Core Stability Current Concepts - PAC Rotterdam · Development of clinical assessment of stability...

Core Stability Current Concepts

Implications to the Prevention and

Management of Lumbopelvic Dysfunction

2007 Dutch Congress of Sports Physiotherapy

Michael Nicol

www.performance-stability.com

Objectives

• Overview of Core Stability definitions

• Review of evidence for Movement Screening

• Outline of Performance Matrix and

implications to lumbopelvic dysfunction

• Application to clinical practice


Integration of Current Theory

Kinetic Control:� Systematic analysis of movement and function� Evidence based

� Development of clinical assessment of stabilitydysfunction (based on low trheshold recruitment

efficiency)� Diagnosis of movement dysfunction

� Development of principles of stability training� Local & global motor control testing & Rx

� Clinical reasoning led exercise prescription� Integrated 'Core Stability' retraining

� Application of Ax & Rx to the whole body

Performance Stability:� 'Performance Matrix' (evidence based)� Assessment of low & high force

performance function� Systematic analysis of performance

'weak links'� Development of risk management

(assessment and correction)� Integrated multi-dimensional core stability

training� High standard training and accreditation

Stretching & Strengthening(Historical Developments)

Sahramann:

global

- whole body

Janda:

global

- trunk & limbs

Muscle Balance:

Restrictions & Compensation

'Traditional' Strengthening:

overload training

- power & endurance

'Core' Strengthening:

(McGill)

overload training

- trunk & girdles

Task Specific Training& Functional Integration

Analysis of

'Alternative' Therapies

& Approaches

Motor Control Research

& Training Model:

(Hodges,Jull, Richardson)

- local spinal control

- global trunk stability

Kinetic Control:

- research literature review

- analysis & development of

movement system model

- research

- clinical evaluation &

application

Model of Clinical Movement Analysis &

Movement Dysfunction Diagnosis

- Sahrmann (Direction Susceptible to Motion)

Kinetic Control (Site & Direction of Uncontrolled Motion)

- O'Sullivan & Dankaerts (Control Impairment)

Flexibility:

- contractile tissue

- connective tissue


Core Stability Overview

isotonic

(concentric)

Any position/

flex-ext plane

(Rot eliminated)

global

mobiliser

High

40-100% MVC

Symmetrical

Limb Loading ‘Traditional’Strengthening

isometric & isotonicisometric & isotonic

(eccentric)

isometricType of

Contraction

neutral core/

rot resist

rot thru ROM

(Rot challenged)

neutral core/

dissociation all 3

planes

neutral position/

No direction

Position /

Direction of

10 Loading

global

stabiliser

global

stabiliser

local

stabiliser

Dominant

Muscle Role

High

40-70% MVC

Low

<40% MVC

Low

<25-30% MVCActivation

Threshold +

Recruitment

Asymmetrical

Trunk Loading

‘Core’ Strengthening

Global Control

Global dominant recruitment

Local Control

Specific local recruitment


Local →→→→ Global Function

• The local muscle system is responsible for controlling translation

� increasing segmental stiffness & controlling

excessive inter-segmental motion

• The global muscle system is responsible for controlling and producing range of motion

� movement production & control of high physiological loads

• Both local & global systems must integrate efficiently for normal movement function


What is Core Stability?


Core Stability Is:

Motor Control

of Low Load

Tasks

Minimal Transversus

contraction in

unloaded function

Symmetrical High

load weight lifting

in saggital plane

Asymmetrical

trunk loading

at high load

Complex task

or sport specific

skill training


Core Stability Is:

Motor Control

of Low Load

Tasks

Minimal Transversus

contraction in

unloaded function

Symmetrical High

load weight lifting

in saggital plane

Asymmetrical

trunk loading

at high load

Function

Evidence for Movement Screening?


