Post on 16-Sep-2019
Core Strengthening from the Inside/Out 3/25/2017
copyright 2016 Riczo Health Education 1
Core Strengtheningfrom the Inside Outsm
Deborah B. Riczo, PT, DPT, MEd©2016
Objectives
• Understand the components of evidenced based core strengthening
• Be able to discuss the role of the inner core in core strengthening and know how to activate it properly
• Be able to identify abnormal patterning during core exercises and know what muscles are overcompensating
Objectives
• Be able to challenge the core through the appropriate progression of exercises
• Know how to address flexibility and strength in the hip in light of the latest research and what exercises are recommended
Core Strengthening from the Inside/Out 3/25/2017
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Overview
• Dynamic core stabilization• Research, integrated model of functioning, muscle slings
• Pelvic Rotator Cuff theory
• Activating the core
• LAB• Static• Dynamic• Other therapeutic exercise
• Stretching
• Strengthening
How do you teach core?
First exercise
List steps
1 minute
5
Reflection Moment
Dynamic Core StabilizationResearch • What is Core?
Integrated Model of Function
https://scontent.cdninstagram.com/hphotos‐xfa1/t51.2885‐15/s320x320/e15/11266709_1613397708918576_2016644901_n.jpg
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Research
• Abdominal canister construct
• Diaphragm and transversus abdominus (TA) muscles
• Tonic and phasic activity with rib cage and abdomen
• Pressure in abdominal cavity
• Improves control of spine
• UE and LE movement
Hodges et al 2000
Research
• Abdominals work with pelvic floor muscles (PFM)
• No matter which initiates contraction
• EMG (fine needle) assessment PFM and rectus abdominus (RA), external oblique (EO), transversus abdominus (TA)
Sapsford et al 2001
Research
• Position of the spine matters
• Co‐activation PFM and abdominals
• EO greatest with lumbar flexion
• TA greatest with lumbar extension
• What does this mean to us clinically??
Sapsford et al 2001
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Research
• What about the multifidi?
• EMG analysis
• Supports
• Superficial
• Spine orientation
• Deep
• Intersegmental motion
Moseley et al 2002
Research
• Hallowing vs TA ?
• TA contraction
• Sacroiliac joint stiffness increased
• Supports use of TA exercise for LBP treatment
Richardson et al 2002
Research
• PFM contributes to postural and respiratory function
• EMG activity anal and vaginal (surface electrodes)
• Respiratory
• Increased PFM with expiration
• Single and repetitive arm movements
• PFM EMG was tonic with phasic bursts
• Influenced by frequency and acceleration of arm movement
• Responds to increased reactive forces on spine
Hodges et al 2007
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Research
• PFM EMG activity in advance of deltoid
• Anticipatory postural activity
• PFM EMG modulated with arm movement not respiratory
Hodges et al 2007
Reflection Moment
Key points of research findings?
Partner activity
1 minute
Research
• Does motor control exercise reduce disability?
• Greater in those poor ability to recruit
• Significant moderate correlation
• Improved TA recruitment and reduction in disability
Ferreira et al 2010
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Research
• Research with single leg squat
• Intentional core activation
• Improved hip and knee kinematics
• More evident in low core group
• Weaker
Shirey et al 2012
Research
• Systematic reviews
• Therapeutics exercise/EMG muscle onset timing (Crow 2011)
• Improves TA muscle onset timing in people with LBP
• Core stability exercise more effective in short term, not long term over general exercise (Wang et al, 2012)
• Pain and function, 6 and 12 months
• Stabilization exercises not more effective than other forms of active exercise in the long term (Smith et al 2014)
Research
• Systematic review: stabilization exercises for non‐specific LBP (Smith et al 2014) (con’t)
• Limitations
• Wide variety of patients
• Low, medium or high socio‐economic groups, employed/unemployed, with or without leg pain, acute or chronic symptoms, high levels of fear avoidance, distressed
• Wide variety of treatment delivery
• Class settings, one to one, class/one to one with home exercise, just home exercises, varying amount of therapist contact time
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Research
• Rehabilitation strategy re stabilization exercises questioned
• Encourage unhealthy thoughts and beliefs on pain and movement
• Biomedical model vs. biopsychosocial model
• Therapist’s beliefs/patient’s beliefs (Nijs et al 2013) (O’Sullivan, 2016)
Smith et al 2014
Reflection MomentAny changes to how you would teach
beginning core exercise based on the research?
What is Core?
• What muscles involved? How to strengthen it?
