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== Introduction ==
[[File:Plank exercise.jpg|right|frameless]]
The [[Core Muscles|core]] is the centre of our body and it functions to stabilize the trunk while the arms and legs move during functional movements. When we view it this way, we see that the core actually includes: 
# Muscles that stabilize the [[Hip|hips]].
# The system of muscles that make up the torso (on the front, the sides, and the back of the body).
# Muscles that stabilize the [[Shoulder|shoulders]].<ref name=":1">Nastionwide Children's [https://www.nationwidechildrens.org/family-resources-education/700childrens/2018/07/core-stability Core Stability] Available: https://www.nationwidechildrens.org/family-resources-education/700childrens/2018/07/core-stability<nowiki/>(accessed 2.1.2022)</ref>
Image 1 and 2: Examples of core exercises: [[Plank exercise|plank]];  [[Abdominal Muscles|abdominal]] drawing in maneuver (Figure 2). [[File:Drawin.jpg|alt=|right|frameless|492x492px]]The importance of the core relate to its function ie sparing the spine from excessive load and transfer force from the lower body to the upper body and vice versa.


== Definition  ==
* Having a strong, stable core helps us to prevent injuries and allows us to perform at our best.
* In order to protect the back, ideally we want to create 360 degrees of stiffness around the spine as we move, run, jump, throw, lift objects and transfer force throughout our body.
* We do this when all of the muscles in our hips, torso and shoulders work together<ref name=":1" /><ref name="p4">4. Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and stability hypothesis. J Spinal Disord. 1992;5:383-9.
</ref>


Core stability is the ability of the lumbopelvic-hip complex to prevent buckling and to return the balance after perturbation <ref name="wilson">Willson J.D., Dougherty P., Ireland M.L. and Mcclay Davis I., Core stability and its relationship to lower extremity function and injury, American academy of orthopaedic surgeons, 2005 (level of evidence C)</ref>&nbsp; When we keep it very simple we could say that local and global lower back muscles (see clinically relevant anatomy) work together perfectly. The local muscles’ function is to control directly the lumbar segment. They act like a ‘deep corset’ that preserves the core stability and the postural sensory sense <ref name="web">http://content.ccrn.com/cce/pdf/conferences/rehabsummit/attendee_info/speaker_mats/ohalloran_core_implications_for_extremities.pdf (Level of evidence D)</ref>&nbsp;<ref name="kibler">Kibler W.B., Press J., Sciasscia A. The role of core stability in athletic function. Sports Medicine. 2006; 36(3): 189-198. (level of evidence D)</ref>The global muscles control the different movements, related to the rib cage and pelvis, around the spine <ref name="web" />. It may provide several benefits to the musculoskeletal system: maintaining low back health, preventing knee ligament injuries, upper extremity injuries… Therefore core stability is of great interest to physiotherapists, musculoskeletal researchers and athletic trainers. <ref name="wilson" />&nbsp;<ref name="web" />&nbsp;<ref name="kibler" />&nbsp;Although&nbsp;there are some static elements involved (bone, soft tissue..), core stability is dominantly maintained by the dynamic function of muscular elements. <br>Current evidence suggests that a decrease of core stability may lead to injury and that appropriate training may reduce injury. <br>
== Clinically relevant anatomy ==
[[File:Abdominal canister - breathing.jpg|right|frameless|499x499px]]
The core is a box structure made up of the [[Abdominal Muscles|abdominal muscles]] in the front and the sides, the paraspinal and [[Gluteal Tendinopathy|gluteal muscles]] at the back, the [[Diaphragm Anatomy and Differential Diagnosis|diaphragm]] at the roof, and the [[Pelvic Floor Anatomy|pelvic floor]] and the hip girdle muscles as the floor. The abdominal muscles create a rigid cylinder around the spine during movement and provide stability.  


