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CORE STABILITY An Introduction
By Donna Sanderson-Hull
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Objectives Definitions Origins Benefits Theory/Posture and anatomy
Research Practical
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WHAT IS CORE STABILITY? “The system the body uses to give spinal support and maintain muscular balance while at the same time providing a firm base of support from which other muscles can work to enable the body to undertake its daily tasks. It is through this system of joint integrity and support that the body is able to maintain its posture – the position from which all movement begins and ends” Chek P. 2000 Corrective high performance exercise kinesiologist
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CORE STABILITY “The ability to maintain neutral spine using the abdominal, back, neck and shoulder girdle muscles as stabilisers rather than movers”
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Orthopaedic view “That state of muscular and skeletal balance which protects the supporting structures of the body against injury or progressive deformity, irrespective of the attitude in which these structures are working or resting” Academy of Orthopaedic Surgeons 1947.
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NOT A NEW CONCEPT STATIC Alexander Technique Pilates DYNAMIC
Tai-chi/Karate Swiss ball training 2 types of stability training – Static and dynamic
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ALEXANDER TECHNIQUE 1869-1955 PRINCIPLES
RE-EDUCATION OF KINAESTHETIC SENSE QUIETING THE MIND TO FOCUS ON THE MIND/BODY CONNECTION ESTABLISHING A GOOD HEAD AND NECK POSITION
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JOSEPH PILATES 1880-1967 PRINCIPLES CONCENTRATION ALIGNMENT BREATHING
CO-ORDINATION STAMINA
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FITNESS PARAMETERS CARDIOVASCULAR STRENGTH / POWER/SPEED ENDURANCE
FLEXIBILITY CORE STABILITY PROPRIOCEPTION / NEUROMUSCULAR CONTROL
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Paradigm Shift: No longer looking to improve strength in one muscle but improvement in multidirectional multidimensional neuromuscular efficiency (firing patterns in entire kinetic chain within complex motor patterns).
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The Theories Spinal Stability
The passively supported spine (bone and ligament will collapse under 20lb (9kg) of load. Muscular components that contribute to lumbo-pelvic stability which take up the slack
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Adapted from Panjabi (1992)
Control subsystem (Neural) Spinal stability Passive subsystem (spinal column) Active subsystem (spinal muscles) Adapted from Panjabi (1992)
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Neutral Zone Concept Every joint has a neutral zone or position
Overall internal stresses and muscular efforts are minimal A region of intervertebral motion around the neutral position where little resistance is offered by the passive spinal column (Panjabi 1992) Movement outside this region is limited by the ligamentous structures providing restraint Panjabi states that…….
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Control of the Neutral Zone
Ligaments - support end of range only - Can be unstable/over-stretched Muscle Can compensate for instability - Increase the stiffness of the spine - Decrease the neutral zone - Form basis for therapeutic intervention in treatment of spinal stability
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Clinical instability A significant decrease in the capacity of the stabilising system of the spine to maintain the internal neutral zones within physiological limits which results in pain and disability (Panjabi)
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Patho-Kinesiological model (Shirley Sarhmann)
Muscular system Articular system Neural system All three must work as an integrated unit The movement system requires optimum function of the core stabilisers resulting in precise arthokinematics and osteokinematics (Sarhmann 2000) 3 systems in the kinetic chain
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Spinal Stability Demonstrated that submaximal levels of muscle activation adequate to provide effective spinal stabilisation Continuous submaximal muscle activation crucial in maintaining lumbopelvic stability for most daily tasks. Thus a comprehensive core stabilisation program should be integrated into all athlete training.
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Benefits of Spinal Stability
Improve Posture and prevent deformities More stable Centre of Gravity and control during dynamic movements contribute to optimal movement patterns breathing efficiency Distribution of forces and absorption of forces Reduce stress on joint surfaces and pain Injury prevention and rehabilitation
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Improved Posture Re-education of stabilisers Reduced stress on joints Reduced injury Increase function and sports performance.
