Functional core stabilization


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Functional core stabilization

  1. 1. Functional Core Stabilization
  2. 2. Chronic Musculoskeletal pain/chronic injuries in the spine and lower extremity are caused or perpetuated by muscle imbalances/weaknesses in the core musculature
  3. 3. Research indicates that 70-85% of all athletes suffer from recurrent low back pain. A comprehensive core stabilization program should be done will all lower extremity rehabilitation programs.
  4. 4. Individuals with a weak core substitute/compensate during dynamic functional movements leading to overuse/chronic injuries both upper and lower extremity
  5. 5. Functional Anatomy Lumbo-pelvic-hip Complex <ul><li>The LPH complex musculature produces force, reduces force, and stabilizes the kinetic chain during functional movements </li></ul><ul><li>The core functions primarily to maintain dynamic postural control by keeping the center of gravity over our base of support during dynamic movements. </li></ul>
  6. 6. Pelvic Girdle <ul><li>29 muscles attach to the core (LPH complex unilaterally) </li></ul>
  7. 8. LPH Complex <ul><li>Stabilization system (Core System) if not functioning optimally will end neuromuscular substituting to utilize the strength power and neuromuscular control in the rest of the body </li></ul>
  8. 12. LPH Complex Cont. <ul><li>Otherwise will get neuromuscular inhibition and CNS will shut down prime movers if LPH not stabilized, thus minimizing the kinetic chain. </li></ul><ul><li>Most athletes have functional strength and control in prime movers but not stabilization in spine (C,T,L) </li></ul>
  9. 13. Definitions: <ul><li>Function: Integrated proprioceptively enriched mulidirectional movement </li></ul><ul><ul><li>vs unidimentional, low proprioception, all three planes </li></ul></ul><ul><ul><li>All functional exercises are triplanar (even walking) appears unidirectional but need other planes to stabilize (frontal & transverse). </li></ul></ul><ul><ul><li>All functional movements required acceleration, deceleration & dynamic stabilization (typically concentrate in concentric and acceleration in rehab) </li></ul></ul>
  10. 14. Definitions: <ul><li>Functional Strength - ability neuromuscular system to produce dynamic eccentric concentric and dynamic isometric stabilization contraction during all functional movement patterns </li></ul>
  11. 15. Definitions: <ul><li>Neuromuscular efficiency: the ability of your entire kinetic chain to work as an integrated functional movement </li></ul><ul><ul><li>This will provide optimal dynamic stabilization at right joint, right time, right plane of movement </li></ul></ul><ul><ul><li>most athletes can produce the force but cannot stabilize or control eccentrically thus increasing stresses in different plane of movement and in different joints (compensation) </li></ul></ul>
  12. 16. Kinetic Chain - <ul><li>When it works efficiently: </li></ul><ul><ul><li>optimal control </li></ul></ul><ul><ul><li>distribute force appropriately </li></ul></ul><ul><ul><li>optimal efficiency during all movements </li></ul></ul><ul><ul><li>impact absorption/ground reaction forces </li></ul></ul><ul><ul><li>no excessive comp0ressive transitory force shear in kinetic chain </li></ul></ul><ul><ul><li>dynamic joint stabilization </li></ul></ul><ul><ul><li>neuromuscular control </li></ul></ul>
  13. 17. Example: Pelvo-Occular reflex (Janda) <ul><li>Cervical spine weak: during running fatigue head will go into extension, thus to see straight in from of you the pelvis tips anteriorly </li></ul><ul><li>This changes length tension ratios of the lower extremity, become less efficient, may end up with hamstring injury </li></ul>
  14. 18. Core Stabilization Function <ul><li>Remember 29 muscles connected to each side of your pelvis. These work synergistically with entire kinetic chain </li></ul><ul><li>Primary Function: maintain center of gravity over base of support during dynamic movement (Example gait cycle - loss of balance) </li></ul><ul><li>Stability & control offers more biomechanically correct position for function of entire core and lower extremity muscles </li></ul>
  15. 19. Patho-Kinesiological Model <ul><li>This is a delicate balance a change in one of these can cause injury </li></ul><ul><ul><li>Example: articular dysfunction with change length tension ration etc.. </li></ul></ul>
  16. 20. Muscle Fatigue <ul><li>Ability to generate or maintain decrease ability to require correct muscle </li></ul><ul><li>Ability to maintain dynamic muscle force decreases </li></ul><ul><li>Example: fatigue running unable to stabilize core: get shear forces and compressive forces in lumbar spine: </li></ul><ul><ul><li>- reason why see many LB comp0laints and hamstring strains (actually attributed to weak abdominals) </li></ul></ul>