• Depends who is talking
• Health professionals
• Researchers
• Fitness professionals
• Consumer magazines/internet
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What is Core?
Men’s Journal
The 10 Moves You Need to Get a Rock‐Solid Core
http://tinyurl.com/qh3u3jo
What is Core?
• Transfer planks
• Hanging leg raises
• Renegade rows
• Ab wheel rollouts
• 4 point touch
• Split stance cable lift
• Dragon flags
•Medicine ball slams
•Weighted back extensions
• Side planking
10 MOVES
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Inner and Outer Core
• Inner Core (local, postural)
• Anticipatory system
• Activate prior to the deltoid in UE tasks
• Outer Core (global, movers)
• Reactive or external core
Inner Core
Inner Core Muscles (Lee 2011, Akuthota 2008 )
• PFM
• TA, IO (internal obliques)
• Multifidus
• Diaphragm
• Deep fibers of the psoas
• Deep hip rotators
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http://womensaction.org/wp‐content/uploads/2010/01/Core1.jpg
Inner Core
Thieme Atlas of Anatomy: General Anatomy and Musculoskeletal System
Iliococcygeus
Piriformis
Coccygeus
Obturator internus
PFM in pelvic bowl, against pelvic bones
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Inner Core
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Transversus AbdominusOrigin: • Lower 6 ribs• Thoracolumbar fascia• Anterior 3/4 of the iliac crest• Lateral 1/3 of inguinal l.
Insertion: • Linea alba• Pubic crest• Pecten of the pubis
Nerves:• Intercostal nerves T7‐T11• Subcostal, iliohypogastric and ilioinguinal nerves
Action: • Compresses abdomen
Internal ObliqueOrigin:• Thoracolumbar fascia• Anterior 2/3 of the iliac crest• Lateral 2/3 of the inguinal ligament
Insertion: • Lower 3rd or 4th ribs• Linea alba• Pubic crest
Nerves:• Intercostal nerves 7‐11• Subcostal, iliohypogastric and ilioinguinal n.
Action: • Trunk flexion and lateral flexion
Inner Core
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Inner Core
• Deep hip rotators
• Piriformis
• Obturator internus
• Gemilli brothers
• Superior and inferior
Inner Core
• Multifidi
• Origin: sacrum, erector spinae aponeurosis, PSIS, iliac crest
• Insertion: spinous process
• Actions: bilateral trunk extension, unilateral side‐bending, contralateral rotation
• Proprioceptive feedback
https://upload.wikimedia.org/wikipedia/commons/thumb/4/4f/Multifidi.png/250px‐Multifidi.png
Inner Core
• Diaphragm
http://www.todayifoundout.com/wp‐content/uploads/2010/06/19072.jpghttp://www.mananatomy.com/wp‐content/uploads/2011/01/diaphragm.gif
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Reflection MomentWhat are the outer core muscles?
Outer Core
• Core (Akuthota et al 2008)
• “Group of trunk muscles that surround the spine and abdominal vicera”
• Outer core predominance fast twitch fibers, “global” vs “local”
• Rectus abdominis
• External obliques
• Erector spinae
• Quadratus lumborum
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Rectus abdominus
Origin: Anterior pubis
Insertion: Cartilages of ribs 5‐7, Xiphoid process of sternum
Nerves: Intercostal nerves
Action: Flexes lumbar spine
• Active during expiration
• Maintenance of abdominal tone
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Abdominal muscles
transverse section of the anterior abdominal wallRectus abdominus is surrounded by sheaths both anteriorly and posteriorly
sheaths are formed by the aponeuroses of the EO, IO, TA muscles • EO aponeurosis anterior to the rectus abdominus• IO aponeurosis splits and passes in front and behind (anterior and posterior) to the rectus abdominus• TA aponeurosis passes behind (posterior) to the rectus abdominus
Dynamic Core Stabilization Inner and Outer Core
• Core
• Muscular box
• 29 pairs of muscles stabilize spine, pelvis and kinetic chain
• Proper force distribution with minimal
• Compressive
• Translational
• Shearing forces at the joints of the kinetic chain
39Akuthota et al 2008
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Dynamic Core Stabilization Inner and Outer Core
• Proximal stability allows distal mobility
• Clinical instability (Panjabi, 2003)
• No neurological deficit or major deformity or incapacitating pain
• Vs. mechanical instability
40Akuthota et al 2008
Dynamic Core Stabilization Inner and Outer Core
Overflow of Internal to External Core
• EMG studies (of PF contraction supine)
• Lumbar flexion—increased external oblique (EO)
• Lumbar extension—increased transversus abdominus (TA) over rectus (RA) or EO
Dynamic Core Stabilization
Lee & Hodges 2003http://image.slidesharecdn.com/corewillitsurvive‐13542664368022‐phpapp01‐121130033054‐phpapp01/95/core‐will‐it‐survive‐48‐638.jpg?cb=1354486308
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Integrated Model of Function
http://www.nydnrehab.com/wp‐content/uploads/2013/10/6248711.png
Form Closure
Integrated Model of Function
• Force Closure
• Muscle function
• SIJ stiffness (van Wingerden JP & Vleeming A 2003)
• Increases during voluntary isometric contractions (EMG)
• Biceps femoris
• Gluteus maximus
• Erector spinae
• Contralateral latissimus dorsi
Integrated Model of Function
http://www.fisiobrain.com/userimages/Il%20bacino_Page_2_Image_0001.jpg
Form + Force Closure
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Integrated Model of Function
• What happens when your inner core is weak?
