Functional Core Stabilization

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Functional Core Stabilization
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Chronic Musculoskeletal pain/chronic injuries in
the spine and lower extremity are caused or
perpetuated by muscle imbalances/weaknesses in
the core musculature
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Research indicates that 70-85 of all athletes
suffer from recurrent low back pain. A
comprehensive core stabilization program should
be done with all lower extremity rehabilitation
programs.
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Individuals with a weak core substitute
substituting/compensating during dynamic
functional movements leading to overuse/chronic
injuries both upper and lower extremity
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Functional Anatomy Lumbo-pelvic-hip Complex

• The LPH complex musculature produces force,
  reduces force, and stabilized the kinetic chain
  during functional movements
• 29 muscles attach to the core (LPH complex
  unilaterally)
• the core functions primarily to maintain dynamic
  postural control by keeping the center of gravity
  over our base of support during dynamic movements.

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LPH Complex

• Stabilization system (Core system) if not
  functioning optimally will end neuromuscular
  substituting to utilize the strength power and
  neuromuscular control in rest of the body.

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LPH Complex Cont.

• Otherwise will get neuromuscular inhibition and
  CNS will shut down prime movers if dont
  stabilize through LPH complex, thus minimizing
  kinetic chain.
• Most athletes have functional strength and
  control in prime movers but not stabilization in
  spine (C,T,L)

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Definitions

• Function Integrated proprioceptively enriched
  multidirectional movement
• vs unidimentional, low proprioception, all three
  planes
• All functional exercises are triplanar (even
  walking Saggital plane, appears unidirectional
  but need to stabilize in other planes ()frontal
  transverse) of movement)
• All functional movements required acceleration,
  deceleration, dynamic stabilization (typically
  concentrate inn concentric and acceleration in
  rehab)

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Definitions

• Functional Strength - ability neuromuscular
  system to produce dynamic eccentric concentric
  and dynamic isometric stabilization contractions
  during all functional movement patterns

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Definitions

• Neuromuscular efficiency the ability of your
  entire kinetic chain to work as an integrated
  functional movement
• this will provide optimal dynamic stabilization
  at right joint, right time, right plane of
  movement
• most athletes can produce the force but more than
  they can stabilize or control eccentrically thus
  get increased stress in different planes of
  movement and in different joint (compensation)

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Kinetic Chain -

• When it works efficiently
• optimal control
• distribute force appropriately
• optimal efficiency during all movements
• g\impact absorption/ ground reaction forces
• no excessive compressive, transitory force, shear
  in kinetic chain
• dynamic joint stabilization
• neuromuscular control

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Example Pelvo- Occular Reflex (Vlatemeir Yanda)-

• Cervical spine weak during running - fatigue
  head will go into extension, thus to see straight
  in front of you the pelvis tips anteriorly
• This changes length tension ration lower
  extremity, become less efficient, may end up
  with hamstring injury

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Core Stabilization Function

• Remember 29 muscles connected to each side of
  your pelvis. These works synergistically with
  entire kinetic chain
• Primary Function Maintain center of gravity over
  base of support during dynamic movements (Example
  gait cycle - loss of balance)
• Stability control offers more biomechanically
  correct position for function of entire core and
  lower extremity muscles

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Patho-Kinisiological Model (Shirley Sarmen)

• Human Movement system Kinetic Chain 3 systems
• muscular system
• articular system
• neural system

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Patho-Kinisiological Model

• All three must work as integrated unit. If all
  three work together
• Optimal length tension ratios
• Thus optimal force coupling
• Thus control normal arthrokinematics
• Thus optimal neuromuscular control
• Thus optimal efficiency of control

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Patho-Kinisiological Model

• This is a delicate balance a change in one of
  this can cause injury
• Example articular dysfunction with change length
  tension ration etc...

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Muscle Fatigue

• Ability to generate or maintain decrease ability
  to require correct muscle
• Ability to maintain dynamic muscle force
  decreases
• Example fatigue running unable to stabilize
  core get shear forces and compressive forces in
  lumbar spine
• reason why see many LBP complains and hamstring
  strains (actually attributed to weak abdominal)

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Transverse Abdominis and Internal Obliques during
functional activity

• Only 2 abdominal muscles that attach to the
  L-spine
• Attach thorocolumbar facia (l-spine)via latteral
  rafia attached to transverse processes
• Thus when they fire they create a tension affect
  - inherent STABILITY in Lumbar spine
• these prevent rotational and transnational forces
• If these muscles are not stabilized the Psoas is
  used to create a compressive force and mimic
  stability

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Transverse Abdominis and Internal Obliques during
functional activity

• Actually creates anterior shear force and
  extension force
• Leading to reciprocal inhibition of the lower
  abdominals
• The pelvis will then tip forward
• Leading to reciprocal inhibition of the gluteals
  (extensor mechanism)
• This can cause hip internal rotation, knee
  overuse syndromes etc...