  17. 21. Transverse Abdominis and Internal Obliques during functional activity <ul><ul><li>Only 2 abdominal muscles that attach to the L-spine </li></ul></ul><ul><ul><ul><li>Attach thorocolumbar facia (L-spine) via lateral rafia attach to transverse processes </li></ul></ul></ul><ul><ul><ul><li>Thus when they fire they create a tension affect inherent STABILITY in L-Spine </li></ul></ul></ul><ul><ul><ul><li>These prevent rotational and transnational forces </li></ul></ul></ul><ul><ul><ul><li>If these muscles are not stabilized the Psoas is used to create a compressive force and mimic stability </li></ul></ul></ul>
  18. 22. Transverse Abdominis and Internal Obliques during functional activity <ul><li>Actually creates anterior shear force and extension force </li></ul><ul><li>Leading to reciprocal inhibition of lower abdominals </li></ul><ul><li>The pelvis will tip forward </li></ul><ul><li>Leading to reciprocal inhibition of the gluteals (extensor mechanism) </li></ul><ul><ul><li>This can cause hip internal rotation knee overuse syndromes etc.. </li></ul></ul>
  19. 23. Basic Concepts of Core Stabilization - Performance Paradigm <ul><li>Stretch/shortening cycle (natural visco-elastic properties of muscles) </li></ul><ul><li>Every single movement (Dynamic functional movement) more efficient the more force can create and absorb) </li></ul><ul><ul><li>efficiency: less wasted movements </li></ul></ul><ul><ul><li>Example walking </li></ul></ul><ul><ul><li>Every single movement we do is the performance paradigm </li></ul></ul>
  20. 24. Paradigm Shift: NO longer looking to improve strength in one muscle but improvement in multidirectional neuromuscular efficiency (firing patterns in entire kinetic chain with complex motor patterns). The body doesn't just fire one muscle at a time for movement
  21. 25. Basic Concepts of Core Stabilization - Planes of Movement <ul><ul><li>With any movement all three planes are working together concurrently </li></ul></ul><ul><ul><li>Even through you may be moving in one plane the other 2 planes must stabilize and work eccentrically for stabilization </li></ul></ul><ul><ul><li>Example: Posterior Pelvic tilt laying on the floor changes the relationship, thus when standing he relationship again changes the exercises have not been functional and will not “work” in the altered position. Again it changes when you lift one leg etc. </li></ul></ul>
  22. 26. Basic Concepts of Core Stabilization - Continuum of Function <ul><li>Movements are not isolated unidirectional </li></ul><ul><li>Must do movements and exercises in a dynamic systematic program </li></ul><ul><li>Practically take the athlete from the challenging position they can control in a functional pattern and progress them from there </li></ul>
  23. 27. Basic Concepts of Core Stabilization - Open and Closed Chain <ul><li>Functional movement is a succession of opening and closing the chain </li></ul><ul><li>Functional activity is therefore a timing issue within opening and closing the chain </li></ul><ul><li>Need core stability to stabilize transition </li></ul>
  24. 28. Biomechnics: Three Phases <ul><li>Pronation - deceleration/force reduction phase (where most injuries occur due to lack of eccentric control) </li></ul><ul><ul><li>For rehabilitation need to look at this phase what muscles are decelerating and stabilizing to create a rehabilitation program </li></ul></ul>
  25. 29. Biomechnics: Three Phases Cont. <ul><li>Supination - acceleration phase/force production phase (most % time) </li></ul><ul><li>Coupling - stabilization, ability to change from pronation to supination phase (stronger the core more efficient that thus less time spend in this phase prevent overuse injuries) </li></ul>
  26. 30. Muscle Function Cont. <ul><li>Stabilization: Prone to develop weakness and inhibition, less activated during most movement patterns, fatigue easily, primarily function during stabilization movement </li></ul><ul><ul><li>Peroneals, anterior tibialis, posterior tibilalis, VMO, gluteus medius/maximus, transverse abdominis, int/ext obliques, serratus anterior, rhomboids, middle, lower trap, deep neck flexors, longus capitus </li></ul></ul>
  27. 31. Sherington’s Law of Reciprocal Inhibition: tight muscles will inhibit it’s functional antagonist. Example:The Psoas (most athletes) inhibit functional antagonists - deep abdominal wall, transverse abdomnis, internal oblique, multifidi, deep transverse spinalis, gluteus maximus. Thus the stabilization and coupli8ng phase will be reduces increasing the movement phase and muscle forces and decreasing efficiency.
