Core stability is a complex issue with many myths and misconceptions. There are several beliefs that are refuted by current evidence: 1) Certain core muscles like transversus abdominis are not uniquely important for spinal stability. 2) Weak abdominal muscles do not necessarily lead to back pain. 3) Strengthening core muscles does not reliably reduce back pain more than general exercises. 4) A strong core will not necessarily prevent injury more than other forms of exercise. Core stability exercises provide benefits similar to general exercises and are not uniquely effective for back pain.

1. Core Stability
-WILL IT
SURVIVE

2. The beliefs
1. That certain muscles are more important for
stabilisation of the spine, in particular
transverses abdominis (TA).
2. That weak abdominal muscles lead to back
pain
3. That strengthening abdominal or core muscle
can reduce back pain
4. That a strong core will prevent injury.

3. The myths
• Single muscle activation issue
• TA and stability issues
• The timing issue
• The strength issue
• Motor learning training issues

4. Core stability?????????

5. Complexity of tensional fields

6. Functional organisation of
motor system
Lederman E 2005 Science and Practice of Manual Therapy, Elsevier.

7. Complexity of tensional fields
• The concept of tensional field can help us to
make an important clinical shortcut:
• there is no need to know the complex and exact
anatomy of muscles for effective neuromuscular
rehabilitation.
• The focus is on movement capacity and not on
individual muscles.

8. Complexity of trunk stabilisation
CONCLUSIONS: No single muscle dominated in the
enhancement of spine stability, and their individual roles
were continuously changing across tasks. Clinically, if the
goal is to train for stability, enhancing motor patterns that
incorporate many muscles rather than targeting just a few
is justifiable.
Kavcic N, Grenier S, McGill SM. Determining the stabilizing role of
individual torso muscles during rehabilitation exercises. Spine. 2004 Jun
1;29(11):1254-65.

9. Stability is only another motor control pattern
Lederman E 2005 Science and
Practice of Manual Therapy,
Skills Elsevier.
Composite abilities
Motor complexity
Balance, motor relaxation,
coordination, fine control,
reaction time, transition rate
Synergetic abilities
Co-contraction reciprocal activation
(Stability, dynamic / (Movement)
static)
Contraction abilities
Force (static & dynamic), velocity and length

10. Natural is best
Individuals in an externally loaded state
appear to select a natural muscular activation
pattern appropriate to maintain spine stability
sufficiently. Conscious adjustments in
individual muscles around this natural level
may actually decrease the stability margin
of safety.
Brown SH, Vera-Garcia FJ, McGill SM. Effects of abdominal muscle
coactivation on the externally preloaded trunk: variations in motor control
and its effect on spine stability. Spine. 2006 Jun 1;31(13):E387-93.

11. Spinal Stability Concept (Panjabi et al 1992)

12. Neutral Zone
 “Part of the ROM with in which there is minimal
resistance to intervertebral motion, panjabi (1992)”.
 Neutral zone ↑ with intersegmental injury, disc
degeneration, etc. ↓ with simulated muscle forces
across motion segment
 Size of NZ determines the stability of spine
 Influenced by interaction between passive, active
and neural control

13. Spinal Stability Concept (Panjabi et al 1992)
• Control spine NZ with in
pain free zone.
• Painful spine with greater
NZ bringing the pain free
zone with in it.
• Stabilised spine has
decreased neutral zone,
therefore is pain-free.

14. Serge Gracovetsky’s “controlled instability”
“It was also proposed that the width of the
neutral zone was related to the stability of the
joint. These conclusions were drawn from
cadaver experiments and mathematical
models on which an extensive amount of
damage had to be inflicted to the joint before
an unstable response was obtained. So far,
the neutral zone argument has remained
academic.”
Serge Gracovetsky 2005 Stability or controlled
instability? Evolution at work. In: Movement, Stability
and Lumbo Pelvic Pain 2nd Edition – Ch14

15. Functional organisation to injury
Psychomotor Reflexive
Executive stage
Effector stage
“Motor
templates” for
motor
injury?
Altered proprioception
+ nociception
Motor stage
Lederman E 2005 Science and Practice of Manual Therapy, Elsevier.

16. Complexity in injury / pain
Multifidus
(Carpenter & Nelson, 1999),
Psoas
(Barker et al., 2004),
Diaphragm
(Hodges et al., 2003),
Pelvic floor muscles
(Pool-Goudzwaard et al., 2005),
Gluteals
(Leinonen et al., 2000)
If a muscle is not involved it is still part
of the protection schema / strategy!