• Compensation, outer core
• Movers not stabilizers
• Splinting occurs
• Muscle spasms, neural compression, pain
Integrated Model of Function
• Force closure and concept of muscle slings• What are muscle slings?
• Slings• Primary (internal, local or anticipatory core )
• External (global or reactive core)
• Anterior Oblique
• Posterior Oblique
• Longitudinal
• Lateral
http://cfile27.uf.tistory.com/image/17337D364E2927801F9B32
Integrated Model
of FunctionMuscle Slings
• Posterior•Lat dorsi, thoracolumbar fascia (TLF), glut max
• Anterior•EO, abdominal fascia, contralateral adductors
• Lateral•Glut med/min, TFL , lateral stabilizers of the thoracopelvic region
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http://i1171.photobucket.com/albums/r549/yingbin_poh/MyofascialSLings.jpg?t=1349075262
Integrated Model
of Function•Anterior Oblique
•Posterior Oblique
•Posterior Longitudinal
•Primary (local)
Notice an error in this diagram?
Integrated Model
of FunctionForce Closure
• Anatomy Trains (Myers T 2014)
• Many myofascial sling systems
• Superficial and deep
http://ecx.images‐amazon.com/images/I/51J6c7ZuYaL._AA160_.jpg
Pelvic Rotator CuffWhat is it? • Muscles • Analogies
http://upwardspiral.co.uk/wp‐content/themes/OptimizePress/timthumb.php?src=http://upwardspiral.co.uk/wp‐content/uploads/2013/02/rotatorcuffpopeye.png&h=200&w=200&zc=1
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Pelvic Rotator Cuffby Janet Hulme
•What is it?
•Who here uses it?
•What muscles are in the PRC?
http://phoenixcoresolutions.com/uploads/images/Products/Books/Big%20Images/book_pelvic_rotator_cuff.jpg
Pelvic Rotator Cuff
•Obturator internus
•Pelvic diaphragm
•Urogenital diaphram
•External urinary & anal sphincters
•Hip adductors
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Pelvic Rotator Cuff
• Acts synergistically
• TA, multifidus, lumbo‐pelvic fascia
• Balance needed
• Excessive EO, RA>PF
• PF descends
• Toothpaste analogy
• Excessive abdominals>>pelvic floor
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Pelvic Rotator Cuff
Pelvic Rotator Cuff
Analogies
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Pelvic Rotator Cuff
• Must function properly to support the pelvic rotator cuff
• Breathing diaphragm
• Latissimus dorsi/contralateral glut max
• Abdominals (especially TA)
• Gluteals
• Multifidus
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http://a2.mzstatic.com/us/r30/Purple5/v4/98/ba/0a/98ba0aa9‐4e53‐eb4a‐2695‐fa1876a6ab0d/icon128‐2x.png
Core strengthening candidates
• Postpartum
• Positive prone instability test
• Aberrant movement during trunk ROM
• Positive • Thigh thrust test
• Active straight leg raise test
• Long dorsal sacroiliac ligament
• Pubic symphysis region
• Trendelenburg sign
• Long hamstrings, greater than 90
Akuthota 2008
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Activating the CoreInner Core Movement Patterns
https://community.landesk.com/support/servlet/JiveServlet/showImage/102‐11662‐2‐18559/RUActivate.JPG
LabActivating the core
Dynamic lumbar stabilizationOther therapeutic exercise
http://cdn.0‐6packabs.com/wp‐content/uploads/0‐6‐Pack‐Abs‐Sales‐Image‐Basic‐Core‐Activation‐1024x491.png
Activating the Core
• Posture considerations• Rib cage over the pelvis posture (Lee 2011)
• Diaphragm
• Numerous studies looking at function (Hodges 2000, 2007)
• Upright unsupported posture (Sapsford et al 2008)• Increased resting PFM activity
• Short lordosis posture (Claus et al 2009)
• Increased multifidus, IO
• Vs slump and flat lumbar posture
• Low activity of multifidus, IO
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Activating the Core
• Piston action of inner core (Hodges et al 2000)
• Diaphragm descent
• Lengthening of abdominals
• Pelvic floor dropping
• Reverse on ascent/exhale
• How would you teach this exercise?
