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Core stability

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  • 1. P. Ratan KhumanM.P.T. (Ortho & Sports)
  • 2. Contents • Terminology • Describe the functional approach to kinetic chain rehab. • Explain the concept of the core. • Anatomical relationships between the musculature of the core. • Review how the core functions to maintain postural alignment and dynamic postural equilibrium during functional activities. • Organize a procedure for assessing the core. • Create the rationale for core stabilization training. • Set up the guidelines for core stabilization training. • Demonstrate appropriate exercises for each of the four levels in core stabilization training,6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 2
  • 3. Terminology  Function – It is an integrated multidimensional movement.  Functional strength – It 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.  Neuromuscular efficiency – It is the ability of CNS to allow agonists, antagonists, synergists, stabilizers, and neutralizers to work efficiently and interdependently during dynamic kinetic chain activities.6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 3
  • 4. Functional Approach To Kinetic Chain Rehab  Traditionally, rehab has focused on isolated absolute strength gains utilizing single planes of motion.  However, all functional activities are tri-planar & require acceleration, deceleration & dynamic stabilization.  Movement might appear to be one-plane dominant, but the other planes need to be dynamically stabilized to allow for optimal neuromuscular efficiency.  The fact is that we train force reduction, force production and dynamic stabilization to occur efficiently during all kinetic chain activities.6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 4
  • 5. Functional Approach To Kinetic Chain Rehab Cont…  A dynamic core-stabilization training program should be a key component of all comprehensive functional CKC rehabilitation programs.  A core stabilization program will improve dynamic postural control ensure appropriate muscular balance and joint arthrokinematics around the lumbo-pelvic-hip complex.  Allow for the expression of dynamic functional strength and improve neuromuscular efficiency throughout the entire kinetic chain.6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 5
  • 6. WHAT IS THE CORE…?  The “CORE” is defined as the lumbo-pelvic-hip complex.  It is the location of our COG & where all movt begins.  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 extremities6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 6
  • 7. The Core  Functions & operates as an integrated unit Entire kinetic chain operates synergistically to produce force, reduce force & dynamically stabilize against abnormal force  In an efficient state –  The CORE enables each of the structural components to operate optimally through:  Distribution of weight  Absorption of force  Transfer of ground reaction forces6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 7
  • 8.  Neuromuscular efficiency –  Ability of CNS to allow agonists, antagonists, synergists, stabilizers & neutralizers to work efficiently & interdependently  Established by combination of postural alignment & stability strength  Optimizes body’s ability to generate & adapt to forces  Dynamic stabilization is critical for optimal neuromuscular efficiency  Rehab generally focuses on isolated single plane strength gains in single muscles  Functional activities are multi-planar requiring acceleration & stabilization  Inefficiency –  Results in body’s inability to respond to demands  Can result in repetitive microtrauma, faulty biomechanics & injury  Compensatory actions result6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 8
  • 9. Functional Anatomy  Global (dynamic, phasic) muscles –  They are the large, torque-producing muscles.  Link the pelvis to the thoracic cage and provide general trunk stabilization as well as movement.  Rectus abdominis, external oblique and the thoracic part of lumbar iliocostalis  Local (postural, tonic) muscles –  They attach directly to the lumbar vertebrae.  Responsible for providing segmental stability and directly controlling the lumbar segments during movement.  Lumbar multifidus, psoas major, quadratus lumborum, the lumbar parts of iliocostalis and longisimus, transversus abdominis, the diaphragm and the posterior fibers of internal Oblique6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 9
  • 10. 6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 10
  • 11. Functional Anatomy Cont… 29 muscles attach to core Lumbar Spine Muscles Transversospinalis group Erector spinae  Rotatores  Iliocostalis  Interspinales  Longissimus  Intertransversarii  Spinalis  Semispinalis Quadratus lumborum  Multifidus Latissimus Dorsi6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 11
  • 12. 6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 12
  • 13.  Transversospinalis group –  Poor mechanical advantage relative to movement production  Primarily Type-I muscle fibers with high of muscle spindles Optimal for providing proprioceptive information to CNS   Inter/intra-segmental stabilization  Erector spinae –  Provide inter-segmental stabilization  Eccentrically decelerate trunk flexion & rotation  Quadratus Lumborum –  Frontal plane stabilizer  Works in conjunction with gluteus medius & TFL  Latissimus Dorsi –  Bridge between upper extremity & core6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 13
  • 14. Functional Anatomy Cont…  Abdominal Muscles –  Rectus abdominus  External obliques  Internal obliques  Transverse abdominus  Work to optimize spinal mechanics  Provide sagittal, frontal & transverse plane stabilization6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 14
  • 15. 6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 15
  • 16. Functional Anatomy Cont… Hip Musculature – Psoas –  Closed chain vs. open chain functioning  Works with erector spinae, multifidus & deep abdominal wall  Works to balance anterior shear forces of lumbar  Can reciprocally inhibit gluteus maximus, multifidus, deep erector spinae, internal oblique & transverse abdominus when tight  Extensor mechanism dysfunction  Synergistic dominance during hip extension  Hamstrings & superficial erector spinae  May alter gluteus maximus function, altering hip rotation, gait cycle6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 16