<br>
Image 3: Abdominal canister 


== Clinically relevant anatomy&nbsp;&nbsp;<ref name="web" /><ref name="kibler" /><ref name="panjabi">Panjabi M.M. The stabilizing system of the spine. Part II. Neutral zone and stability hypothesis. Journal of Spinal Disorders. 1992; 230; 20-4. (level of evidence C)</ref><br>  ==
The inner core muscles include:


'''Local muscles:'''
* Pelvic floor. The increased effort by the abdominal muscles can only increase intra-abdominal pressure during spinal movement if there is co-contraction of the pelvic floor musculature.
* Transversus abdominis. The activity of the [[Transversus Abdominis|Transversus abdominis]] is recorded during the entire range of flexion and extension of the spine. This co-activation of the abdominal muscles during spinal movement is needed to maintain spinal stability.<ref name=":1" />
* [[Internal Abdominal Oblique|Internal Abdominal Obliques]]
* [[Lumbar Multifidus|Multifidus]]. The multifidus, which is deeper, has direct attachments to the spinal segments, and allows stabilization of the motion segment during lifting and rotational movements of the spine. The deeper uni segment muscles being close to the axis of the spine act as force transducers. Higher concentrations of muscle spindles are located in the smaller uni-segmental muscles
* [[Muscles of Respiration|Diaphragm]]
* Some literature also includes the deep fibres of the [[Psoas Major|psoas]] and the deep [[Hip Anatomy|hip rotators]] as part of the inner core.


#Transverse abdominus
The outer core muscles or the global muscles are also referred to as the “movers” and include:
#&nbsp;Multifidus
#Internal obliques
#&nbsp;Diaphragm


&nbsp;Pelvic floor muscles &nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;The transverse abdominus acts like a canister with the diaphragm and pelvic floor muscles. It increases the intra-abdominal pressure, which creates an extension moment at the spine and thus it gives stability.The multifidus increase the rotational segmental stability and contributes to 2/3th of the segmental stability. <br>
* [[Rectus Abdominis|Rectus abdominis]] .
* [[External Abdominal Oblique|External obliques]]: Involved in rotational movements. Do not have a direct attachment to the spinal segment, unable to stabilize the individual segments.
* [[Erector Spinae|Erector spinae]]: Involved in lifting. Do not have a direct attachment to the spinal segment, unable to stabilize the individual segments.
* [[Quadratus Lumborum|Quadratus lumborum]]
* [[Hip Anatomy|Hip muscle groups]]


<br>
'''Change in Motor Patterns due to Pain'''


'''Global muscles'''
The neural subsystem anticipates the loading of the spine and activates contraction of the transverse abdominis and multifidus muscle ahead of the loading.<ref name=":2">Studnicka K, Ampat G. [https://www.ncbi.nlm.nih.gov/books/NBK562179/ Lumbar Stabilization]. StatPearls [Internet]. 2021 Jan 29.Available:https://www.ncbi.nlm.nih.gov/books/NBK562179/ (accessed 2.1.2022)</ref> When there is a delay in the contraction of the multifidus, the larger and global superficial muscles eg erector spinae contract to compensate for the delay in increasing the stiffness of the lumbar spine.<ref name=":2" />


#Rectus abdominus
* In individual with low back pain due to impaired proprioceptive deficits  this biofeedback is delayed leading to excessive stress on structures of low back. Due to pain there is further proprioceptive deficit leading to a vicious cycle of pain and disability<ref>Lin J, Halaki M, Rajan P, Leaver A. Relationship Between Proprioception and Pain and Disability in People With Non-Specific Low Back Pain. A Systematic Review With Meta-Analysis. Spine J. 2019;44(10):E606–17.</ref>
#Erector spinae
* There is strong evidence supporting the effectiveness of treatment aimed at normalizing this function by way of specific [[Motor Control and Learning|motor control]] training, and specific muscle activation<ref name="p8">Cosio-Lima LM, Reynolds KL, Winter C, Paolone V, Jones MT. [http://fitnessmais.com.br/download/treinamento-funcional(2)/Instability_15.pdf Effects of physioball and conventional floor exercises on early phase adaptations in back and abdominal core stability and balance in women]. The Journal of Strength & Conditioning Research. 2003 Nov 1;17(4):721-5. Available:http://fitnessmais.com.br/download/treinamento-funcional(2)/Instability_15.pdf (accessed 3.1.2022)</ref>.
#External obliques