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Basic Concepts of Core Stabilization -
Performance Paradigm

• Stretch/Shortening Cycle (Natural visco-elastic
  properties of muscles)
• Every single movement (dynamic functional
  movement) more efficient the more force can
  create and absorb)
• Efficiency less wasted movements
• Example walking
• Every single movement we do is the performance
  paradigm

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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). The body
doesnt just fire one muscle at a time for
movement
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Basic Concepts of Core Stabilization - Planes of
Movement

• With any movement all three planes are working
  together concurrently
• Even though you may be moving in one plane the
  other 2 plane must stabilize and work
  eccentrically for stabilization.
• Example Posterior Pelvic tilt, laying on the
  floor changes the relationship, thus when
  standing the relationship again changes an the
  exercises have not been functional and will not
  work in the altered position. Again it changes
  when you lift one leg etc..

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Basic Concepts of Core Stabilization - Continuum
of Function

• Movement are not isolated unidirectional
• Must do movements and exercises in a dynamic
  systematic program
• Practically take the athlete from the challenging
  position they can control in a functional pattern
  and progress them from there.

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Basic Concepts of Core Stabilization - Open and
Closed Chain

• Functional movement is a succession of opening
  and closing the chain.
• Functional activity is therefore a timing issue
  within opening and closing the chain
• Need core stability to stabilize transition

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Biomechanics Three Phases

• Pronation - deceleration/force reduction phase
  (where most injuries occur due to lack of
  eccentric control)
• For rehabilitation need to look at this phase
  what muscles are decelerating and stabilizing to
  create a rehabilitation program.

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Biomechanics Three Phases Cont.

• Supination - acceleration phase/force production
  phase (most time)
• Coupling - stabilization, ability to change from
  pronation to supination phase (stronger the core
  more efficient and thus less time spend in this
  phase - prevent overuse injuries)

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Muscle Function

• Muscles have anatomic individuality but not
  functional individuality (easier to
  compartmentalize muscle function for thought
  process but not practical)
• Example Dynamic Movement - tri-planar movement
  involving muscle strategy neuromuscular control.

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Muscle Function Cont.

• Muscles can be placed into two groups
• Movement Prone to develop tightness readily
  activated during most movement patterns and when
  an athlete is in a fatigues state or learning new
  movement patterns, these are the muscles that
  primarily fire
• Think about this for injuries the beginning of
  the season.
• Gatrocs, Soleus, Hamstring, All Hip flexors,
  Abdductors, Erector Spinae, Quadratus Lumborum,
  Pec Major/Minor, Upper Trapezius, Levator, Teres
  Major, Latissimus, Sternocledomastoid, Scalenes
• If you would do a flexibility assessment these
  are the muscles that are tight

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Muscle Function Cont.

• Stabilization Prone to develop weakness and
  inhibition, less activated during most movement
  patterns, fatigue easily, primarily function
  during stabilization movements
• Peroneals, anterior tibialis, posterior tibialis,
  VMO, gluteus medius/maximus, transverse
  abdominis, int/ext oblique serratus anterior,
  rhomboids, middle.lower trapezius, deep neck
  flexors longus coli, longus capitus

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Sheringtons Law of Reciprocal Inhibition Tight
Muscle will inhibit its 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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Muscle Functions - Abdomen

• External Oblique - Decelerate transverse plane
  rotation, some extension

• Internal Oblique - Decelerate transverse plane
  rotation, frontal plane and transverse plane
  stability
• Rectus Abdominis Decelerate Extension, create
  pelvic stability during dynamic movement

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Muscle Functions - Abdomen

• Transverse Abdominis - The most important
  abdominal muscle (attach to lumbar spine)
  contracts in feed forward mechanism, contracted
  1st before any other muscle (research following
  back pain the transverse abdominis is inhibited,
  thus when you move for example an arm, your
  transverse abdominis does not stabilize thus the
  psoas fires - compensation

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Muscle Function Lumbar Spine

• Superficial Erector Spinae Extends Spine,
  creates extension force and shear force and L5/S1
  works with the Psoas (when Psoas tight it
  facilitated erector spinae further increasing the
  shear forces and inhibit posterior muscles)
• Deep Erector Spine Posterior translation and
  L4/L5/S1, if weak or inhibited cannot
  counterinteract affect of superficial erector and
  get shearing forces

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Muscle Function Lumbar Spine

• Transversal Spinalis Muscles (Rotatories,
  Multifiti, interspinalis, intertranversari)
  Provide intrinsic, intrasegmental stability,
  proprioceptive feeback since constantly under
  compression and torsinal forces. IF these
  muscles are inhibited, loose the ability to
  create dynamic stabilization from lack of
  proprioceptive feedback.

