Dr satbir singh , sports medicine

consultant
IMPORTANCE OF CORE:
 Core muscle act as- bridge between upper
and lower limbs

Force is transmitted from the core(POWERHOUSE)

to the limbs

Thus provides correct postural alignment and a

strong foundation to the body for effective
force production
(ACC/O AMERICAN COLLEGE OF SPORTS MEDICINE-,JUNE 2005, Vol.4 ,
Issue 3.p 179-183;studies have demonstrated a relationship between
core stability and increased incidence of injury)
Aim of core training :
 Effectively recruit the stabilizers of body muscular
system

 Learn to control position of lumbar spine and

extremities during dynamic movements

 Improve load handling ability of the spine which

trains the body to work in a more biomechanically
efficient way.
Pyramid of performance :
1.THORACOLUMBAE FASCIA(TLF)-

 Provides tensile support to the lumbar spine via deep trunk

muscle activity.

 Transverse abdominis(TA) and internal obliques(IO) both attach

to the TLF,

 This fascia wraps around the spine, connecting deep muscles

to it,

 As TA contracts-it increases tension in TLF- which transmits

compressive force to the lumbar spine- enhancing its stability,

 Also the increased tension of TLF compresses erector

spinae(EP) and multifidus(MF) muscles,encouraging their
contraction and resisting spinal flexion forces.
2.INTRA ABDOMINAL PRESSURE(IAP)-

 IAP mechanism can provide supportive effect for the whole lumbar
area

 Co-contraction of pelvic floor+TA+IO+Low back muscles increases

IAP,which exerts tensile forces on rectus sheath,

 This sheath encloses the rectus abdominis muscle and attaches to IO

and TA,surrounding the abdomen,

 Tension on sheath increases pressure within abdomen like a

pressurized balloon,

 This supportive “bag of air” reduces compression and shear forces

acting on the spine

Researches show that IAP increase before and during weight lifting
activities , Zatsiorski (1994). Science and practice of strength training
(1994;human kinetics.champaign. And also during running
international Journal of Sports Medicine, 1(4), November 2000 thus
suggesting that this mechanism plays crucial role in lumbar stability
 PARASPINAL MUSCLES -

 Interspinalis and intertransverserii

 These provide an individual stabilizing effect on there
adjacent vertebrae, acting like ligaments.

DEEP LUMBAR MUSCLE-

 Multifidus(MF)
 Has been shown to be active throughout a full ROM of
lumbar spine and during movements of upper limb and lower
limb (spine.21,2763-2769.)
Relevant anatomy:
(1) MULTIFIDUS

inferior attachment=from transverse process of thoracic

vertebrae

superior attachment=fibres run superiorly and medially

between transverse process and
spinous process, inserts along length
of spine

*most superior fasiculi-one vertebra to 3rd/4th

* intermediate-one vertebra to 2nd/3rd above
*deepest-connects adjacent vertebrae
MULTIFIDUS
(2)TRANSVERSE ABDOMINIS
superior attachment-costal cartilage of lower 6 vertebrae
-interdigiting with diaphragm,TLF,
between iliac crest and 12th rib
inferior attachment-pubic crest,
-apponeurosis that fuses with internal
oblique

*it is innermost of the three abdominal muscles.

Abdominal muscles
 INNER UNIT  OUTER UNIT
functional synergy between
-rectus abdominis
-transversus abdominis -erector spinae
-post. fibers of internus -external obliques
obliques
-psoas
-pelvic floor muscle
-multifidus
-lumbar portion of
longissimus, iliocostalis
-diaphragm
 COMPARING CORE TO A SHIP :

large guy wires (outer unit) support the mast of the ship, but its functionality is
dependent upon the support provided by small guy wires (inner unit).
 Internal oblique
*internal oblique muscles of the deep
core

*located beneath external oblique

and above TA.

*acts as antagonist of diaphragm

Abdominal Muscles - The External Obliques

Abdominal Muscles - The Internal Obliques

TRANSVERS ABDOMINIS:
Function-narrows waist,
-flattens abdomen
-stabilizes low back and pelvis
before movement of arm/legs
can occur.

When healthy;TA can anticipate motion,

thus we use imagery in our core training.
Factors causing delay in TA activation:
1. Low back pain
2. Abdominal injury/surgery
3. Excessive lengthening(pregnancy)

Cause delay/absence in anticipatory

contraction of TA.

If TA dysfunction not corrected, this delay

will remain even after pain subsides.
Steps for retraining TA:

STEP 1 = Isolation of TA
STEP 2 = Strengthen the co-activated core
STEP 3 = Incorporate into other activities
Step 1 – *lie on your back, maintain neutral spine

*utilize imagery,e.g. imagine a line connecting the inside of both

hip bone,think about connecting along this line.

