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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
www.performance-stability.com
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
www.performance-stability.com
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
www.performance-stability.com
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
www.performance-stability.com
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
www.performance-stability.com
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
www.performance-stability.com
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
www.performance-stability.com
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…
www.performance-stability.com
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
www.performance-stability.com
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
www.performance-stability.com
Evidence
• The evidence is strong for a history of
previous injury predicting injury(Watson 2001, Parkkari et al 2001, Schwellnus 2004, Locke 2006)
www.performance-stability.com
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)
www.performance-stability.com
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
www.performance-stability.com
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)
www.performance-stability.com
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)
www.performance-stability.com
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)
www.performance-stability.com
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
www.performance-stability.com
‘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
www.performance-stability.com
Implications to lumbopelvic dysfunction
Direct
• Facet jt injury
• SIJ
• Disc Prolapse
• Groin injury
Indirect
• Medial Knee pain
• ACL Tears
• Shoulder dysfunction
www.performance-stability.com
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
www.performance-stability.com
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’
www.performance-stability.com
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!
www.performance-stability.com
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
www.performance-stability.com
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’
www.performance-stability.com
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)
www.performance-stability.com
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
www.performance-stability.com
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
www.performance-stability.com
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
www.performance-stability.com
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
www.performance-stability.com
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.
www.performance-stability.com
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