  • 17. Hip Musculature cont…  Gluteus medius –  Frontal plane stabilizer  Weakness increases frontal & transverse plane stresses (patellofemoral stress)  Controls femoral adduction & IR  Weakness results in synergistic dominance of TFL & quadratus lumborum  Gluteus maximus –  Hip extension & ER during OKC, concentrically  Eccentrically hip flexion & IR  Decelerates tibial IR with TFL  Stabilizes SI joint  Faulty firing results in decreased pelvic stability & neuromuscular control6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 17
  • 18. Hip Musculature cont…  Hamstrings –  Concentrically flex the knee, extend the hip & rotate the tibia  Eccentrically decelerate knee extension, hip flexion & tibial rotation  Work synergistically with the ACL to stabilize tibial translation  All muscles produce & control forces in multiple planes6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 18
  • 19. Diaphragm and pelvic floor  Diaphragm serves as the roof of the core.  Stability is imparted to the lumbar spine by contraction of the diaphragm and increasing intra-abdominal pressure.  Ventilatory challenges on the body may cause further diaphragm dysfunction and lead to more compressive loads on the lumbar spine.  Thus, diaphragmatic breathing techniques may be an important part of a core strengthening program.6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 19
  • 20. CORE STABILIZATION TRAINING CONCEPTS  A specific core strengthening program can:  IMPROVE dynamic postural control  Ensure appropriate muscular balance & joint arthrokinematics in the lumbo-pelvic-hip complex  Allow for expression of dynamic functional performance throughout the entire kinetic chain  Increase neuromuscular efficiency throughout the entire body  Spinal stabilization –  Must effectively utilize strength, power, neuromuscular control & endurance of the “prime movers”  Weak core = decreased force production & efficiency  Protective mechanism for the spine  Facilitates balanced muscular functioning of the entire kinetic chain  Enhances neuromuscular control to provide a more efficient body positioning6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 20
  • 21. Postural Considerations  Core functions to maintain postural alignment & dynamic postural equilibrium  Optimal alignment = optimal functional training and rehabilitation  Segmental deficit results in predictable dysfunction  Serial distortion patterns  Structural integrity of body is compromised due to malalignment  Abnormal forces are distributed above and below misaligned segment6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 21
  • 22. Neuromuscular Considerations  Enhance dynamic postural control with strong stable core  Kinetic chain imbalances = deficient neuromuscular control  Impact of low back pain on neuromuscular control  Joint/ligament injury  neuromuscular deficits  Arthrokinetic reflex  Reflexes mediated by joint receptor activity  Altered arthrokinetic reflex can result in arthrogenic muscle inhibition  Disrupted muscle function due to altered joint functioning6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 22
  • 23. Assessment of The Core  Muscle imbalances  Arthrokinematic deficits  Core  Endurance  Neuromuscular control  Strength  Power  Real-time Ultrasound Imaging  Overall function of lower extremity kinetic chain6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 23
  • 24. CORE ENDURANCE TEST6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 24
  • 25. Core Endurance Tests  4 endurance tests advocated are –  Prone bridges  Lateral bridges  Torso flexor  Torso extensor  Other Test –  Single-legged squat Test  The bridge tests are functional.  They assess strength, muscle endurance and how is the ability to control the trunk by the synchronous activation of many muscles.6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 25
  • 26. Prone Bridge Endurance Test  Primarily assesses the anterior and posterior core muscles.  It is performed by supporting the bodys weight between the forearms and toes  The pelvis in the neutral position and the body straight  Failure occurs when client loses neutral pelvis and falls into a lordotic position with anterior rotation of the pelvis.6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 26
  • 27. Lateral Bridge Endurance Test  It assesses the lateral core muscles.  Legs are extended and the top foot placed in front of the lower foot for support.  Support themselves on one elbow & feet while lifting hips off the floor to create a straight line over their body length.  The uninvolved arm is held across the chest with the hand placed on the opposite shoulder  Failure occurs when the patient loses the straight posture and the hip falls towards the table.6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 27
  • 28. Torso Flexor Endurance Test  It is time based test, how long the patient can hold a position of seated torso flexion at 60°.  The client sits at 60° with both hips & knees at 90°, arms folded across chest with the hands placed on the opposite shoulder, & toes secured under toe straps or by examiner  Failure occurs when the athletes torso falls below 60°.6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 28
  • 29. Torso Extensors Endurance test  The test is performed in prone position of the client.  The client is at the edge with upper body out of the table while securing pelvic & leg.  Failure occurs when the upper body falls from horizontal into a flexed position.6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 29
  • 30. Mean Endurance times (in sec) in Young Healthy Subjects (mean age 21 yrs) Men WomenExtension 161 185Flexion 136 134Side Bridge (R) 95 75Side Bridge (L) 99 78Flexion/Extension Ratio 0.84 0.72 6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 30