  28. 32. Muscle Functions - Abdomen: <ul><li>Internal Oblique - Decelerate transverse plane rotation, frontal plane and transverse plane stability </li></ul><ul><li>Rectus Abdominis: Decelerate Extension, create pelvic stability during dynamic movement </li></ul><ul><li>External oblique - Decelerate transverse plane rotation some extension </li></ul>
  29. 36. Muscle Functions - Abdomen: <ul><li>Transverse Abdominis - The most important abdominal muscle (attach to lumbar spine) contract in feed forward mechanism contract 1st before any other muscle (research following back pain the transervse abdominis is inhibited, thus when you move for example an arm, your transverse abdomnis does not stabilize thus the psoas fires - compensation </li></ul>
  30. 37. Muscle Function: Lumbar Spine <ul><li>Superficial Erector Spinae: Extends Spine creates extension force and shear force at L4-S1 works with the Psoas (when Psoas tight it facilitates erector spinae further increasing the shear forces and inhibit posterior muscles) </li></ul><ul><li>Deep erector Spine: Posterior translation and L4-S1, if weak or inhibited cannot counterinteract affect or superficial erector and get shearing forces </li></ul>
  31. 38. Muscle Function: Lumbar Spine <ul><li>Transversal Spinalis Muscles (Rotatories, Multifidi, interspinalis, interanversari) Provide intrisic, intrasegmental stability proprioceptive feedback since constantly under compression and torsinal forces. If these muscles are inhibited, loose the ability to create dynamic stabilization from lack of proprioceptive feedback. </li></ul>
  32. 39. SPINE MUSCLES <ul><li>Heads </li></ul><ul><ul><ul><li>Iliocastalis </li></ul></ul></ul><ul><ul><ul><ul><li>Lumborum </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Thoracis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cervicis </li></ul></ul></ul></ul><ul><ul><ul><li>Longissimus </li></ul></ul></ul><ul><ul><ul><ul><li>Thoracis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cervicis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Capitis </li></ul></ul></ul></ul><ul><ul><ul><li>Spinalis </li></ul></ul></ul><ul><ul><ul><ul><li>Thoracis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cervicis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Capitis </li></ul></ul></ul></ul>
  33. 40. ANATOMY Macro anatomy. Multifidus (MF) is the largest and most medial of the lumbar paraspinal muscles.  Each muscle consists of five separate, overlapping bands that form a triangle as these bands run caudo laterally from the midline. Insertion: spinous process at caudal tip. Origin: transverse process at mamillary process, iliac crest, and sacrum (polysegmental: 2-4 segments below insertion at spinous process).