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For Sporting Performance
Forces transmitted - trunk to the limbs Core muscles support the spine to transmit power from the trunk. Power is transferred for kicking and throwing activities If the peripheral limbs are too heavy this will cause stress on the chassis No good if athletes have functional strength and control in the prime movers but have poor stabilisation thru the chassis to transmit that power.
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ANATOMY OVERVIEW LOCAL STABILISERS GLOBAL STABILISERS
Intertransversarii Interspinales Multifidus TrA Longissimus thoracis pars lumborum Illiocostalis lumborum pars lumborum Quadratus lumborum medial fibres IO (insertion into TLF) GLOBAL STABILISERS Longissimus thoracis pars thoracis Illiocostalis lumborum pars thoracis Quadratus lumborum lateral fibres External obliques (Bergmark 1989) Local stablilisers – deep muscles that have origin or insertion on the lumbar spine,Closer to the centre of rotation,Shorter muscle lengths Control intersegmental motion. Global large, superficial assist with rapid ballistic movement to produce high force or powerGLLOBA STABIISERS ISOMETRICALLY HOLD POSITIONS ECCENTRICALLY CONTROL OR DECELERATE FUNCTIONAL LOAD AGAINST GRAVITY CONCENTRICALLY SHORTEN INTO FULL PHYSIOLOGICAL INNER RANGE CONTRIBUTE TO ROTATION CONTROL IN ALL FUNCTIONAL MOVEMENTS Comerford and Mottram, 2001
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STABILISING CORE MUSCLES
THE INNER CORE Transversus abdominus Multifidus Pelvic Floor Muscles Diaphragm Muscles work in harmony. Trans ab and multifidus form a cylinder and the pelvic floor and diaphragm form the base and lid
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The Outer Core Systems Anterior Oblique – ext and int obliques and contralateral hip adductors connected by anterior abdominal fascia Posterior Oblique – Lat Dorsi and contralateral Glut Max connected by T/L fascia Deep Longitudinal – Erector spinae and c/l sacrotubrous ligament and biceps femoris (connected by T/L fascia) Lateral – Glut med and min and c/l adductors
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TRANSVERSUS ABDOMINUS
DEEPEST OF THE ABDOMINAL MUSCLES ORIGINATES FROM CARTILAGE OF LOWER 6 RIBS THORACOLUMBAR FASCIA ILIAC CREST & INGUINAL LIGAMENT INSERTS INTO LINEA ALBA PUBIC CREST
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Transversus Abdominus
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FUNCTION TRANSVERSUS ABDOMINUS
SUPPORT OF ABDOMINAL CONTENTS VIA CIRCUMFERENTIAL ARRANGEMENT BILATERAL CONTRACTION CAUSES DRAWING IN OF ABDOMINAL WALL CAN WORK WITH MULTIFIDUS VIA TENSION OF THORACOLUMBAR FASCIA CONTRIBUTES TO BOTH SUPPORTING AND TORQUE ROLES (JULL, RICHARDSON ET AL 1999)
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MULTIFIDUS ORIGINATES ON DORSAL SURFACE OF SACRUM
SACROTUBEROUS & POSTERIOR SACROILIAC LIGAMENT PSIS & ERECTOR SPINAE APONEUROSIS INSERTS ON SPINOUS PROCESSES OF SACRAL & LUMBAR VERTEBRAE FILLS CHANNELS BETWEEN SACRUM & ILIUM & BETWEEN LUMBAR SPINOUS & TRANSVERSE PROCESSES
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Multifidus
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FUNCTION (MULTIFIDUS)
Provides control of shearing forces of intervertebral motion segments Unique segmental arrangement of multifidus suggests capacity for fine control of movement Control anterior rotation translation in trunk flexion Continuously active in upright posture compared with recumbency Provides anti gravity support Active in both ipsilateral and controlateral trunk rotation Stabiliser rather than prime mover (Richardson, Jull et al 1999)
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Gluteal Stabilisers
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Gluteus medius: provides frontal plane stabilization, decelerate femoral adduction , assist in deceleration femoral internal rotation (during closed chain activity)
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Gluteus Medius Provides frontal plane stabilisation in walking cycle
Prevents downward rotation of the pelvis (Trendelenburg) Allows unsupported leg to swing clear of the ground Decelerates femoral adduction and internal rotation Anterior fibres assist the iliotibial tract to flex hip and stabilise the extended knee
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Optimum Dynamic Function
Integrated proprioceptively enriched multi-directional movement controlled by an efficient neuromuscular system Optimum human dynamic function involves …… From walking to more challenging sporting movment patterns. All exercise is subject to forces saggital, frontal and transverse and therefore the system is also able to provide control against these forces, reduce the forces and stabilise the body.