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Activating the Core
Progressions
• Stable symmetrical
• Asymmetrical
• Mobility
• Agility
Activating the Core
Concepts
• Neutral pelvis, rib cage
• Exhale with effort
•Watch for substitution patterning (poor movement strategies)
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Down‐Trainingvs
Up‐Training
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Activating the Core
Awareness of substitution patterning
• Flare of rib cage, weak EO
• Overactive rectus, mounding
• Arching low back, hyperactive erector spinae
• Lifting of buttocks when prone‐‐hip flexor tightness
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Down‐Trainingvs
Up‐Training
Reflection Moment
What should you consider regarding your patient’s position when teaching
beginning core exercise?
Activating the Core
Static• Supine (knees straight or bent, hips over wedge for very weak PF)
•Diaphragmatic Breathing/umbrella imagery
•PF activation (stop gas/urine) with exhale (HISS)
•TA•Zip up tight jeans
•Drawing in maneuver
•Blow up balloon
•Repeat in prone, 4 point, ½ kneel, standing
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Activating the Core
Static• Repeat in prone, 4 point, ½ kneel, standing
•Diaphragmatic Breathing/umbrella imagery
•PF activation (stop gas/urine) with exhale (HISS)
•TA•Zip up tight jeans
•Drawing in maneuver
•Blow up balloon
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Activating the Core
Dynamic
Down‐Trainingvs
Up‐Training
Challenging the core with movement
•Supine
•Alternate arms
•Stretching of latissimus/pectorals
•Alternate knee lifts •May need to modify
•Rocking of pelvis
•Instability indicated
•Combine opposite arm and leg, alternate
Activating the Core
Dynamic
Down‐Trainingvs
Up‐Training
Challenging the core with movement
•Alternate knee lift modification
•Heel slides
•Bent knee abd/adduction
Activating the Core
Dynamic
Down‐Trainingvs
Up‐Training
Challenging the core with movement
•Alternate knee extension
•SLR
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Core Strengthening from the Inside/Out 3/25/2017
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Activating the Core
Down‐Trainingvs
Up‐Training
•Prone (pillow)
•Glut sets with core activation
•Closed chain hip extension
•Alternate arms
•Alternate arm/legs
Dynamic
Activating the Core
Down‐Trainingvs
Up‐Training
Dynamic•4 Point
•Alternate arms
•Alternate arms/legs
Activating the Core
Down‐Trainingvs
Up‐Training
Dynamic•½ kneel
•Balance
•Alternate arms
•Trunk rotation
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Activating the Core
Down‐Trainingvs
Up‐Training
DynamicChallenging the core with movement
•Standing •Alternate arms
•Thera‐band
•Body Blade
•Standing balance on BOSU
Activating the Core
Higher Level
Down‐Trainingvs
Up‐Training
•Plank on elbows
•Knees
•On toes
Activating the Core
Higher level
Down‐Trainingvs
Up‐Training
•Side plank
•On knees
•On feet
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Activating the Core
Higher Level
Down‐Trainingvs
Up‐Training
•Single leg bridge
•4 point alternate arm/leg balance
Activating the Core
Agility/balanceWhole body movements
• In place lunges, forward, side, back
• Moving forward lunges and side squats with coordinated arm movements/breathing
• High stepping, hand to opposite heel while moving
Is your core activated?
https://s.yimg.com/fz/api/res/1.2/cRE23jtno1LdtogKSeYQFg‐‐/YXBwaWQ9c3JjaGRkO2g9NjQ0O3E9OTU7dz03OTU‐/http://1000awesomethings.files.wordpress.com/2009/10/question‐marks.jpg?w=795
Questions??
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Reflection MomentWhat else besides core?
• Key muscles to stretch?
• To strengthen?