== Diagnostic procedures&nbsp;<ref name="akuthota">Akuthota V. et al, Core Stability Exercise Principles, spine conditions, 2008. (level of evidence A1)</ref> ==
== Physiotherapy Assessment ==
1. Local / deep muscles: Assessment of the function of the local/deep muscles is analogous with providing treatment. An understanding of the normal response is required for the abdominal drawing-in maneuver (transversus abdominis), isometric activation of multifidus, normal breathing ([[Diaphragmatic Breathing Exercises|diaphragm]]), and [[Pelvic Floor Anatomy|pelvic floor]] activation<ref name="akuthota">Akuthota V, Ferreiro A, Moore T, Fredericson M. Core stability exercise principles. Current sports medicine reports. 2008 Jan 1;7(1):39-44.</ref>.{{#ev:youtube|fUU0pGZ0v_U|300}}<ref>daney20. 02 Activating & Training Multifidus Muscle Contractions. Available from: http://www.youtube.com/watch?v=fUU0pGZ0v_U[last accessed 26/1/2020]</ref>


2.Global/superficial muscles: There is a wide range of [[Outcome Measures|outcome measures]] for the dysfunction of the global muscles regarding core stability/motor control. Examples include: <ref name=":0">Lederman E. The myth of core stability. Journal of bodywork and movement therapies. 2010 Jan 1;14(1):84-98.</ref>
#[[Prone Instability Test|Prone instability test]]
#Prone extension endurance test ([[Biering-Sorenson Test|Biering-Sorenson paraspinal endurance strength]])
#Side bridge endurance test ([[Quadratus Lumborum|quadratus lumborum]] endurance strength)
#[[Bridging|Pelvic bridging]]
#[[Leg Lowering Test|Leg lowering test]] (lower abdominal strength)
#[[Curl-ups|Curl-up Test]]
#Hip external rotation strength
#Modified [[Trendelenburg Test|Trendelenburg tes]]<nowiki/>t (single leg squat with observation in the frontal plane)
#Single leg squat in the sagittal plane
#Single leg squat in the transverse plane


Clinical prediction rules identifying people (with low back problems) likely to respond to specific motor control/specific muscle activation of the local muscles <ref name="p7">Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Archives of physical medicine and rehabilitation. 2005 Sep 1;86(9):1753-62..</ref>:


#Prone instability test
*Younger age (&lt;40)
#Prone extension endurance test (Biering-Sorenson paraspinal endurance strength)
*Greater general [[flexibility]] (hamstring length greater than 90°, postpartum)
#Side bridge endurance test (quadratus lumborum endurance strength)
*[[Prone Instability Test|Positive prone instability test]]
#Pelvic bridging
*Presence of aberrant movement during spinal range of motion (painful arc of motion, abnormal lumbopelvic rhythm, and using arms on thighs for support)
#Leg lowering test (lower abdominal strength)
 
#Trunk curl
== Physiotherapy Treatment ==
#Hip external rotation strength
Treatment focuses on retraining Motor Control.
#Modified Trendelenburg test (single leg squat with observation in frontal plane)
 
#Single leg squat in sagittal plane
# Local/deep muscles: People with significant pathology where there is local muscle dysfunction, are likely to retrain a specific motor control before moving into more global training.<ref name="p9">Stanton R, Reaburn PR, Humphries B. The effect of short-term Swiss ball training on core stability and running economy. The Journal of Strength & Conditioning Research. 2004 Aug 1;18(3):522-8.</ref>
#Single leg squat in transverse plane
# Global /superficial muscles: It is important for practitioners/sports personnel attempting to global/superficial muscle strength to have a clear understanding of any pathoanatomical problems that may be positively or negatively affected by such exercise. Ideally, all of these exercises should be done with correct lumbopelvic posture and control of the local/deep muscles. With most of these exercises duration of hold and repetitions can be varied (depending on the aim of the retraining/strengthing program) provided the exercise is done with good control.
 
Examples of exercises to improve the motor control /core stability of the lumbar spine. See [[Core Strengthening]] for a more in depth read.
 
'''<u></u>'''
 
'''Crunches'''- Lie supine on the floor with your knees bent, arms crossed over your chest and the feet flat on the floor. Then lift your shoulders from the ground and curl your stomach. Avoid a full sit up and ensure the low back remains in contact with the floor.
 
'''Obliques crunches''' - As per a normal crunch but leading with one [[shoulder]] towards the opposite [[knee]] (alternate sides each repetition).
 