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PROPRIOCEPTION “Nerve impulses originating from the joints, muscles, tendons and associated deep tissues which are then processed in the central nervous system to provide information about joint position, motion, vibration and pressure”. (Bruckner & Khan 1999)
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WHY IS PROPRIOCEPTION IMPORTANT?
Sub-cortical systems are not under conscious control Stabilisation response needs to be second nature. Sub-cortical systems act faster - rapid muscle reaction times. More rapid reaction times can be learnt which may lead to increased stability of the lumbar spine.
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To improve the proprioceptive system in dynamic joint stability it must be challenged.
Pain-free does not mean cured. If the proprioceptive deficit has not been addressed a complete rehabilitation has not been accomplished. Mechanically stable joints are not necessarily functionally stable ( eg. ACL reconstruction)
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WHAT HAPPENS WHEN THE SYSTEM GOES WRONG?
The Theories
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“MUSCLE PAIN SYNDROMES ARE SELDOM CAUSED BY ISOLATED PRECITATING FACTORS AND EVENTS BUT ARE THE CONSEQUENCES OF HABITUAL IMBALANCES IN THE MOVEMENT SYSTEM” (Sahrmann 1993)
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REPEATED MOVEMENTS SUSTAINED POSTURES
ALTERS MUSCLE LENGTH ALTERS STRENGTH ALTERS STIFFNESS ALTERS FLEXIBILITY ALTERS CARTILAGE AND BONE STRUCTURE – BY OVERLOADING AT COMPENSATORY SITES OF MOVEMENT Flexibility of the the hips and pelvis will influence alignment and therefore stability in the trunk. Mulligan refutes this in that mobilisation of either lumbar or hip joints can immediately effect soft tissue length. Therefore, could be neural inhibition.
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STRUCTURAL/SEGMENTAL DYSFUNCTION
PAIN POSTURAL DYSFUNCTION MUSCULAR DYSFUNCTION STRUCTURAL/SEGMENTAL DYSFUNCTION “The body has the ability to adapt to minor stresses, but as you increase the number, the body has less room to adapt until you reach a point where the body cannot adapt any further” “Sarhmann muscle pain syndromes are seldom caused by located precipitating factors and events” “The body has the ability to adapt to minor stresses, but as you increase the number, the body has less room to adapt until you reach a point where the body cannot adapt any further” “Sarhmann muscle pain syndromes are seldom caused by located precipitating factors and events”
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POSTURE AND PAIN Poor posture can lead to increased stress on the stabilising system of the joints (Chek P 1999) Multifidus dysfunction occurs after first episode acute unilateral LBP (Hides et al 1994) Multifidus dysfunction does not spontaneously restore following resolution of pain and disability (Hides et al 1996) Specific retraining does restore dysfunction (Hides et al 1996)
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TrA contraction is delayed during normal movements in subjects with low back pain (Richardson et al 1999) Mulifidus function can be affected by spinal surgery Atrophy of multifidus has been shown to be more prevalent in post operative patients (Jull, et al 1999)
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Sherington’s Law of Reciprocal Inhibition:
Tight Muscles inhibit the functional antagonist. Leads to Positive Cross Syndromes of the lower or upper limb TIGHT MUSCLE WILL INHIBIT IT’S FUNCTIONAL ANTAGONIST. EXAMPLE: THIGH PSOAS (MOST ATHLETES) INHIBIT FUNCTIONAL ANTAGONISTS - DEEP ABDOMINAL WALL, TRANSVERSE ABDOMINIS, INTERNAL OBLIQUE, MULTIFIDI, DEEP TRANSVERSE SPINALIS MUSCLES AND GLUTEUS MAXIMUS. THUS THE STABILIZATION AND COUPLING PHASE WILL BE REDUCED INCREASING THE MOVEMENT PHASE & MUSCLE FORCES AND DECREASING EFFICIENCY.