17. Are abs essential for stability?
TA is absent or fused to the internal oblique
muscle as a normal variation
Gray’s Anatomy (36th edition 1980, page 555)

18. Is LBP in pregnancy due to loss in stability?
• Body mass index,
• History of hypermobility
• History of amenorrhea (Mogren & Pohjanen, 2005)
• Low socioeconomic class,
• Previous LBP (Orvieto et al., 1990)
• Posterior fundal location of placenta
• Correlation between fetal weight to LBP with radiation (Orvieto et al.,
1990)
Fast A, Weiss L, Ducommun EJ, Medina E, Butler JG 1990 Low-back pain in pregnancy. Abdominal muscles,
sit-up performance, and back pain. Spine. Jan;15(1):28-30 / Gilleard & Brown, 1996

19. Is LBP in pregnancy due to loss in stability?
Postpartum, Rectus abdominus takes about 4 weeks to re-shorten, and 8
weeks for pelvic stability to normalize (Gilleard & Brown, 1996)
Out of 869 pregnant women who were recruited for the study, 635 were
excluded because of their spontaneous unaided recovery within a week
of delivery (Bastiaenen et al., 2006)
Whereas all non-pregnant women could perform a sit-up, 16.6% of
pregnant women could not perform a single sit-up. There was no
correlation between the sit-up performance and backache. (Fast et al.,
1990)

20. In patient with pelvic girdle pain increased intra-abdominal
pressure could exert potentially damaging forces on various
pelvic ligaments.
Study recommends teaching the patients to reduce their intra-
abdominal pressure, i.e. no CS.
Mens et al., 2006

21. Are abs essential for stability?
Weight gains and obesity are only weakly associated
with LBP
(Leboeuf-Yde, 2000)

22. Are abs essential for stability?
Results in weakness of abdominal muscles. No effect on back pain or
impairment to the patient’s functional / movement activities, measured
up to several years after the operation (Mizgala et al., 1994; Simon et
al., 2004).
Mark A. LePage, MD, Ella A. Kazerooni, MD, Mark A. Helvie, MD and Edwin G. Wilkins, MD. Breast
Reconstruction with TRAM Flaps: Normal and Abnormal Appearances at CT 1 Radiographics. 1999;19:1593-1603

23. Are abs essential for stability?
Conclusion:
Conclusion
Imbalances between anterior and posterior trunk
muscles are a normal variation
Weak abdominals do not lead to instability or
back pain

24. Force levels of trunk muscles
In standing, ES, psoas and QL are virtually silent! In some
subjects there is no detectable EMG activity in these muscles
(Andersson et al., 1996).
Co-contraction in standing is less than 1% MVC rising up to 3%
MVC when a 32 Kg weight is added to the torso. With a back
injury it is estimated to raise these values by only 2.5% MVC for
the unloaded and loaded models (Cholewicki et al., 1997).
During walking rectus During bending and lifting a
abdominis has a average weight of 15 kg co-
activity of 2% MVC and contraction increases by
external oblique 5% MVC only 1.5% MVC (van Dieen
(White & McNair, 2002). et al., 2003b).

25. myth of strong abs
In a study of fatigue in CLBP, four weeks of stabilisation
exercise failed to show any significant improvement in
muscle endurance (Sung, 2003).

26. myth of strong abs
No study has shown that
strengthening core muscle will
re-normalise motor control!

27. “DM and TrA do not maintain tonic co-contraction. However, these
muscles do share functional similarities. As with tonic activation of DM,
training co-contraction of DM and TrA as part of therapeutic exercise
programmes is unlikely to restore typical activation patterns”
“EMG studies refute the belief that DM is tonically active during static
postures, trunk movements and gait. It is, therefore, unlikely that
training tonic activity of multifidus restores the normal function of this
muscle”
“DM and TrA do not maintain tonic co-contraction. However, these
muscles do share functional similarities. As with tonic activation of DM,
training co-contraction of DM and TrA as part of therapeutic exercise
programmes is unlikely to restore typical activation patterns”
David A. MacDonalda, G. Lorimer Moseley, Paul W. Hodges, The lumbar multifidus:
Does the evidence support clinical beliefs? Manual Therapy 2006

28. Conflicts with motor learning and
training principles
• The similarity and specificity principle
• Economy of movement
• Internal-external focus principles

29. "There is no basis to expect training effects from
one form of exercise to transfer to any other form
of exercise. Training is absolutely specific."
Tim Noakes - Professor of Exercise and Sports Science, Department of Physiology,
University of Cape Town, SA.