Other Therapeutic Exercise
Targeted stretching
• Muscle groups• Hip rotators (IR and ER)• Hamstrings• Hip flexors/quads• Hip adductors• Lumbar spine• Gastrocnemius• Latisimus• Pects• Scap depressors/retractors
Other Therapeutic Exercise
• Dynamic vs. static stretching (Behm et al 2011) • Dynamic stretching shown to have no negative effect, may augment
performance• Positive response to neuromuscular system
• Static stretching• Not before strengthening, high speed, explosive or reactive activities• Important to include to increase ROM/flexibility, post‐exercise or separate
session
• Sensory theory suggested sensory endpoints important (Weppler et al 2010)
• How it feels
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What are we working on in this exercise?
What are we working on in this exercise?
Other Therapeutic Exercise
Targeted Strengthening
• Gluteus medius• Primary role as SIJ stabilizer
• Which exercise had the highest EMG activity for gluteus medius all portions?
O’Sullivan K et al 2010
Unilateral wall squat
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912252/bin/1758‐2555‐2‐17‐2.gif
Pelvic drop
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912252/bin/1758‐2555‐2‐17‐3.gif
Wall press
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912252/bin/1758‐2555‐2‐17‐4.gif
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Other Therapeutic Exercise
Targeted Strengthening
• Wall press highest activation for all divisions
• Posterior most activated
O’Sullivan K et al 2010http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912252/bin/1758‐2555‐2‐17‐4.gif
Wall press
Other Therapeutic Exercise
• Gluteus medius
• Lateral step‐up exercises vs. forward step‐up?
• Lateral step‐up vs. side‐lying abduction?
• Increased glut med EMG activation lateral step up
Mercer 2009
Other Therapeutic Exercise
• Resisted side stepping (bands)
• Which leg had increased EMG activation? Stance or non‐stance?
• Upright vs with squat, when is TFL most active?
• When is glut max more active?
• Stance leg increased EMG
• With squat increased glut max, decreased TFL
Berry et al 2015
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Other Therapeutic Exercise
• Gluteus medius (Yoo 2014)• Case study: 32 year old woman with left SIJ dysfunction
• Strengthening all portions of gluteus medius
• + special tests
• Gaenslen, Patrick and REAB (resisted abduction)
• All special tests negative at end of 3 weeks
• Side‐lying left abduction (anterior)
• Wall press (mid)
• Pelvic drop (posterior)
• 3 sets of 30 reps/day
Other Therapeutic Exercise
• Gluteus maximus (Barker 2014)
• Generates compressive forces at SIJ
• Cadaver dissection (n=11)
• Originated from gluteus medius fascia, ilium, TLF, ES aponeurosis, sacrum, coccyx, dorsal SIJ ligament and sacrotuberous ligament (all specimens 11)
• 70% fibers crossed SIJ
• Assists effective load transfer
Other Therapeutic Exercise
• Gluteus maximus (Stevens et al 2006)
• EMG studies of 4 point exercises normal/healthy
• Single leg and arm/leg
• Highest relative muscle activity
• Ipsilateral
• Multifidus (MF)
• Gluteus maximus
• EO
• Contralateral
• IO
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Other Therapeutic Exercise
• Gluteus maximus• Generates compressive forces at SIJ (Barker 2014)
• EMG studies of 4 different glut max exercises prone (Sakamoto 2009)• Prone hip extension
• Knee extension
• Knee flexed
• Lateral hip rotation with knee extension
• Lateral hip rotation with knee flexion
• WHAT DO YOU THINK?
Other Therapeutic Exercise
• Gluteus maximus
• Increased gluteus maximus EMG
• Prone hip extension with addition of knee flexion or lateral rotation
• Decreased semitendinous activity
Sakamoto 2009
Summary
• Core strengthening is well accepted to be crucial to optimal functioning
• There is a wide variety of approaches to core strengthening
• Evidence supports isolated muscle training to improve muscle onset timing, especially for the transversus abdominus
• Evidence supports anticipatory inner core muscle activation prior to extremity movement
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Summary
• Normal inner core functioning is a balance between the diaphragm, pelvic floor, transversus and multifidus in a rhythmic piston action in normal functioning
• Muscles work in slings
• We can move in compensatory patterns with or without pain
• Impaired hip strength has been identified in people with low back pain
Summary
• In people who have signs or history of inner core weakness address the inner core before progressing to higher level core work in a logical systematic order to prevent injury and achieve optimal results
Core strengthening from the Inside Outsm!
Thank You!