*breathe in and on breathe out contract TA with the help of image

*isolated contraction will feel like light deep tension under

fingertips

*continue the contraction without holding breathe

*watch out for substitution strategies-posterior pelvic tilt,breathe

holding,bulging of abdomen,depression of rib cage
Step 2 –

*after successfully isolating TA,and practising it in various

positions,progress to this step.

*proper breathing pattern should be used to coordinate muscle

activity.

*in side lying while maintaining core contraction

-lift top knee(inner thigh outward) with ankle kept

together,return to starting position
-lift top knee,then lift top ankle,then return to starting position
-lift top knee,ankle and extend leg,then flex leg,then return
to starting position
*Crook lying:

-slowly move right leg to right,keeping low back and

pelvis stable,return to centre,repeat with left

-slide right foot into knee extension,slide back to

flexion,do not lift foot.repeat with left.

-lift right foot off the floor keeping knee bent,return and
repeat with other foot.

-lift the foot,extend the leg while maintaining TA

contraction,return to starting position,repeat with
other side.

-lift right foot off the floor,then left foot off the
floor,alternate leg extension,exert with
exhalation,breathe in to rest/hold.
Step 3 –

*use core during regular routine activities.

*getting up from chair,lifting,bending or

reach activities all should be performed
while using core muscles.

*goal is to teach body to resume normal

stabilization strategy of connecting to
the core BEFORE movement begins.
 MULTIFIDUS:
Function – it works together with TA, pelvic
floor muscles to low back and
pelvis before movement of arm
and leg occurs.
- it extends the spine.

Can anticipate motion,so activation training

comes before strengthening.
Step 1 –*side lying with spine in neutral, palpate MF(felt at
gutter area just adjacent to the spine)

*Imagine a line running from inner side of thigh-to groin-

through pelvis-till the finger placed over spine.

*contract MF using imagery,

*It should feel like slow, firm swelling(like balloon filling up)
beneath finger tips.

*hold contraction, continue breathing.

*substitution can occur by-anterior pelvic tilting, hip

flexion,gluteal contraction.
Step 2 –

*Practice isolation in various positions

*After activating easily progress to co-

contractions with TA,pelvic floor muscles in
following manner;

*In side lying-keep ankles together, move top

knee as high as you can

- lift ankle and knee both

-lift ankle,knee,perform leg flexion-extension

Step 3 –

*Incorporate into other activities

*Utilize this activation pattern while performing

various ADLS,so that body can adapt to
training in function.
 According to “Panjabi” The ligaments’ main
influence comes at the end range of the
movement within the joint. In the mid-range of
the joint, what Panjabi calls the neutral zone,
the action of muscles would be necessary to
maintain the joint’s stability.

 The length of fibers of the stabilizers does not

change very much over the course of a
movement. Instead they remain consistently
short to hold the joint in its neutral zone
(before the end range where the ligaments get
involved), to help it keep its integrity while it is
handling load or doing larger motion.

Panjabi, M, The stabilizing system of the spine, Part 1 and 2.

Journal of Spinal Disorders 5:383-397 1992
The deep postural muscles The prime movers bend
pull the vertebrae into axial the joints as they contract, usually
compression. generating joint motion.
Global muscles and local muscles:
 Local muscles are usually deeper and closer to the
joint than the muscles involved in moving the joint,
the global muscles.

 Local muscles also often attach directly to the joint

capsules. Richardson,1999. p.81
 Global muscles are more superficial and tend to be
larger. They are responsible for transferring and
balancing external loads and for bigger movements.

 The local muscles’ length changes very little and

thereby does not have a big impact on the actual
movement of the joint. The job of local muscles is
primarily to stabilize the joint while the other muscles
do the moving.
Two muscles have been identified as primary
stabilizers of the low back: lumbar Multifidus and
Transversus abdominis.

The responsibility of these deep support muscles--

Transversus abdominis and lumbar Multifidus--is not
to move the spine, but to stabilize it so that other
muscles can move the trunk without compromising
the integrity of the joints.

For the lumbar spine, Transversus and lumbar

Multifidus are examples of local muscles. Rectus
abdominis and the external obliques are examples of
global muscles
The role of lumbar Multifidus and Transversus in low
back pain rehabilitation(RESEARCH)
Carolyn Richardson and her colleagues in Australia investigated the role of
these muscles in back pain and healthy patients, the researchers found that
only 10% of those with a history of low back pain could activate the
transversus abdominis, compared with 82% of the non-low-back-pain
subjects. They found that patients who performed exercises that specifically
targeted the Transversus abdominis over the course of 10 weeks
experienced a significant decrease in pain and an increase in functional
ability compared to the control group which received conventional treatments
such as swimming, workouts and sit-ups.