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Joint Dysfunction Example

• Joint dysfunction example lock up SI joint,
  plant and twist, Multifitus is inhibited
  complains of low back pain, the erectors will
  fire and attempt to stabilize (therefore a muscle
  is doing opposite of its muscle function). This
  is why pain syndromes are perpetuated

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Muscle Function Hip Musculature

• Gluteus Maximus decelerate hip flexion,
  decelerate hip internal rotation during heel
  strike.
• Psoas tightness creates inhibition of gluteus
  maximus (anterior tilt)

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Muscle Function Hip Musculature

• If the gluteus maximus is inhibited or weak will
  loose ability to control femur, femur will
  internally rotate
• Microtruma can be created on medial capsule of
  knee
• Paltellar tendonitis, non-contact ACL injuries,
  posterior tibial tendonitis, plantar faciitis

• 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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Lack of flexibility is often a phenomenon created
by lack of stability in an attempt to stabilize
the body for activity.
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Gleuteus Maximus and minimus are inhibited in
most athletes due to tight psoas (Summer, 1988).
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Muscle Function Hip Musculature

• Gluteus medius provides frontal plane
  stabilization, decelerate femoral adduction ,
  assist in deceleration femoral internal rotation
  (during closed chain activity)
• VB/BB with Patellar tendonitis originate from
  tight psoas and lack of core strength.
• Attempting to get triple extension during
  jumping, couldnt extend through hip using
  gluteus maximus due to psoas tightness
• Thus they would 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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Muscle Function Hip Musculature

• Adductors frontal plane stability
• Hip External Rotator Create Pelvo-femoral
  rhythm,
• Gemeli, Obturators, Piriformis help to decelerate
  femur. If inhibited they become extremely tight
  because they are attempting to stabilize.
• Often we attempt to stretch these muscle where a
  core program would eliminate the origin of the
  problem.

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Force Couples

• Saggital Plane Psoas and superficial erector
  spinae which create and extension force and shear
  force in the lumbar spine
• counteracted by transverse abdominis internal
  oblique multifidi, transversal spinalis groups,
  gluteus maximus.
• Trend - most athletes the psoas and erector
  overdeveloped inhibiting stabilizers

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Force Couples Cont.

• Frontal Plane Gluteus Medius, ipsilateral
  adductor and contralateral quadratus lumborum
• Example Weak gluteus medius will cause
  contralateral LBP, lead into knee pain on
  opposite side

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Force Couples Cont.

• Transverse PlaneLeft rotation - left internal
  oblique, left adductor, right external oblique
  and right external rotators of the hip.
• Example Synergistic dominance Weak transverse
  abodminis and internal oblique the same side
  adductor will become tight and inhibit gluteus
  medius causing anterior knee pain , posterior tib
  tendonitis etc down the kinetic chain.

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Principles of Core Training

• Postural Alignment Primary Function -
  misalignment will produce predictable stresses,
  pain, chronic injuries, joint dysfunction

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Common Postural Dysfunction

• Lower Cross System Anterior Tilt in most
  athlete, increase lumbar lordosis
• Tight muscles movement group muscles, erector
  spinae superficial, psoas, upper rectus, rectus
  femoris, sartorius, tensor facia latae, adductors
• Weaker muscle/inhibited - stabilizing group deep
  abdominal wall, transverse abdominis, internal
  oblique multifidus, deep erector spinae biceps
  femoris, gluteus medius/maximus
• muscle that decelerate femoral are inhibited
• Joint dysfunction illiosacral rotations, SI,
  L-spine, Tib-fib joint, subtalar joint
• Injury Patterns plantar faciitis, patellar
  tendonitis, posterior tib tendonitis

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Common Postural Dysfunction

• Upper Cross System Rounded Back/Forward Head
• Tight muscles pec major/minor, latisimuss, upper
  trap levator, subscap, teres major,
  sternocleidomastoid, rectus capitus and scalenes
• Weak muscles rhomboids, middle trap/lower trap,
  teres minor infraspinatus, posterior deltoid,
  deep neck flexors
• Joint dysfunction Upper cervical, cervical
  thoracic, SC joint problems (which can cause
  rotator cuff problems)