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Gluteus Maximus and minimus are inhibited in most athletes due to tight psoas (Summer, 1988).
ATTEMPTING TO GET EXTENSION DURING JUMPING, COULDN’T EXTEND THROUGH HIP USING GLUTEUS MAXIMUS DUE TO PSOAS TIGHTNESS HYPEREXTEND AT THE KNEE AND DRIVE THE INFERIOR POLE OF THE PATELLA INTO THE FAT PAD CREATING THE INFLAMMATORY RESPONSE. (SUMMER, 1988).
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Poor recruitment in the local stabilisers can lead to over- activity of the global stabilisers to compensate.
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Lack of flexibility is often a phenomenon created by lack of stability in an attempt to stabilize the body for activity. 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
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If the glutei's are inhibited or weak
Lateral pelvic stability reduced Femur adducts 29 muscles connected to each side of pelvis Work synergistically with entire kinetic chain Maintain center of gravity over base of support during dynamic movements gait cycle - loss of balance
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Compensations for Weak Glut Med
Adaptations Effects Excessive lateral pelvis tilt O/L of TFL, SIJ, Lsp Medial knee drift P/f jt, ITB, Pt, Kn jt Lateral knee drift Pop, Lat comp’t Lateral flexion of trunk Facet jts, SIJ
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Lower Cross System Anterior Pelvic Tilt/Increase lumbar lordosis
Tight - ES, IP, upper rectus, RF, sartorius,TFL, adductors Weaker -TA, internal oblique, multifidus, erector spinae biceps femoris, glut med/max Joint dysfunction - sacral rotations, SI, L-spine, Injury Patterns - plantar faciitis, AKP, Tib Post
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Upper Cross System: Rounded Back/Forward Head
Tight - pec mj/min, lat dorsi, upper trap levator, subscap, teres major, rnocleidomastoid, rectus capitus and scalenes Weak - rhomboids, middle trap/lower trap, teres minor, infraspinatus, post deltoid, deep neck flexors Joint Dysfunction - Upper cervical, cervical thoracic, SC joint, rotator cuff problems
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Pronation Distortion Syndrome: Flat feet
Tight - Peroneals, lateral gastroc IT-band, Psoas Weak - Intrinsic foot muscles, Anterior/posterior tibialis, VMO, bicep femoris, piriformis, glut medius Injury Pattern - muscles that control pronation are inhibited and weak causing overuse injuries
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Muscle Fatigue Decreased ability to maintain dynamic muscle force
Fatigue running Unable to stabilise core Shear forces and compressive forces in lumbar spine Hamstring strains Sixties, neurological and paeds. Ongoing development through the above.Today ITU and orthopaedics, used in the few years in gyms and the fitness industry
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Pelvo-Occular Reflex (Vlatemeir Yanda)
Running Head Extension (Fatigue or weakness) Visual compromise Compensation Anterior tilt pelvis Changes of length tension ratio lower limb muscles
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The Critics Standaert et al. review:
“Lumbar stabilisation exercises no more effective than a less specific exercise programme” Eyal Lederman “Core stability exercises do not help functionality and conflicts with so many areas of science in context of research into motor control..Offering simple answers to complex problems
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BJSM – Transversus Abdominus and Core Stability: Has the pendulum Swung? Allison et al.
(VMO and PFPS) BJSM – “Claims for the effectiveness of these modalities has been touted well beyond what the research has shown” Cook Jill (isokinetics, reformers, vibration plates, kinesiotaping, nintendo wii, wii fit!)