  34. 41. Joint Dysfunction Example <ul><li>Joint dysfunction example: lock up SI joint plant and twist, Multifitus is inhibited complains for low back pain, the erectors will fire and attempt to stabilize (therefore a muscle is doing opposite of it’s muscle function). This is why pain syndromes are perpetuated </li></ul>
  35. 42. Muscle Function: Hip Musculature: <ul><li>Gluteus Maximus: decelerate hip flexion, decelerate hip internal rotation during heel strike. </li></ul><ul><li>Psoas tightness creates inhibition of gluteus maximus (anterior tilt) </li></ul>
  36. 43. Muscle Function: Hip Musculature: <ul><li>If the gluteus maximus is inhibited or wak will loose ability to control femur, femur will internally rotate: </li></ul><ul><ul><li>Microtruma can be created on medial capsule of knee </li></ul></ul><ul><ul><li>Patellar tendonitis non-contact ACL injuries posterior tibial tendonitis, plantar facitis </li></ul></ul><ul><ul><li>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) </li></ul></ul>
  37. 44. Lack of flexibility is often a phenomenon created by lack of stability in an attempt to stabilize the body for activity
  38. 45. Gluteus Maximus and minimus are inhibited in most athletes due to tight psoas (Summer, 1988).
  39. 46. Muscle Function: Hip musculature <ul><li>Gluteus medius: provides frontal plane stabilization, decelerate femoral adduction, assist in deceleration femoral internal rotation (during closed chain activity) </li></ul><ul><ul><li>VB/BB with patellar tendonitis originate from tight psoas and lack of core strength </li></ul></ul><ul><ul><ul><li>attempting to get triple extension during jumping, couldn’t extend through hip using gluteus maxiumus due to thigh psoas </li></ul></ul></ul><ul><ul><ul><li>Thus they hyperextend at the knee and drive the inferior pole of the patella into the fat pad creating the inflammatory response (Summer, 1988). </li></ul></ul></ul>
  40. 47. Muscle Function: Hip Musculature <ul><li>Adductors: frontal plane stability </li></ul><ul><li>Hip External Rotator: Create Pelvo-femoral rhythm </li></ul><ul><ul><li>Gemeli, Obturators, Piriformis help to decelerate femur, If inhibited they become extremely tight because they are attempting to stabilize </li></ul></ul><ul><ul><li>Often we attempt to stretch these muscle where a core program would eliminate the origin of the problem </li></ul></ul>
  41. 48. Force Couples <ul><li>Saggital Plane: Psoas and superficial erector spinae which create and extension force and shear force int he lumbar spine </li></ul><ul><ul><li>counteracted by transverse abdominis, internal oblique multifidi, transversal spinalis groups, gluteus maximums </li></ul></ul><ul><ul><li>Trend - most athletes the psoas and erector overdeveloped inhibiting stabilizers </li></ul></ul>
  42. 49. Frontal Plane: Gluteus Medius, ipsilateral adductor and contralateral quadratus lumborum <ul><li>Example: weak gluteaus medius will cause contralateral LBP, into knee pain on opposite side </li></ul>
  43. 50. Force Couples Cont. <ul><li>Transverse Plane Left Rotation - left internal oblique, left adductor, right external oblique and right external rotators of the hip </li></ul><ul><ul><li>Example: synergistic dominance Weak transverse abdominis and internal oblique the same side adductor will become tight and inhibit gluteus medius causing anterior knee pain, posteior tib tendonitis etc. Down the kinetic chain. </li></ul></ul>
  44. 51. Principle of Core Training: <ul><li>Postural Alignment: Primary Function - misalignment will produce predictable stresses, pain, chronic injuries, joint dysfunction </li></ul>