.
At the 30 month follow up, the improvement had been maintained As for
the Multifidus, it was found that in patients with back pain, the size of the
muscle was reduced at the segment and on the side of the pain.

The studies found that when the size of the lumbar Multifidus had been
increased through specific exercises, there was a significantly lower
incidence of recurrence of low back pain episodes.
LYING LEG LIFT STABILIZATION:
 Lying on your back with your knees bent
 Ensure your back is in neutral
 Place your hands on your hips for biofeedback
 Breathe in and relax
 Breathe out and, as you do so, perform the
abdominal hollowing
 Once you have established some TA tension, slowly
slide your left leg out along the floor until it is straight
and then slide it back
 Your back should not have moved, and your pelvis
should not have tilted as you performed this action
 If your back or pelvis moved, you did not achieve the
correct stability
 Repeat for the other side 10 times each leg
THE WAITERS BOW :
 Stand up with good posture, knees soft, lumbar
spine in neutral, head up and shoulders back and
relaxed
 Breathe in and relax
 Breathe out and as you do so perform the abdominal
hollowing action
 Keeping the tension, slowly lean forward from the
hips 20° and stop, like a waiter's bow, keeping your
back completely straight and long as you lean
 Hold the lean position for 10 seconds - you will feel
your TA and MF supporting you if you hold the
correct position
 Keeping the tension and the alignment, slowly return
to your start position
 Repeat 10 times
THE LUNGES :
 Stand with feet hip width apart in front of a mirror
 Ensure your lumbar spine is in neutral and your back
is tall with your shoulders back and head up
 Lunge forward and bend your knee only halfway
down
 Ensure that your front knee is in line with your toes
and your back has remained upright with your
lumbar spine in neutral and your hips level
 Push back up, initiating the movement by pushing
down into the floor with your front foot
 The force from your legs should bring you back up
quickly and easily to your start position
 Your back should have remained totally still and your
hips level as you performed the push back
SPINAL STABILIZATION EXERCISES :
Floor stabilization exercises :
A) Lumbo -pelvic functional range exploration
- crook lying with anterior, posterior pelvic tilting
- in supine lying
- in sitting
- in standing
- in quadruped position
- in kneel sitting
- in kneel standing
B) Dead -bug track
-crook lying, one arm raise overhead
-both arms raise
-foot march
-knee to chest
-alternate knee to chest and arm raise
-leg kicks
-dead bug
-add weights
C) Bridge track (gluteals and quadriceps)
-crook lying, raise pelvis then spine to
bridge, maintain post. tilting
-bridge up, alternate heel lifts
-march, shift weight prior to bridging
-bridge up with SLR
-bridge up and dips with SLR
D) prone track (glutealmaximus)
-single arm raise with pillow
-arm and opposite leg raise with pillow
-without pillow
E) quadruped track (gluteus max.,medius)
-all four with one arm raise
-one leg raise
-opposite arm and leg raise
-add weights/therapist resistance
-one arm raise, trunk rotation
-support one arm on board,trunk rotation
F) kneeling track (quads., gluteus max.)
-sitting on heels,raise torso by extending hip
-same position,arms raised
-with weights
-with flexing and extending arms
G) Abdominals
-crunch with passive prepositioning
-crunch with active prepositioning
-trunk curl with knees partially bent
H) Lunge(quadriceps)
-feet shoulder width apart
*check for substitution
-attach pulleys from behind
I) Squats
-perform partial squats
-repeat
 Styrofoam, medicine ball, tubing
stabilization exercises:
 Gymnastic ball exercises:
1. seated-ant./post. Tilting
2.single leg raises
3.roll back, support at mid back
4.progress to leg lifts
5.same position, pelvic tilts
6.supine lying, lower legs on ball,brigde and
roll back
7.wall squats with ball
 Pulleys and pulldowns:
Dead–bug position
Styrofoam stability exercises: progression by using small bag
Progression of bridge track:
Alternating leg extension
 Dead Bug
(advanced abdominal)
Lunge position
Posterior Pelvic Tilt & Bridge-Up
Trunk twists
Gravity assisted pull-downs
Gravity resisted pull-ups
References:
 Clinical biomechanics of spine: White
and Panjabi
 Rehabilitation of spine: Craig Liebenson
 Pathomechanics :Carol A.Oatis
 www.about.com
 Grays anatomy(diagrams)
 Google images
THANK YOU ..

SUBMITTED BY :SWAT I
BHAGWANI
(MPT-musculoskeletal)