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ASSESSMENT Posture, ROM, control Alignment Single knee bend
Forward flexion Seated knee extension Thomas test Prone knee bend Post glut medius
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Rules of Stability Training
Differentiate – hypermobility, instability, normal movement and hypomobility Safe Must be challenging/multisensory Progressive – several stages Offer variety All planes of motion Integration into functional activity Make it fun – not bore stability!
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Progression and Variety
Floor work – Static Floor work – Dynamic
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Swiss ball – Static Swiss ball – Dynamic
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Cables Medicine Balls, dumbells Open and closed chain, speed Standing, kneeling, lying, one leg etc
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Progression of training
progress from slow to fast simple to complex known to unknown low force to high force static to dynamic
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Breathing Correct inspiration underrated and critical for stability
Allows the diaphragm help stabilise trunk Increased intra-abdo’ pressure Helps to activate Trans Abs (modulates with resp’n) Inhibits use of external obliques Helps maintain thorax posture Increases breathing efficiency and performance
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Swiss Ball Systems
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HYPOTHESIS FOR SWISS BALL TRAINING
Reactive training with a Swiss Ball may encourage activation of the spinal stabilisers. Carrier B (1998) Swiss ball exercises may help to re-educate TrA and multifidus due to the unstable environment. Carrier B (1998) Multifidus is very difficult to activate voluntarily. Janda V (1996) Sub-cortical control of stabilisation can be learnt through proprioceptive exercises on labile surfaces such as exercise balls. Saxton et al (1993), Saal & Saal (1998)
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De-stabilising the training environment Challenges the neuro muscular system Improves proprioception improves equilibrium / co-ordination Improves functional skill Greater sporting performance.
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Swiss Ball Optimal dynamic stabilisation at right joint, right time, right plane of movement With any movement all three planes are working together concurrently Producing force in one plane whilst stabilising or controlling in other 2 planes eccentrically
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Benefits Proprioception Postural re-education
Improves balance / co-ordination Challenges the CNS - improve joint stability and sports performance
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References Shirley Sahrmann (2002) Treatment and Diagnosis of Movement Impairment Syndromes. Mosby: St. Louis Diane Lee (2000) The Pelvic Girdle: An approach to the examination and treatment of the lumbo-pelvic-hip region. Churchill Livingstone: Edinburgh M.J Comerford and S.L Mottram (2001) Functional Stability Retraining: Principles and strategies for Managing Mechanical Dysfunction. Manual Therapy; 6(1) 3-14 Hides, Julie A.; Richardson, Carolyn A.; Jull, Gwendolen A (1996).. Multifidus Muscle Recovery Is Not Automatic After Resolution of Acute, First-Episode Low Back Pain Spine. 21(23): Richardson, Carolyn A.; Snijders, Chris J.; Hides, Julie A.; Damen, Léonie; Pas, Martijn S.; Storm, Joop. (2002). The Relation Between the Transversus Abdominis Muscles, Sacroiliac Joint Mechanics, and Low Back Pain Spine. 27(4): Standaert et al. (2008). Evidence-informed management of chronic low back pain with lumbar stabilization exercises. The Spine Journal 8(1) 114. Allison et al. (2008) Transversus Abdominus and Core Stability: Has the pendulum swung? British Journal of Sports Medicine 42:930 Lederman. E The myth of core stability. www. Cpdo.net/myth_of_core_stabiity.doc Cook (2008) Jumping on bandwagons: taking the right clinical message from research. British Journal of Sports Medicine 42 (11) 563 Goldby et al. (2006) A randomized control led trial investigating the efficiency of musculoskeletal physiotherapy for chronic low back disorder. Spine 31: 1083 Cairns, Mindy C.; Foster, Nadine E.; Wright, Chris (2006) Randomized Controlled Trial of Specific Spinal Stabilization Exercises and Conventional Physiotherapy for Recurrent Low Back Pain Spine. 31(19):E670-E681 Trueland. J (2009) Core Values Frontline 15: 6
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