Core Stability

Original Editor - Sem Bras

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Definition

Core stability The human lumbar spine without muscles and viscera collapses easily. To allow movement, carry loads and protect the spinal cord and nerve roots “stability” is required. Stability is provided in a co-ordinated manner by the active (eg muscles), passive (eg lumbar spine) and control (eg neurological systems).[1] There is controversy and some confusion on the definition of the term “core stability”.[2-4] Traditionally this term has referred to the active component to the stabilizing system including deep/local muscles that provide segmental stability (eg transversus abdominis, lumbar multifidus) and/or the superficial/global muscles (eg rectus abdominis, erector spinae) that enable trunk movement/torque generation and also assist in stability in more physically demanding tasks.[2] Different proponents have advocated different types of core stability exercises ranging from the abdominal drawing in maneuver (Figure 1) to sit ups or “plank” type exercises (Figure 2).

Figure 1: Correct and incorrect abdominal drawing in

Figure 2: Plank on a medicine ball

Training the local muscles (developed by physiotherapists) is a complex skill for participant and trainer that requires precise and rigorous assessment, exercise instruction and feedback.[5] Training the superficial muscles can be equally complex and is undertaken by a range of health and sporting professionals with a large variety approaches evident.
An alternative term to “core stability” is “motor control” that reflects concepts around lumbar stability in a more holistic approach including: the brain, sensory inputs, motor outputs, mechanical properties of muscles/joints, what is normal/abnormal and what may be adaptive/maladaptive.[4]

Clinically relevant anatomy  

Local muscles:

1. Transverse abdominus
2.  Multifidus
3. Internal obliques
4.  Diaphragm

 Pelvic floor muscles                                                                                                                                                                                                                                                                                                                                                                                                  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.

Global muscles

1. Rectus abdominus
2. Erector spinae
3. External obliques

Diagnostic procedures 

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. Trunk curl
7. Hip external rotation strength
8. Modified Trendelenburg test (single leg squat with observation in frontal plane)
9. Single leg squat in sagittal plane
10. Single leg squat in transverse plane

                         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  

Predictors to determine which patients are more likely to benefit from lumbar stabilization :

• 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)

Physical therapy management 

Here are som examples of exercises to improve the core stability.

1. Crunches- 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.                       
2. Obliques cruches - 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
3. The plank - 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.
4. Static leg and back - 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.
5. Dynamic leg and back - 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.
6. Hamstring raises - 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.
7. Superman - 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.
8. Static straight legs - 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.
9. Lowering and raising legs - 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. 
10. 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 cn of the ground. Then simpli tap the ground 100 times. Focus on keeping your hips and legs completely still and your back flat.
11. Leg extensions - 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.
         

                   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. Akuthota et al gave an example of how to build up a program with these exercices  

•  Go over anatomy of the core
• Active participation emphasized
• Basic exercises - isolate core muscles in different positions - Transversus abdominus (advance if able to perform 30 reps with 8 s hold)

• Abdominal bracing
• Bracing with heel slides
• Bracing with leg lifts
• Bracing with bridging
• Bracing in standing
• Bracing with standing row
• Bracing with walking Paraspinals/multifidi (advance if able to perform 30 reps with 8 s hold)
• Quadruped arm lifts with bracing
• Quadruped leg lifts with bracing
• Quadruped alternate arm and legs lifts with bracing
• Quadratus lumborum and obliques (advance if able to perform 30 reps with 8 s hold)
• Side plank with knees flexed
•  Side plank with knees extended
• Trunk curl Facilitation techniques if necessary (pelvic floor contraction, visualization,palpation, identifying substitution patterns like pelvic tilt, ultrasound) Progression
• Functional training positions with activation of core

                 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 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 

Critical Analysis 

However there are few authors who deny the Core stabilisation Concept with questioning about training motor control of the core muscles. 

Recent Related Research (from Pubmed)


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