{{#ev:youtube|SHsDnDwNjec|300}} <ref>YOURHEP. Trunk Curl.mov
. Available from: http://www.youtube.com/watch?v=SHsDnDwNjec[last accessed 2/2/2021]</ref>
 
'''[[Plank exercise|Plank]]''' -  see link
 
{{#ev:youtube|TvxNkmjdhMM|300}} <ref>Passion4Profession. How to Plank
. Available from: http://www.youtube.com/watch?v=TvxNkmjdhMM[last accessed 2/2/2021]</ref>
 
'''Bridges''' - Lie supine with your knees bent and the feet flat on the floor. Lift your pelvis off the ground while supporting on your feet and shoulders. The bridge can be progressed by lifting one foot off the ground end extending the knee.
 
'''Hamstring raises'''/ '''Bird Dog leg only'''- Balance on your hands and knees with your back flat and your arms/thighs perpendicular to the floor. Raise one leg behind you until it is horizontal. Alternate.
 
{{#ev:youtube|2=https://youtu.be/p5YSSeXdA88}} <ref>Bird and Dog leg Only. Available from you tube: https://youtu.be/p5YSSeXdA88.[Last accessed on 15/11/2021]</ref>
 
'''Superman''' – As per a hamstring raise but progress by lifting the opposite arm to a horizontal position at the same time. Alternate.
 
{{#ev:youtube|gGy0wINNWxk|300}} <ref>Performance Training Systems. Quadruped alternating Arm & Leg Extensions | Bird Dog
.Available from: http://www.youtube.com/watch?v=gGy0wINNWxk[last accessed 2/2/2021]</ref>


'''Leg raises''' - Lie on your back with your legs straight and your arms by your sides. Then lift one leg 4 inches of the ground. Your back has to stay flat on the floor. Don’t allow it to arch. Alternate. The exercise can be progressed by lifting both legs at the same time.


{{#ev:youtube|gSi8z1gIdC8|300}} <ref>EkhartYoga.Single Leg raises for Leg and Ab strength Yoga. Available from: http://www.youtube.com/watch?v=gSi8z1gIdC8[last accessed 2/2/2021]</ref>


&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;This isn’t a battery of tests where you give a score to each test and you ad these scores, no these are separate tests that just give you an idea of how well trained certain muscles of the core are. Well trained in strength but also the neuromuscular controls are tested by this exercises and the passive subsystem of osseous and ligamentous elements. These are the three interacting elements that gives us spinal stability. Stabilization exercises work best in individuals who are young, with increased flexibility or with exam findings suggesting an interspinal segment with increased painful movement <ref name="delitto">Delitto, A., R.E. Erhard, and R.W. Bowling. A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Phys. Ther. 75:470Y485, 1995. (level of evidence A1)</ref>&nbsp;
'''Hundreds''' - Lie on your back with your legs straight and your arms by your sides. Then lift both legs so that they form a right angle in the hip and knees. Lift your arm straight a few inches off the ground. Focus on keeping your hips and legs completely still and your back flat.


Predictors to determine which patients are more likely to benefit from lumbar stabilization <ref name="hicks">Hicks, G., J.M. Fritz, and A. Delinto. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch. Phys. Med. Rehabil. 86:1753Y1762, 2005. (level of evidence B)</ref>:
{{#ev:youtube|UaqpuUzs1i8|300}}  <ref>Howcast.How to Do The Hundred | Pilates Workout.Availablefrom:http://www.youtube.com/watch?v=UaqpuUzs1i8[last accessed 2/2/2021]</ref>


*Younger age (&lt;40)
There are also multiple exercises that can be performed with a physioball. The exercises were proven to have a greater gain of torso balance and neural activity than regular floor exercises.<ref name="ludmila">Cosio-Lima LM, Reynolds KL, Winter C, Paolone V, Jones MT. Effects of physioball and conventional floor exercises on early phase adaptations in back and abdominal core stability and balance in women. The Journal of Strength & Conditioning Research. 2003 Nov 1;17(4):721-5.</ref>
*Greater general flexibility (hamstring length greater than 90°, postpartum)
*Positive prone instability test
*Presence of aberrant movement during spinal range of motion (painful arc of motion, abnormal lumbopelvic rhythm, and using arms on thighs for support)


<br>
== Summary  ==


== <span>&nbsp;</span>&nbsp;Physical therapy management&nbsp;<br>  ==
There is no single muscle or single exercise for low back problems and motor control/core stability as a treatment. At a minimum practitioners/sports personnel should be aware of key concepts in motor control and exercise and follow an evidence-based approach to exercise prescription.


