rotation Concentric lateral flexion ( same side) When left muscle contractions rotation to the right side occurs When left muscle contracts in conjunction with left QL and Erector Spinae left side flexion occurs Ipsilateral – same side Contralateral – opposite side

FUNCTIONAL ANATOMY INTERNAL OBLIQUES Concentric rotation ( same side) Concentric lateral flexion (same side) When right contracts, right rotation occurs - ipsilateral

FUNCTIONAL ANATOMY TRANSVERSE ABDOMINUS (probably most important muscle ) Increase intra-abdominal pressure Dynamic stabilization Active during all trunk movements Small muscle, very important Acts as a girdle around your hips to hold your tummy in Dynamic Stabilization Attaches to the spine and wraps around to connect in the front Should be contracted all the time in conjunction with the maltifidus muscles. People that have a lot of back pain usually have weak transverse abominus and maltifidus

FUNCTIONAL ANATOMY HIP MUSCULATURE PSOAS GLUTEUS MEDIUS GLUTEUS MAXIMUS HAMSTRINGS

FUNCTIONAL ANATOMY PSOAS If tight, increase shear on L4/L5

FUNCTIONAL ANATOMY GLUTEUS MEDIUS If weak, Can increase shear @ lumbo-pelvic, tibio-femoral and patello-femoral joints Can lead to tightness of the ITB and the lumbar spine

FUNCTIONAL ANATOMY GLUTEUS MAXIMUS Major SI joint stabilizer

FUNCTIONAL ANATOMY HAMSTRINGS Work synergistically with ACL

POSTURAL CONSIDERATIONS serial distortion patterns? Predictable patterns of dysfunction that occur when one segment of the kinetic chain is out of alignment. Therefore, there is a “break” in the kinetic chain.

MUSCULAR IMBALANCES “the interplay of many muscles about a joint is responsible for the coordinated control of movement.” Therefore, changes in strength, length, etc of muscles has an effect on other muscles about the same joint (and other joints). This can cause problems with normal movement patterns which could lead to increased susceptibility of injury.

MUSCULAR IMBALANCES i.e. tight psoas causes reciprocal inhibition of glut max, TrA, multifidus and internal obliques. May decrease normal lumbo-pelvic hip stability

NEUROMUSCULAR CONSIDERATIONS Injury to one ligament/structure alters function of other muscles crossing same joint. i.e., swelling in knee…affects rectus femoris at both knee and hip Therefore, can alter hip mechanics

ASSESSMENT OF “THE CORE” tests that can be used: 1. erector spinae: Prone lumbar extension. Lying on a table Hold at 30 degrees for as long as possible.

Core Testing 2. upper abdominals: straight leg lowering test, bp cuff under L4-L5,cuff raised to 40 mmHg, legs are extended while hip flexed to 90 degrees . Athlete draws in (TrA) and then flattens back into table . The athlete then lowers their legs to the table while maintaining a flat back . Test is over when pressure in the cuff decreases below 40 mmHg. Measure hip angle

ASSESSMENT OF “THE CORE” 3. Lower abdominals: bent knee lowering test, same as above but now knees flexed to 90 degrees. 4. core power: Overhead medicine ball throw, hold medicine ball between legs and squat down , then jump as high as possible while throwing the medicine ball backwards over their head. measure distance ball travels

Med ball throw

Transversus Abdominis The main muscles of lumbo-pelvic stability are the Transversus Abdominus, the Pelvic Floor muscles, and the Multifidus. Many other muscles play a role too. These muscles are too deep to be obvious, so you need special training to learn how to activate them. The following exercise teaches how to activate the transversus abdominus:-

TrA Lie in the relaxation position and find pelvic neutral (back not too arched ) . Put your hands on the area of your abdomen that would be covered by the front part of a bikini / Speedo. For the time being, we shall call this the “bikini patch”. Have your thumbs touching at the navel, and your fingers touching at the midline, about 6 cm below the navel.

Now imagine that you have to zip up a very tight pair of jeans: - Hollow the area under you thumbs and fingers toward your spine. There may only be a very small movement. (maintain Pelvic and Chest Neutral) Now imagine (if it hasn’t already happened), that the area under your fingers is being zipped together like that tight pair of jeans! (keep the rest of your body relaxed, maintain Pelvic and Chest Neutral!)

Up until now you had no awareness of the Transversus abdominis Up until now you had no awareness of the Transversus abdominis. It is a deep, slow moving, postural muscle. The Transversus abdominis can and indeed should be working at 2 to 20% of maximum contractile force during all your waking hours. Note: Your breathing will undoubtedly feel restricted, by Transversus abdominis contraction

SCIENTIFIC RATIONALE FOR CORE STAB. TRAINING Need to train properly. need to stabilize pelvis, increase EMG activity when drawing in manoeuvre was performed prior to core training Therefore, don’t inhibit TrA If not trained properly, can increase interdisc pressures and compressive forces in the lumbar spine. ( traditional curl ups increase intra-dicscal pressure)

CORE STABILIZATION Primary slow twitch muscles Respond best to time under tension Contraction lasts from 6 – 20 seconds

GUIDELINES Systematic, progressive, and functional Begin in most challenging environment the athlete can control Perform in a proprioceptively enriched environment

PROGRAM VARIATION Plane of motion Range of motion Loading parameter Body position Speed of movement Amount of control Duration Frequency

EXERCISE SELECTION Safe Challenging Stress multiple planes Proprioceptively enriched Activity-specific

EXERCISE PROGRESSION Slow to fast Simple to complex Stable to unstable Low force to high force General to specific Correct execution to increased intensity