30. Energy expenditure
Co-contraction
Reciprocal activation
Practice

31. Economy of movement
“to improve locomotion (and motion), mechanical work should
be limited to just the indispensable type and the muscle
efficiency be kept close to its maximum. Thus it is important
to avoid: …. using co-contraction (or useless isometric force)”
Minetti, A. E. (2004). Passive tools for enhancing muscle-driven motion and locomotion. J
Exp Biol 207, 1265-1272
“At higher levels of competition, it is likely that 'natural
selection' tends to eliminate athletes who failed to either inherit
or develop characteristics which favour economy”
Anderson T. (1996). Biomechanics and running economy. Sports Med 22, 76-89.

32. Prevention of injury
Description Outcome Note
(Helewa et al., 1999 asymptomatic Observed for 1 yr Recruited
subjects (n=402) Abs strengthening asymptomatic
back education or no added protection subjects identified
back education + as having weak
abdominal abdominal muscles,
strengthening but no back pain!
exercise
Nadler et al., 2002 Core-strengthening No effect
program effect on
LBP
collegiate athletes
(n=257)

33. CS therapeutic value
Description CS compared to: Result Note
O'Sullivan et al., 1997 CLBP General practitioner CS better
(spondylolysis or care
spondylolisthesis)
Hides et al., 2001 Reccurence after General practitioner CS better
first episode LBP care + medication
Goldby et al., 2006 CLBP Control and MT CS first Only 7.5% had spinal
MT second instability
Bias to CS
Also global muscles
included
Stuge et al., 2004 LBP in preg Physical therapy CS better
Nilsson-Wikmar et al., LBP in preg General exercise Same
2005
(Franke et al., 2000;) CLBP General exercise Same
Koumantakis et al., CLBP General exercise Same
2005
Rasmussen-Barr et al., CLBP General exercise Same
2003;

34. CS in relationship to biomechanical factors: sitting
Sitting condition Risk factor CS implications
Normal prolong no None
sitting Core tensing irrelevant
Unusual sitting Yes Advice on posture.
posture Core tensing irrelevant
Sitting + whole body Yes Advice on occupation
vibration Core tensing irrelevant
CLBP + sitting May exacerbate Avoid prolong sitting
existing LBP Encourage a dynamic working
patterns
Core tensing irrelevant

35. CS in relationship to biomechanical factors: sitting
Which is better for developing spinal stability?
• No difference in muscle activation of 14 trunk muscles
• No difference in stability and spinal compression values
S.M. McGill , N.S. Kavcic, E. Harvey. Clinical Biomechanics 21 (2006) 353–360

36. CS in relationship to biomechanical factors: bending + lifting
In patients with CLBP lifting is associated with higher levels of
trunk co-contraction and spinal loading
Marras et al., 2005; Cholewicki et al., 1997
Bending and lifting is associated with low abdominal muscle
activity, which contributes to further spinal compression
de Looze et al., 1999
Any further tensing of the abdominal muscle may lead to
additional spinal compression.
“Since the spinal compression in lifting approach the margins
of safety of the spine, these seemingly small differences are
not irrelevant”
Biggemann et al., 1988
Psychological stress during lifting resulted in a dramatic
increase in spinal compression associated with increases in
trunk muscle co-contraction and less controlled movements
Davis et al., 2002

37. Exercise seems to help
• May normalise motor control
• Musculoskeletal system loves movement and exercise
• “Exercise is good for you”
• Improve blood flow – exercise increase capillary density in muscle
• Improve trans synovial flow in facet joints – may help reduce joint
effusion inflammation
• Lymph flow highly responsive to movement and exercise – help
reduce build up of fluid in tissue etc.
• Exercise may reduce pain by modulating nociception
• Exercise also empower the patient – strong correlation between
socio-economic / psychological factors and chronic back pain

38. THOUGHT PROCESS
• NEED FOR CHANGE DUE
TO INCREASING
RESPONSIBILITY

39. People of the world relax (your trunk)
Tightening your trunk muscles will not:
 Prevent back injury
 Prevent back pain*
 Will not cure back pain*
 Will not improve your sports performance
* More than general exercise
* More than general exercise

40. • Weak trunk muscles, weak abdominals and
imbalances between trunk muscles groups are
not pathological, just a normal variation.
• The division of the trunk into core and global
muscle system is a reductionist fantasy, which
serves only to promote CS.
• Weak or dysfunctional abdominal muscles will
not lead to back pain.
• Tensing the trunk muscles is unlikely to
provide any protection against back pain or
reduce the recurrence of back pain.