Here are som examples of exercises to improve the core stability. <br>1)Crunches<br>Lie on the floor with your knees bent and the feet flat on the floor. Then lift your schoulders from the ground en curl you stomach.<br> 2)Obliques cruches<br>Lie on the floor with 90° flexion in the hip and kniies. Then lift your schoulders of the floor and twist triing to reach the left knee witch the right elbow. Now try this in the opposite direction.<br> <br> The plank<br>Assume a front supporting position resting on your forearms with the elbows right under the shoulders. Assume this position 1 minute. To make the exercise more difficult try to lift one leg of the ground.Lie on your side while supported by your feet and your forearm with your shoulder above your elbow. Assume this position for 1 minute.<br> <br> Static leg and back<br>Lie on your back witch your knees bent and the feet flat on the floor. Lift your pelvis of the ground while supporting on your feet and shoulders. Lift one feet of the ground end extend the leg. Hold this for 30 s and do this multiple times for both sides.<br> <br>Dynamic leg and back<br>Lie on your back witch your knees bent and the feet flat on the floor. Lift your pelvis of the ground while supporting on your feet and shoulders. Lower your pelvis but do not allow it to touch the floor. Then lift the pelvis again to its original position.<br> Hamstring raises<br>Balance on you hands and knees with your back flat and your hips parallel to the floor. Raise one leg behind you until you can not lift it any higher. Your back has to stay flat and the hips parallel to the floor.<br> Superman<br>Balance on your hands and knees while your back is flat and your hips parallel to the floor. Raise your right hand in front of you and your left leg behind you, keeping it straight. Do this for both sides and hold this for 30s.<br> Static straight legs<br>Lie on your back with your legs straight and your arms by your sides. Then lift you legs 4 inches of the ground. Do this for 1 min. Your back has to stay flat on the floor. Don’t allow it to arch.<br> Lowering and raising legs<br>Lie on your back with your legs straight and your arms by your sides. Then lift both legs slowly and then raise them again. Repeat this. Your back has to stay flat on the floor. Don’t allow it to arch.<br> Hundreds<br> Lie on your back with your legs straight and your arms by your sides. Then lift both legs so that they form a right angle in the hip and knees. Lift your arm straight a few cn of the ground. Then simpli tap the ground 100 times. Focus on keeping your hips and legs completely still and your back flat.<br> Leg extensions<br>Lie on your back with your legs straight and your arms by your sides. Then lift one leg until there is a flexion of 90° in the hip and knee. Then lower this leg straight so that it is 4 cm of the ground. Meanwhile the other leg is raised until it has a flexion of 90° in the hip and knee.<br> <br>There are also multiple exercises that can be performed with a pysioball. The exersises where proven to have a greater gain of torso balance and neuronal activity then regular floor exercises.(5) Akuthota et al gave an example of how to build up a program with these exercices [6]: General<br>• Go over anatomy of the core<br>• Active participation emphasized<br>Basic exercises - isolate core muscles in different positions<br>• Transversus abdominus (advance if able to perform 30 reps with<br>8 s hold)<br>o Abdominal bracing<br>o Bracing with heel slides<br>o Bracing with leg lifts<br>o Bracing with bridging<br>o Bracing in standing<br>o Bracing with standing row<br>o Bracing with walking<br>• Paraspinals/multifidi (advance if able to perform 30 reps with 8 s hold)<br>o Quadruped arm lifts with bracing<br>o Quadruped leg lifts with bracing<br>o Quadruped alternate arm and legs lifts with bracing<br>• Quadratus lumborum and obliques (advance if able to perform 30 reps<br>with 8 s hold)<br>o Side plank with knees flexed<br>o Side plank with knees extended<br>• Trunk curl Facilitation techniques if necessary (pelvic floor contraction, visualization,<br>palpation, identifying substitution patterns like pelvic tilt, ultrasound) Progression<br>• Physioball<br>• Functional training positions with activation of core<br>• Build endurance Compliance with home exercise program in this program it is important to ‘awake’ the transversus abdominis first, and to learn to activate the wall musculature. Cueing individuals on abdominal hollowing, which may activate the transversus abdominis, as well as abdominal bracing, which activates many muscles including the transversus<br>abdominis, external obliques, and internal obliques, is an important beginning step. If this training is for athletes it is important to advance quickly to more functional exercices in sitting, standing and walking positions. Because non weight bearing core exercises such as on a physioball, may not translate to improved athletic performance. [7]
Currently, there is strong evidence for specific motor control/specific muscle activation in isolation, progressing to more global and functional exercises.