  45. 52. Common Postural Dysfunction <ul><li>Lower Cross System: Anterior Tilt in most athletes increase lumbar lordosis </li></ul><ul><ul><li>tight muscles movement groups muscles erector spinae superifical psoas, upper rectus, rectus femoris, sartorius, tensor facia latae, adductors </li></ul></ul><ul><ul><li>Weaker muscle/inhibited - stabilizing group deep abdominal wall transverse abdominis, internal oblique multifidus, deep erector spinae biceps femoris gluteaus medius/maximus </li></ul></ul><ul><ul><ul><li>muscle that decelerate femur are inhibited </li></ul></ul></ul><ul><ul><li>Joint dysfunction illiosacral rotations, S1, L-spine, Tib-fib joint, subtalar joint </li></ul></ul><ul><ul><li>Injury patterns: plantar faciiitis, patellar tendonis, posterior tib tendonitis </li></ul></ul>
  46. 53. Common Postural Dysfunction <ul><li>Upper Cross System: Rounded Back/Forward Head </li></ul><ul><li>Tight muscles pec major/minor, lat, upper trap, levator, subscap, teres major, sternocleidomastoid, erectus capitus, and scalenes </li></ul><ul><li>Weak muscle: rhomboids, middle.lwr trap, teres minor , infraspinatus, posterior deltoid, deep neck flexors </li></ul><ul><li>Joint dysfunction: Upper cervical, cervical throricis, SC joint problems (which can cause rotator cuff problems) </li></ul>
  47. 54. Common Postural Dysfunction <ul><li>Pronation Distortion Syndrome: Flat feet </li></ul><ul><ul><li>tight muscles: peroneals, lateral gastroc IT band, Psoas </li></ul></ul><ul><ul><li>Weak muscles: intrinsic foot muscles, anterior/post tibialis, VMO, bicep femoris, piriformis, glut medius </li></ul></ul><ul><ul><ul><li>muscles that control pronation are inhibited and weak causing overuse injuries </li></ul></ul></ul>
  48. 55. Pronation Distortion Syndrome <ul><li>Joint dysfunction: 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 the core chain into movements of the extremity). The same can occur with sprain ankle and lock tibo-talar joint </li></ul>
  49. 56. Through the kinetic chain, muscle problems can lead to joint problems and joint problems can lead to muscle problems.
  50. 57. Postural Considerations <ul><li>Many individuals have well developed muscle strength and power to perform specific activities, however few have developed stabilization systems optimally </li></ul><ul><li>Optimal alignment of each segment in the kinetic chain is a cornerstone for all functional rehabilitation programs </li></ul>
  51. 58. Postural Considerations <ul><li>If one segment in the kinetic chains is out of alignment, then predictable patterns of dysfunction will develop in other parts of the kinetic chain </li></ul><ul><li>A weak core is a fundamental problem o inefficient movement which leads to injury </li></ul>
  52. 59. Low Back Pain & Rehabilitations <ul><li>Transerve abdominis, multifitus, internal oblique are inhibited in someone with LBP </li></ul><ul><li>Decrease in stabilization endurance can perform the movement until fatigue. OK for 3x20 but once start functional movement revert back to previous positions </li></ul><ul><li>Increase interdisck pressure and compressive forces with lack of pelvic stabilization </li></ul><ul><li>Think about athletes that “lift” and then have LBP cause may not be stabilizing and can perpetuate muscle imbalances creating hamstring dysfunction etc. </li></ul><ul><li>Address through unstable ball training </li></ul>
  53. 60. Hilton’s Law: any muscle that crosses that joint will be inhibited. With injuries the individual will have a lot of joint substitutions and muscle imbalances
  54. 61. Muscle Imbalances <ul><ul><li>An optimal functioning core helps to prevent the development of muscle imbalances </li></ul></ul><ul><ul><li>Optimal core neuromuscular efficiency allows for the maintenance of the normal: </li></ul></ul><ul><ul><ul><li>Length-tension relationships </li></ul></ul></ul><ul><ul><ul><li>Force-couple relationships </li></ul></ul></ul><ul><ul><ul><li>The path of instantaneous center of rotation </li></ul></ul></ul><ul><ul><li>A strong stable core can improve neuromuscular efficiency throughout the kinetic chain by improving dynamic postural control </li></ul></ul>
