P.

Ratan Khuman
M.P.T. (Ortho & Sports)
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,

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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.

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 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.

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 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.

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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 extremities

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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 forces

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  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 result

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 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 Oblique
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 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 Dorsi

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  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 & core

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 Functional Anatomy Cont…
 Abdominal Muscles –
 Rectus abdominus
 External obliques
 Internal obliques
 Transverse abdominus

 Work to optimize spinal mechanics

 Provide sagittal, frontal & transverse plane stabilization

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 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 cycle
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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 control
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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 planes

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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.

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 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
positioning
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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 segment

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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 functioning

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Assessment of The Core
 Muscle imbalances
 Arthrokinematic deficits
 Core
 Endurance
 Neuromuscular control
 Strength
 Power
 Real-time Ultrasound Imaging
 Overall function of lower extremity kinetic chain

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 CORE
ENDURANCE TEST

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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.
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Prone Bridge Endurance Test
 Primarily assesses the anterior and posterior core muscles.
 It is performed by supporting the body's 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.

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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.

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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 athlete's torso falls below 60°.

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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.

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Mean Endurance times (in sec) in Young Healthy
Subjects (mean age 21 yrs)
Men Women
Extension 161 185
Flexion 136 134
Side Bridge (R) 95 75
Side Bridge (L) 99 78
Flexion/Extension Ratio 0.84 0.72
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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.

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 CORE
NEUROMUSCULAR TEST

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 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 & multifidus

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 CORE STRENGTH TEST

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 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.

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 Core Power Test

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 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.

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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 deficiency

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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.

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 Core
Stabilization Training

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 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.

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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)

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Exercise Selection.
 Safe
 Challenging
 Stress multiple planes
 Proprioceptively enriched
 Activity specific/ sports specific

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Exercise Progression
 Slow to fast
 Simple to complex
 Stable to unstable
 Low force to higher force
 General to specific
 Correct execution to increased intensity

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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?

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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 action

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  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.

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Core Stabilization Training Program
 4 levels to core stabilization training program –
 Level 1 = Stabilization
 Level 2 = Stabilization & strength
 Level 3 = Integrated stabilization strength
 Levcl4 = Explosive

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 Level I: Stabilization

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 Level II: Stabilization & Strength

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 Level II: Stabilization & Strength

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 Level III:
Integrated Stabilization Strength

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Level IV: Explosive Stabilization

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References
 Prentice, W.E. (2004). Rehabilitation Techniques for Sports
Medicine & Athletic Training, 4th ed.
 Peter Brukner & Karim Khan with colleagues. Clinical
sports medicine, 3rd ed

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