== <br> <br><br>References<br> ==
== References ==


<br>
<references />  


<span>&nbsp;</span>1. Willson J.D., Dougherty P., Ireland M.L. and Mcclay Davis I., Core stability and its relationship to lower extremity function and injury, American academy of orthopaedic surgeons, 2005 (level of evidence C)<br>2. http://content.ccrn.com/cce/pdf/conferences/rehabsummit/attendee_info/speaker_mats/ohalloran_core_implications_for_extremities.pdf (Level of evidence D)<br>3. Kibler W.B., Press J., Sciasscia A. The role of core stability in athletic function. Sports Medicine. 2006; 36(3): 189-198. (level of evidence D)<br>4. Panjabi M.M. The stabilizing system of the spine. Part II. Neutral zone and stability hypothesis. Journal of Spinal Disorders. 1992; 230; 20-4. (level of evidence C)<br>5. LUDMILA M. COSIO-LIMA, KATY L. REYNOLDS, CHRISTA WINTER,<br> VINCENT PAOLONE, AND MARGARET T. JONES. Effects of Physioball and Conventional Floor<br> Exercises on Early Phase Adaptations in Back and Abdominal Core Stability and Balance in Women. Journal of Strength and Conditioning Research, 2003, 17(4), 721–725 (level of evidence B)<br>6. Akuthota V. et al, Core Stability Exercise Principles, spine conditions, 2008. (level of evidence A1)<br>7. Stanton ., P.R. Reaburn, and B. Humphries. The effect of short-term Swiss ball training on core stability and running economy. J. Strength Cond. Res. 18:522Y528, 2004. (level of evidence A2)<br>8. Delitto, A., R.E. Erhard, and R.W. Bowling. A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Phys. Ther. 75:470Y485, 1995. (level of evidence A1)<br>9. Hicks, G., J.M. Fritz, and A. Delinto. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch. Phys. Med. Rehabil. 86:1753Y1762, 2005. (level of evidence B)<br>&lt;/div&gt;
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]
[[Category:Sports Medicine]]

Latest revision as of 09:44, 22 April 2022

Original Editor - Sem Bras

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Introduction[edit | edit source]

Plank exercise.jpg

The core is the centre of our body and it functions to stabilize the trunk while the arms and legs move during functional movements. When we view it this way, we see that the core actually includes:

  1. Muscles that stabilize the hips.
  2. The system of muscles that make up the torso (on the front, the sides, and the back of the body).
  3. Muscles that stabilize the shoulders.[1]

Image 1 and 2: Examples of core exercises: plank; abdominal drawing in maneuver (Figure 2).

The importance of the core relate to its function ie sparing the spine from excessive load and transfer force from the lower body to the upper body and vice versa.

  • Having a strong, stable core helps us to prevent injuries and allows us to perform at our best.
  • In order to protect the back, ideally we want to create 360 degrees of stiffness around the spine as we move, run, jump, throw, lift objects and transfer force throughout our body.
  • We do this when all of the muscles in our hips, torso and shoulders work together[1][2]

Clinically relevant anatomy[edit | edit source]

Abdominal canister - breathing.jpg

The core is a box structure made up of the abdominal muscles in the front and the sides, the paraspinal and gluteal muscles at the back, the diaphragm at the roof, and the pelvic floor and the hip girdle muscles as the floor. The abdominal muscles create a rigid cylinder around the spine during movement and provide stability.

Image 3: Abdominal canister

The inner core muscles include:

  • Pelvic floor. The increased effort by the abdominal muscles can only increase intra-abdominal pressure during spinal movement if there is co-contraction of the pelvic floor musculature.
  • Transversus abdominis. The activity of the Transversus abdominis is recorded during the entire range of flexion and extension of the spine. This co-activation of the abdominal muscles during spinal movement is needed to maintain spinal stability.[1]
  • Internal Abdominal Obliques
  • Multifidus. The multifidus, which is deeper, has direct attachments to the spinal segments, and allows stabilization of the motion segment during lifting and rotational movements of the spine. The deeper uni segment muscles being close to the axis of the spine act as force transducers. Higher concentrations of muscle spindles are located in the smaller uni-segmental muscles
  • Diaphragm
  • Some literature also includes the deep fibres of the psoas and the deep hip rotators as part of the inner core.