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Common Postural Dysfunction

• Pronation Distortion Syndrome Flat feet
• Tight muscles Peroneals, lateral gastroc
  IT-band, Psoas
• Weak muscles intrinsic foot muscles,
  Anterior/posterior tibialis, VMO, bicep femoris,
  piriformis, glut medius
• muscle that control pronation are inhibited and
  weak causing overuse injuries

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Postural Dysfunction

• Pronation Distortion Syndrome
• Joint dysfunctions 1st MTB joint (EX cause
  anterior shoulder pain stub toe and then lack
  normal passive extension, shorten stride,
  internal rotation of the femur, causing pain up
  chain though spine into movements of the upper
  extremity due to core inhibition). The same can
  occur with sprain ankle and lock tibo-talar jiont

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Though the kinetic chain, muscle problems can
lead to joint problems and joint problems can
lead to muscle problems.
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Postural Considerations

• Many individuals have well developed muscle
  strength and power to perform specific
  activities, however, few have developed
  stabilization systems optimally
• Optimal alignment of each segment in the kinetic
  chain is a cornerstone for all functional
  rehabilitation programs.

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Postural Considerations

• If one segment in the kinetic chain is out of
  alignment, then predictable patterns of
  dysfunction will develop in other parts of the
  kinetic chain
• A weak core is a fundamental problem of
  inefficient movements which leads to injury

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Low Back Pain Rehabilitation

• Transverse abdominis , multifitus, internal
  oblique are inhibited in someone with LPB
• Decrease in stabilization endurance Can perform
  the movement until the become fatigue. Ok for
  3x20 but once start functional movements revert
  back to previous positions.
• Increase interdisk pressure and compressive
  forces with lack of pelvic stabilization
• Think about athletes that lift and then have
  LBP cause may be not stabilizing and can
  perpetuate muscle imbalances creating hamstring
  dysfunction etc.
• Address through unstable ball training

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Hiltons Law any muscle that crosses that joint
will be inhibited. With injuries the individual
will have a lot of joint substitutions and muscle
imbalances
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Muscle Imbalances

• An optimal functioning core helps to prevent the
  development of muscle imbalances
• Optimal core neuromuscular efficiency allows for
  the maintenance of the normal
• length-tension relationships
• force coupe relationships
• the path of instantaneous center or rotation
• A strong stable core can improve neuromuscular
  efficiency throughout the kinetic chain by
  improving dynamic postural control

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Assessment of the Core

• Core strength can be assessed using the straight
  leg lowering test
• Core power can be assessed using the overhead
  medicine ball throw
• Core muscle endurance can be assessed using back
  extension

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Core Stabilization to create program

• Abdominal strength assessment (Hodges, P.)
• muscle imbalance assessment
• joint assessment
• lower extremity profile assessment (Grey,G.)
• functional assessment stabilization endurance

• functional assessment stabilization endurance
• Sports Demand Analysis
• demands of the individual sport Baseball vs
  basketball etc.)
• demands of the athlete (player vs non-player)
• demands of the position/specialty

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Core Stabilization to create program

• Sports Demand Analysis
• demands of the individual sport Baseball vs
  basketball etc.)
• demands of the athlete (player vs non-player)
• demands of the position/specialty

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Guidelines for Core Training

• A comprehensive core stabilization training
  program should
• progress from slow to fast
• simple to complex
• known to unknown
• low force to high force
• static to dynamic

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Guidelines for Core Training

• Exercises should be safe, challenging, stress
  multiple planes, incorporate a multi-sensory
  environment, and activity specific.
• Put each athlete in the most challenging
  environment they can control

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Guidelines for Core Training

• Change program often
• ROM
• Loading (cable, tubing, dumbbells, body plane)
• plane of motion
• body position (floor, standing, ball, one leg,
  knees )

• speed of movement (core slow twitch - time under
  tension but change with dynamic patterns)
• duration (how long train)
• frequency (in-season, out-of-season, injury
  status)

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Abdominal Bracing Key

• Transverse Abdominis - draw belly-button into
  spine make self skinny)
• Pelvic tilts work rectus abdominis
• avoid anchoring feet so as not to activate hip
  flexors or psoas
• Full ROM
• Exercise Progression
• Stretch antagonists between sets to prevent
  inhibition (if working abdominal stretch hip
  flexors between sets)

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Exercise Progression

• Stage I Learning Abdominal Bracing
• maintain stability
• change duration and frequency
• Stage II
• Educate on daily use
• Increase ROM and instability mainly uni-planar,
  change body position

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Exercise Progression

• Stage III Instability
• Maximize the use of functional activities with
  abdominal bracing
• Maximize multidirectional patterns and unstable
  positions
• Maximize frequency and duration changes
• Stage IV
• Challenge the individual with high intensity
  strength and power