Pre-Participation Screening

• Mandatory in elite & professional sport

• Commonplace in competitive sport

• Occasionally at junior levels

• Even crossing into pre-employment

screening in the workplace


Evidence

There is almost no reliable evidence base to

support the use of screening for physical

factors to either predict risk of injury or to

prevent injury in the systematic review or

meta-analysis databases

However…


Acceptance

There is universal acceptance and support to assess or screen for physical factors from allstakeholders in sport:

� Players / competitors

� Coaches

� Sports medicine professionals (doctors, physios, trainers)

� Family

� Administrators

� Sponsors

� Insurers


Discrepancy

• Why does this discrepancy exist?� Assumptions and misguided beliefs prevail

� Too hard to prove− too many variables

− complex variables can’t be measured

− low incidence (cohort studies not easy)

� Wrong outcomes being measured− poor design of studies

� Looking at the wrong physical factors− body is designed to adapt

− isolated testing of muscles & joints is not functional

� Costly


Evidence

• The evidence is strong for a history of

previous injury predicting injury(Watson 2001, Parkkari et al 2001, Schwellnus 2004, Locke 2006)


Evidence

Predictors of acute muscle injury:

− previous recent muscle injury

− history of past muscle injury

− ↑ age

− ↓ eccentric muscle strength

− ↑ training load

• Predictors of chronic muscle injury

− History of previous muscle injury(Schwellnus 2004)


Evidence

• There is strong evidence linking motor

control deficiencies in deep (force inefficient)

local stability muscles controlling inter-

segmental movement to pain and recurrence(Hodges et al 2006, Moseley & Hodges 2006, Richardson et al 2004,

Jull 2000, Sterling et al 2005)

• The evidence to support assessing local

stability muscles as part of routine screening

is poor …unless there is a previous history

of pain in that region


Evidence

• The evidence for imbalance in muscle

antagonist to agonist force ratios

contributing to injury risk is moderate(Garrick 2004, Cameron et al 2003)

• There is strong evidence linking motor

control deficiencies in the control of

direction related load to provocative

movement direction(Janda 1996, Sahrmann 2002, Comerford & Mottram 2001, Falla et al

2004, O’Sullivan 2005, Dankaerts et al 2006, O’Sullivan et al 2006)


Evidence

• The evidence is strong that stretching does

not prevent injury(Pope 1999, Thacker et al 2004)

• The evidence for general muscle strength

training preventing injury is poor(Cameron et al 2003, Schwellnus 2004)

• The evidence is moderate for high levels of

aerobic fitness preventing injury (Gabbett et al 2004, Pope 1999)


Evidence

There is evidence to support that problems in

one part of the body are compensated for at

other sites within the chain of linked joints

� Previous hamstring or calf injuries predispose to

a 4 times increased risk of low back pain

� Previous back pain predisposes to an increased

risk of lower limb injury(Locke 2006)

Development of an

Assessment Tool


Dynamic Stability Dysfunction (‘GIVE’)

It is associated with:

• maladaptive control of the

trajectory or path of motion

Motion that is poorly controlled defines stability dysfunction (‘Weak Link’ or ‘Give’)

‘GIVE’ or ‘Weak Link’ = Uncontrolled motion

within normal or hypermobile range


‘Weak Link’ = Uncontrolled Movement

It is defined by:

• The site of uncontrolled motion

• The direction of uncontrolled motion

� relates to the direction of tissue stress or

strain and therefore to the direction of pain

producing movements

� determines a mechanical subgroup of

movement dysfunction


Implications to lumbopelvic dysfunction

Direct

• Facet jt injury

• SIJ

• Disc Prolapse

• Groin injury

Indirect

• Medial Knee pain

• ACL Tears

• Shoulder dysfunction


Functional testing for

altered control strategies

• In normal function, global & local stability muscles have integrated patterns of multidirectional recruitment

• Normal function rarely:

� eliminates movement from one joint system

� moves in only one plane


Dissociation: Control of the ‘Weak Link’ Direction

• Performance of unfamiliar movement

patterns is a test of motor control efficiency

� Dissociation:− co-activate stability muscles to isometrically prevent

movement at one joint system (control the site & direction

of weak link)…

− while concurrently moving in a specific direction at

another joint system

… everybody has the ability to learn and perform patterns of

movement that are not habitually used in ‘normal function’


History Predicts Recurrence

• Since the evidence points to the history of injury

as a predictor of high risk of re-injury

…Then clearly there is a problem in the way that we

manage the previous injury

• Perhaps the outcomes of:

� asymptomatic function

� normal range of joint motion (isolated testing)

� normal muscle strength (isolated testing)

are not adequate to prevent recurrence!