The outer core muscles or the global muscles are also referred to as the “movers” and include:

Change in Motor Patterns due to Pain

The neural subsystem anticipates the loading of the spine and activates contraction of the transverse abdominis and multifidus muscle ahead of the loading.[3] When there is a delay in the contraction of the multifidus, the larger and global superficial muscles eg erector spinae contract to compensate for the delay in increasing the stiffness of the lumbar spine.[3]

  • In individual with low back pain due to impaired proprioceptive deficits  this biofeedback is delayed leading to excessive stress on structures of low back. Due to pain there is further proprioceptive deficit leading to a vicious cycle of pain and disability[4]
  • There is strong evidence supporting the effectiveness of treatment aimed at normalizing this function by way of specific motor control training, and specific muscle activation[5].

Physiotherapy Assessment[edit | edit source]

1. Local / deep muscles: Assessment of the function of the local/deep muscles is analogous with providing treatment. An understanding of the normal response is required for the abdominal drawing-in maneuver (transversus abdominis), isometric activation of multifidus, normal breathing (diaphragm), and pelvic floor activation[6].

[7]

2.Global/superficial muscles: There is a wide range of outcome measures for the dysfunction of the global muscles regarding core stability/motor control. Examples include: [8]

  1. Prone instability test
  2. Prone extension endurance test (Biering-Sorenson paraspinal endurance strength)
  3. Side bridge endurance test (quadratus lumborum endurance strength)
  4. Pelvic bridging
  5. Leg lowering test (lower abdominal strength)
  6. Curl-up Test
  7. Hip external rotation strength
  8. Modified Trendelenburg test (single leg squat with observation in the frontal plane)
  9. Single leg squat in the sagittal plane
  10. Single leg squat in the transverse plane

Clinical prediction rules identifying people (with low back problems) likely to respond to specific motor control/specific muscle activation of the local muscles [9]:

  • Younger age (<40)
  • Greater general flexibility (hamstring length greater than 90°, postpartum)
  • Positive prone instability test
  • Presence of aberrant movement during spinal range of motion (painful arc of motion, abnormal lumbopelvic rhythm, and using arms on thighs for support)

Physiotherapy Treatment[edit | edit source]

Treatment focuses on retraining Motor Control.

  1. Local/deep muscles: People with significant pathology where there is local muscle dysfunction, are likely to retrain a specific motor control before moving into more global training.[10]
  2. Global /superficial muscles: It is important for practitioners/sports personnel attempting to global/superficial muscle strength to have a clear understanding of any pathoanatomical problems that may be positively or negatively affected by such exercise. Ideally, all of these exercises should be done with correct lumbopelvic posture and control of the local/deep muscles. With most of these exercises duration of hold and repetitions can be varied (depending on the aim of the retraining/strengthing program) provided the exercise is done with good control.

Examples of exercises to improve the motor control /core stability of the lumbar spine. See Core Strengthening for a more in depth read.

Crunches- Lie supine on the floor with your knees bent, arms crossed over your chest and the feet flat on the floor. Then lift your shoulders from the ground and curl your stomach. Avoid a full sit up and ensure the low back remains in contact with the floor.

Obliques crunches - As per a normal crunch but leading with one shoulder towards the opposite knee (alternate sides each repetition).

[11]

Plank - see link

[12]

Bridges - Lie supine with your knees bent and the feet flat on the floor. Lift your pelvis off the ground while supporting on your feet and shoulders. The bridge can be progressed by lifting one foot off the ground end extending the knee.

Hamstring raises/ Bird Dog leg only- Balance on your hands and knees with your back flat and your arms/thighs perpendicular to the floor. Raise one leg behind you until it is horizontal. Alternate.

[13]

Superman – As per a hamstring raise but progress by lifting the opposite arm to a horizontal position at the same time. Alternate.

[14]

Leg raises - Lie on your back with your legs straight and your arms by your sides. Then lift one leg 4 inches of the ground. Your back has to stay flat on the floor. Don’t allow it to arch. Alternate. The exercise can be progressed by lifting both legs at the same time.

