1. CORE STABILITY An Introduction
By Donna Sanderson-Hull

2. Objectives Definitions Origins Benefits Theory/Posture and anatomy
Research
Practical

3. 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

4. CORE STABILITY
“The ability to maintain neutral spine using the abdominal, back, neck and shoulder girdle muscles as stabilisers rather than movers”

5. 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.

6. NOT A NEW CONCEPT STATIC Alexander Technique Pilates DYNAMIC
Tai-chi/Karate
Swiss ball training
2 types of stability training – Static and dynamic

7. 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

8. JOSEPH PILATES 1880-1967 PRINCIPLES CONCENTRATION ALIGNMENT BREATHING
CO-ORDINATION
STAMINA

9. FITNESS PARAMETERS CARDIOVASCULAR STRENGTH / POWER/SPEED ENDURANCE
FLEXIBILITY
CORE STABILITY
PROPRIOCEPTION / NEUROMUSCULAR CONTROL

10. 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).

11. 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

12. Adapted from Panjabi (1992)
Control subsystem
(Neural)
Spinal
stability
Passive subsystem
(spinal column)
Active subsystem
(spinal muscles)
Adapted from Panjabi (1992)

13. 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…….

14. 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

15. 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)

16. 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

17. 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.

18. 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

19. Improved Posture Re-education of stabilisers Reduced stress on joints Reduced injury Increase function and sports performance.

20. 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.

21. 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

22. 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

23. 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

24. 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

25. Transversus Abdominus

27. 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)

28. 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

30. Multifidus

31. 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)

32. Gluteal Stabilisers

33. Gluteus medius: provides frontal plane stabilization, decelerate femoral adduction , assist in deceleration femoral internal rotation (during closed chain activity)

34. 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

35. 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.

36. 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)

37. 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.

38. 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)

39. WHAT HAPPENS WHEN THE SYSTEM GOES WRONG?
The Theories

40. “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)

41. 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.

42. 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”

43. 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)

44. 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)

45. 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.

46. 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).

47. Poor recruitment in the local stabilisers can lead to over- activity of the global stabilisers to compensate.

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. 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!)

58. ASSESSMENT Posture, ROM, control Alignment Single knee bend
Forward flexion
Seated knee extension
Thomas test
Prone knee bend
Post glut medius

59. 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!

60. Progression and Variety
Floor work – Static
Floor work – Dynamic

61. Swiss ball – Static
Swiss ball – Dynamic

62. Cables
Medicine Balls, dumbells
Open and closed chain, speed
Standing, kneeling, lying, one leg etc

63. Progression of training
progress from slow to fast
simple to complex
known to unknown
low force to high force
static to dynamic

64. 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

65. Swiss Ball Systems

66. 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)

67. De-stabilising the training environment Challenges the neuro muscular system Improves proprioception improves equilibrium / co-ordination Improves functional skill Greater sporting performance.

68. 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

69. Benefits Proprioception Postural re-education
Improves balance / co-ordination
Challenges the CNS - improve joint stability and sports performance

70. 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