Assess ‘real’ not isolated function

• Assessing the control of ‘real’ function must

consider the influence of :

� multiple muscle interactions (synergists & antagonists)

� multiple joints linked in functional movement

� functionally orientated tasks

� low & high threshold environments

• Universally put in the ‘too hard’ basket


Objective

…to develop an integrated

assessment and retraining process for

performance related movement issues

‘find and fix the weak links in the

functional performance chain’


Performance Matrix: unique features

• Tests efficiency of movement (motor control)

• Functional multi-joint tasks to identify the

uncontrolled joint in a chain

• Functionally orientated generic tasks

• Screens for both motor control (low

threshold) and core strength (high threshold)

deficiencies

• Identifies performance assets (fast tracking)

Case Review


Athlete

• 28 yr old male footballer

• Currently ¾ of the way through the season,

in full training and playing matches

• Has two year Hx of SIJ related pain

• This season he has had three bouts of SIJ

pain requiring min 2 weeks out of training

• Has ongoing mechanical problems that are

effectively treated by club medical team


Athlete

• Athlete is leading member in squad in most

club fitness tests of strength and speed

• Previous rehab has addressed core strength

using plank and side plank exercises

• Also TVa and Multifidus activation exercises

provided at the beginning of the season


Case review

• Rehab reviewed in relation to 4 subgroups

• Traditional Strength not a concern

• Asymmetrical trunk load training has not

sufficiently addressed rotation

• Poor global motor control (Ext and Rot)

• Local control exercises must be readdressed

Local Control

Specific local recruitment

Global Control

Global dominant recruitment

Asymmetrical

Trunk Loading

‘Core’ Strengthening

Symmetrical Limb

Loading ‘Traditional’Strengthening


Summary

• 4 key core stability categories

• Screening vital for injury prevention, athletic

preparation and rehabilitation

• Lack of evidence supporting current

screening techniques

• Performance Matrix identifies site, direction

and threshold of weak links


Reference List

• Comerford M J, Mottram S L 2001 Movement and stability dysfunction – contemporary developments. Manual Therapy 6(1):15-26

• O’Sullivan PB, Twomey L, Allison G 1997 Dysfunction of the neuro-muscular system in the presence of low back pain - implications for physical therapy. Journal of Manual and Manipulative Therapy 5(1):20-26

• O’Sullivan PB, Twomey L, Allison G 1997 Evaluation of specific stabilising exercise in the treatment of chronic low back pain with radiological diagnosis of spondylosis or spondylolisthesis. Spine 22(24):2959-2967

• Hides J A, Jull G A, Richardson C A. 2001. Long term effects of specific stabilizing exercises for first episode low back pain. Spine 26(11):243-8.

• Danneels L A, Vanderstraeten G G, Cambier D C, Witvrouw E E. 2001. Effects of the three different training modalities on the cross sectional area of the lumbar multifidus muscles in patients with chronic low back pain. British J Sports Med 35:186-91.

• Janda V 1996 Evaluation of muscle imbalance. In: Liebenson C (eds) Rehabilitation of the Spine Williams & Wilkins, Baltimore

• Sahrmann S A. 2002. Diagnosis & Treatment of Movement Impairment Syndromes. Ist ed. Mosby, USA.

• Goldspink G, Williams PE 1992 Muscle fibre and connective tissue changes associated with use and disuse. In: Ada L & Canning C (Eds.) Key Issues in Neurological Physiotherapy. Butterworth Heinemann.

• Norris, CM, 1999 Functional Load Abdominal Training. Journal of Bodywork and Movement Therapies.


Bibliography

• Tranversus Training - a Waste of Time in the GymScott M, Comerford MJ, Mottram SL, FitPro Network, April / May 2006, p30-32 www.performance-stability.com

• Hides J A, Richardson C A, Jull G A 1996 Multifidus recovery is not automatic after resolution of acute, first-episode low back pain. Spine 21(23): 2763-2769

• Hodges P W 1999 Is there a role for transversus abdominis in lumbo-pelvic stability? Manual Therapy 4(2): 74-86

• Mottram S L, Comerford M 1998 Stability dysfunction and low back pain. Journal of Orthopaedic Medicine 20:2 13 – 18

• Richardson C A, Snijders C J, Hides J A. 2002. The relationship between the transversus abdominis muscles sacroiliac joint mechanics and low back pain. Spine 27(4):399-405.

• Sahrmann S A. 2002. Diagnosis & Treatment of Movement Impairment Syndromes. Isted. Mosby, USA.

• McGill, S. 2000 Low Back Disorders – Evidence based prevention and rehabilitation

Core Stability Current Concepts - PAC Rotterdam · Development of clinical assessment of stability...

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