[15]

Hundreds - Lie on your back with your legs straight and your arms by your sides. Then lift both legs so that they form a right angle in the hip and knees. Lift your arm straight a few inches off the ground. Focus on keeping your hips and legs completely still and your back flat.

[16]

There are also multiple exercises that can be performed with a physioball. The exercises were proven to have a greater gain of torso balance and neural activity than regular floor exercises.[17]

Summary[edit | edit source]

There is no single muscle or single exercise for low back problems and motor control/core stability as a treatment. At a minimum practitioners/sports personnel should be aware of key concepts in motor control and exercise and follow an evidence-based approach to exercise prescription.

Currently, there is strong evidence for specific motor control/specific muscle activation in isolation, progressing to more global and functional exercises.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Nastionwide Children's Core Stability Available: https://www.nationwidechildrens.org/family-resources-education/700childrens/2018/07/core-stability(accessed 2.1.2022)
  2. ↑ 4. Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and stability hypothesis. J Spinal Disord. 1992;5:383-9.
  3. ↑ 3.0 3.1 Studnicka K, Ampat G. Lumbar Stabilization. StatPearls [Internet]. 2021 Jan 29.Available:https://www.ncbi.nlm.nih.gov/books/NBK562179/ (accessed 2.1.2022)
  4. ↑ Lin J, Halaki M, Rajan P, Leaver A. Relationship Between Proprioception and Pain and Disability in People With Non-Specific Low Back Pain. A Systematic Review With Meta-Analysis. Spine J. 2019;44(10):E606–17.
  5. ↑ Cosio-Lima LM, Reynolds KL, Winter C, Paolone V, Jones MT. Effects of physioball and conventional floor exercises on early phase adaptations in back and abdominal core stability and balance in women. The Journal of Strength & Conditioning Research. 2003 Nov 1;17(4):721-5. Available:http://fitnessmais.com.br/download/treinamento-funcional(2)/Instability_15.pdf (accessed 3.1.2022)
  6. ↑ Akuthota V, Ferreiro A, Moore T, Fredericson M. Core stability exercise principles. Current sports medicine reports. 2008 Jan 1;7(1):39-44.
  7. ↑ daney20. 02 Activating & Training Multifidus Muscle Contractions. Available from: http://www.youtube.com/watch?v=fUU0pGZ0v_U[last accessed 26/1/2020]
  8. ↑ Lederman E. The myth of core stability. Journal of bodywork and movement therapies. 2010 Jan 1;14(1):84-98.
  9. ↑ Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Archives of physical medicine and rehabilitation. 2005 Sep 1;86(9):1753-62..
  10. ↑ Stanton R, Reaburn PR, Humphries B. The effect of short-term Swiss ball training on core stability and running economy. The Journal of Strength & Conditioning Research. 2004 Aug 1;18(3):522-8.
  11. ↑ YOURHEP. Trunk Curl.mov . Available from: http://www.youtube.com/watch?v=SHsDnDwNjec[last accessed 2/2/2021]
  12. ↑ Passion4Profession. How to Plank . Available from: http://www.youtube.com/watch?v=TvxNkmjdhMM[last accessed 2/2/2021]
  13. ↑ Bird and Dog leg Only. Available from you tube: https://youtu.be/p5YSSeXdA88.[Last accessed on 15/11/2021]
  14. ↑ Performance Training Systems. Quadruped alternating Arm & Leg Extensions | Bird Dog .Available from: http://www.youtube.com/watch?v=gGy0wINNWxk[last accessed 2/2/2021]
  15. ↑ EkhartYoga.Single Leg raises for Leg and Ab strength Yoga. Available from: http://www.youtube.com/watch?v=gSi8z1gIdC8[last accessed 2/2/2021]
  16. ↑ Howcast.How to Do The Hundred | Pilates Workout.Availablefrom:http://www.youtube.com/watch?v=UaqpuUzs1i8[last accessed 2/2/2021]
  17. ↑ Cosio-Lima LM, Reynolds KL, Winter C, Paolone V, Jones MT. Effects of physioball and conventional floor exercises on early phase adaptations in back and abdominal core stability and balance in women. The Journal of Strength & Conditioning Research. 2003 Nov 1;17(4):721-5.
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