  55. 62. Assessment of the Core: <ul><li>Core strength can be assessed using the straight leg lowering test </li></ul><ul><li>Core power can be assessed using the overhead medicine ball throw </li></ul><ul><li>Core muscle endurance can be assessed using back extension </li></ul>
  56. 63. Core Stabilization to create program: <ul><li>Sport Demand Analysis </li></ul><ul><ul><li>Demands of the individual sport </li></ul></ul><ul><ul><li>Demands of the athlete (player vs non-player) </li></ul></ul><ul><ul><li>Demands of the position/specialty </li></ul></ul>
  57. 64. Guidelines for Core Training: <ul><li>A comprehensive core stabilization training program should: </li></ul><ul><ul><li>progress from slow to fast </li></ul></ul><ul><ul><li>simple to complex </li></ul></ul><ul><ul><li>known to unknown </li></ul></ul><ul><ul><li>low force to high force </li></ul></ul><ul><ul><li>static to dynamic </li></ul></ul>
  58. 65. Guidelines for core Training <ul><li>Exercises should be safe, challenging, stress multiple planes, incorporate a multi-sensory environment, and activity specific </li></ul><ul><li>Put each athlete in the most challenging environment they can control. </li></ul>
  59. 66. Guidelines for core Training <ul><li>Change program often </li></ul><ul><ul><li>ROM </li></ul></ul><ul><ul><li>Loading (Cable, tubing etc.) </li></ul></ul><ul><ul><li>Plane of motion </li></ul></ul><ul><ul><li>Body position, floor standing, one leg etc..) </li></ul></ul><ul><ul><li>speed of movement </li></ul></ul><ul><ul><li>duration </li></ul></ul><ul><ul><li>frequency </li></ul></ul>
  60. 67. Abdominal Bracing Key <ul><li>Transverse Abdominis - draw belly-button into spine “Make self skinny”) </li></ul><ul><ul><li>Pelvis tilts work rectus abdominis </li></ul></ul><ul><ul><li>avoid anchoring feet so as not to activate hip flexors or psoas </li></ul></ul><ul><ul><li>Full ROM]Exercise profession </li></ul></ul><ul><ul><li>Stretch Antagonists between sets to prevent inhibition (if working abdominal stretch hip flexors between sets) </li></ul></ul>
  61. 68. Exercise Progression <ul><li>Stage I: Learning Abdominal Bracing </li></ul><ul><ul><li>maintain stability </li></ul></ul><ul><ul><li>change duration and frequency </li></ul></ul><ul><li>Stage II </li></ul><ul><ul><li>Educate on daily use </li></ul></ul><ul><ul><li>Increase ROM and instability mainly uniplanar, change body position </li></ul></ul>
  62. 69. Exercise Progression <ul><li>Stage III: instability </li></ul><ul><ul><li>Maximize the use of functional activities with abdominal bracing </li></ul></ul><ul><ul><li>Maximize multidirectional patterns and unstable positions </li></ul></ul><ul><ul><li>Maximize frequency and duration changes </li></ul></ul><ul><li>Stage IV: </li></ul><ul><ul><li>Challenge the individual with high intensity strength and power </li></ul></ul>
  63. 70. SPINE MUSCLES <ul><li>Heads </li></ul><ul><ul><ul><li>Iliocastalis </li></ul></ul></ul><ul><ul><ul><ul><li>Lumborum </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Thoracis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cervicis </li></ul></ul></ul></ul><ul><ul><ul><li>Longissimus </li></ul></ul></ul><ul><ul><ul><ul><li>Thoracis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cervicis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Capitis </li></ul></ul></ul></ul><ul><ul><ul><li>Spinalis </li></ul></ul></ul><ul><ul><ul><ul><li>Thoracis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cervicis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Capitis </li></ul></ul></ul></ul>
  64. 71. ANATOMY Macro anatomy. Multifidus (MF) is the largest and most medial of the lumbar paraspinal muscles.  Each muscle consists of five separate, overlapping bands that form a triangle as these bands run caudo laterally from the midline. Insertion: spinous process at caudal tip. Origin: transverse process at mamillary process, iliac crest, and sacrum (polysegmental: 2-4 segments below insertion at spinous process).