  • 31. Single-legged Squat Test  The test is used as an indicator of lumbo-pelvic-hip stability.  It is functional test, requires control the body over a Single weight-bearing lower limb  It is frequently used clinically to assess hip and trunk muscular coordination and/or control.6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 31
  • 32. CORE NEUROMUSCULAR TEST6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 32
  • 33. Abdominal Neuromuscular Control Test Supine with hips & knees in 90 Pressure cuff placed under lumbar spine (L4-5) & raised to 40 mmHg Performs drawing in maneuver (belly button to spine) Lower legs until pressure decreases Assesses lumbar spine moving into extension (ability of lower abs wall to stabilize the lumbo-pelvic-hip complex)  Hip flexors begin to work as stabilizers  Increases anterior shear forces & compressive forces at L4-L5  Inhibits transversus abdominis, internal oblique & multifidus6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 33
  • 34. 6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 34
  • 35. CORE STRENGTH TEST6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 35
  • 36. Straight-Leg Lowering Test  Supine with knees in extension  Pressure cuff placed under lumbar spine (L4-L5) & raised to 40 mmHg with knees extended, hips to 90  Performs drawing in maneuver (belly button to spine) & then flattens back maximally into the table & cuff  Gradually lower legs to table while maintaining flat back  The test is over when the pressure in the cuff decreases.  The hip angle is then measured with a goniometer to determine the angle.6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 36
  • 37. 6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 37
  • 38. Core Power Test6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 38
  • 39. Backwards, overhead medicine ball jump & throw  The client is instructed to hold a 4-kg medicine ball between their legs as they squat down.  Instructed to jump as high as possible while simultaneously throwing the medicine ball backward over their head.  The distance is measured from a starting line to the point where the medicine ball stops.  This is an assessment of total body power production with an emphasis on the core.6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 39
  • 40. Lower Limb Functional Profiles  Isokinetic tests  Balance tests  Jump tests  Power tests  Sports specific functional tests  Kinetic chain assessment must assess all areas of potential deficiency6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 40
  • 41. Ultrasound imaging  Ultrasound imaging is also used as an assessment technique.  The real-time ultrasound imaging is a means of assessing muscle size and activity.  Most emphasis has been on the assessment the transversus abdominis and multifidus muscles.  These measures have been shown to be valid.6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 41
  • 42. Core Stabilization Training6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 42
  • 43. Guidelines for Core Stabilization Training Program 1. The program should be based on science. 2. The program should be systematic, Progressive & functional. 3. The program should begin in the most challenging environment the athlete can control. 4. The program should be performed in a proprioceptively enriched environment.6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 43
  • 44. Program Variation  Plane of motion  Range of motion  Loading  (physioball, med. ball, body blade, weight vest, tubing)  Body position  Amount of control & speed  Feedback  Duration and frequency (sets, reps, time under tension)6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 44
  • 45. Exercise Selection.  Safe  Challenging  Stress multiple planes  Proprioceptively enriched  Activity specific/ sports specific6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 45
  • 46. Exercise Progression  Slow to fast  Simple to complex  Stable to unstable  Low force to higher force  General to specific  Correct execution to increased intensity6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 46
  • 47. Questions to Ask Yourself  Is it dynamic?  Is it multi-planar?  Is it multidimensional?  Is it proprioceptively enriched?  Is it systematic?  Is it progressive?  Is it activity-specific?  Is it based on functional anatomy & science?6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 47
  • 48. Abdominal “Draw In” Maneuver Aim –  To use the correct muscles in response to command “draw in” your abdominal without moving spine or pelvis & hold for 10 sec while breathing normally.  To activate Transversus abdominis + lumbar multifidus Patient best position –  The 4-point kneeling position is best position to teach the action6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 48
  • 49.  Procedure –  Ask the patient to take a relaxed breath in & out & then draw the abdomen up towards the spine without taking a breath.  The contraction must be performed in a slow and controlled manner.  At the same time contracts the pelvic floor and slightly anteriorly rotates the pelvis to activate the multifidi.6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 49
  • 50. Core Stabilization Training Program  4 levels to core stabilization training program –  Level 1 = Stabilization  Level 2 = Stabilization & strength  Level 3 = Integrated stabilization strength  Levcl4 = Explosive6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 50
  • 51. Level I: Stabilization6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 51
  • 52. Level II: Stabilization & Strength6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 52
  • 53. Level II: Stabilization & Strength6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 53
  • 54. Level III: Integrated Stabilization Strength6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 54
  • 55. Level IV: Explosive Stabilization6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 55
  • 56. References  Prentice, W.E. (2004). Rehabilitation Techniques for Sports Medicine & Athletic Training, 4th ed.  Peter Brukner & Karim Khan with colleagues. Clinical sports medicine, 3rd ed6/19/2012 Ratankhuman M.P.T. (Ortho & Sports) 56

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