41. • Core stability exercises are no more effective
than, and will not prevent injury more than, any
other forms of exercise.
• Core stability exercises are no better than other
forms of exercise in reducing chronic lower back
pain.
• Any therapeutic influence is related to the
exercise effects rather than CS issues.

42. • There may be potential danger of damaging
the spine with continuous tensing of the trunk
muscles during daily and sports activities.
Patients who have been trained to use
complex abdominal hollowing and bracing
maneuvers should be discouraged from using
them

43. PGP & SIJ – In vogue
• No correlation b/w Sx’s &
Imaging techniques (CT,
MRI, Scintigraphy) (walker JM
1992)
• Poor outcome after disc
resection and fusion
• Life long complications
following surgeries
• Detailed understanding of
correlation between PGP, LL
dysfunctions & LBP.

44. Thoracolumbar Fascia
www.google.com/images

45. Thoracolumbar fascia
Vleeming et al 1997 Pg. 6162

46. Thoracolumbar Fascia
Sourced:www.moon.ouhsc.edu/dthompso/ namics/gifiles/tlf.gif)

47. Optimal & Non- optimal Stability
• According to European guidelines (2004):
• Optimal stability is achieved when the balance between
performance (the level of stability) and effort is optimized to
economize the use of energy.
• Non-optimal joint stability implicates altered laxity/stiffness
values leading to increased joint translations resulting in a
new joint position and/or exaggerated/reduced joint
compression, with a disturbed performance/effort ratio
(Vleeming et al, 2004; Lee, 2004).

48. Integrated Model of Function
(Lee D & Hodges, 2003)

49. Form Closure
• Shape & Plane of SIJ’s
• Friction Coefficient
www. Google images.pn.jcon.org/images

50. Force Closure & Myofascial Slings
• Outer Unit
 Anterior Oblique Sling
 Posterior Oblique Sling
 Deep Longitudinal Sling
 Lateral Sling
www. Google images.pn.jcon.org/images

51. Myofascial Slings
Anterior Oblique Sling
Vleeming et al 1997

52. Myofascial Slings
• Posterior Oblique Sling
Vleeming et al 1997

53. Myofascial Slings
• Deep Longitudinal
Slings
Vleeming et al 1997

54. Myofascial Slings
• Lateral Sling
Vleeming et al 1997

55. Force Closure
• Inner Unit
 Transversus Abdominis
 Multifidus
 Diaphragm
 Pelvic Floor

56. The GOD Gifted Belt
• Transversus Abdominis
www.primal.com 2007

57. Inner Unit
 Pelvic Floor
 Diaphragm
www.primal.com 2007

58. Pilates
Efficacy of the technique is monitored while patient
doing activity of the muscle, usually happens when
patient doesn’t understand the skill or feel greater
difficult in activating muscles.
→ normal
doing with more of the external oblique muscle,
→ depressed ribcage and the skin crease across the
upper-middle abdomen
→ utilizing breath holding and rib elevation.
Observation of abdominal wall/ palpating either of TA
Multifidus will help in identifying incorrect action.

59. Second Stage- Refining
Refining a particular movement
• faulty and pain provocation movement are break
down in to components (Flex+ Lateral flexion+Rot)
with local muscle contraction
• First in lordotic posture and then with normal spinal
movements.
• Segmental control and pain control must be
maintained
Training: daily 50-60reps , control breathing.

60. Third Stage- Autonomous
• Low degree of attention is required in this
stage
• During functional demands of daily living.
• It became permanent, and patient try to apply
it in all of her functional activities like:
walking, jogging, driving, cooking, at work,
sports, recreation etc.

61. Mental practice can enhance motor learning.
Mental rehearsal of some tasks can be almost as effective as
physically practicing it.
(From: Rawlings EI, Rawlings IL, Chen CS
et al 1972 The facilitating effects of mental rehearsal in the
acquisition of rotary pursuit tracking. Psychonomic Science 26:71–
73.)

62. Future directions for core to survive
ASSESSMENT OF CORE STABILITY: DEVELOPING PRACTICAL
MODELS Andy Waldhelm 2011
• Create and determine the reliability of a
comprehensive core stability test.
• Evaluate how individual core stability tests
correlate to the functional core stability
tests.
• Validate the core stability test using a proven
intervention.

63. INVESTIGATE THE BIG TALK !