Journal of Bodywork & Movement Therapies (2013) 17, 541e559

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

‘The core’: Understanding it, and retraining

PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

its dysfunction
Josephine Key, MAPA, MMPAA, APAM*,1

Edgecliff Physiotherapy Sports and Spinal Centre, Suite 505 Eastpoint Tower, 180 Ocean Street
Edgecliff, Sydney, NSW 2027, Australia

Received 8 October 2012; received in revised form 7 February 2013; accepted 7 March 2013

KEYWORDS Summary “Core stability training” is popular in both the therapeutic and fitness industries
Core strength; but what is actually meant and understood by this concept? And does everyone need the same
Back pain; training approach?
Pilates; This paper examines the landscape of ‘the core’ and its control from both a clinical and
Yoga; research perspective. It attempts a comprehensive review of its healthy functional role and
Injury prevention how this is commonly changed in people with spinal and pelvic girdle pain syndromes.
The common clinically observable and palpable patterns of functional and structural change
associated with ‘problems with the core’ have been relatively little described.
This paper endeavors to do so, introducing a variant paradigm aimed at promoting the un-
derstanding and management of these altered patterns of ‘core control’.
Clinically, two basic subgroups emerge. In light of these, the predictable difficulties that
each group finds in establishing the important fundamental elements of spino-pelvic ‘core con-
trol’ and how to best retrain these, are highlighted.
The integrated model presented is applicable for practitioners re-educating movement in phys-
iotherapy, rehabilitation, Pilates, Yoga or injury prevention within the fitness industry in general.
ª 2013 Elsevier Ltd. All rights reserved.

Introduction

Despite a lot of research around the subject, there is

apparent confusion in understanding what goes wrong with
* Tel.: þ61 0293261168; fax: þ61 02 93281695.
‘the core’ and how to properly retrain it. The noted
E-mail address: [email protected]. researcher, McGill (2009) opines: “There’s so much my-
URL: http://www.edgecliffphysio.com.au.http://www. thology out there about the core. The idea has reached
keyapproach.com.au. trainers and through them the public that the core means
1
Neuro-musculo-skeletal physiotherapist. only the abs. There’s no science behind that”.

1360-8592/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jbmt.2013.03.012
 542 J. Key

‘Core confusion’ and/or reductionism of ‘core’ as syn- muscles was variably delayed and/or diminished during
onymous with the abdominals and by association, the ‘need movement (Hodges and Richardson, 1998, 1999a;
to strengthen them’ utilizing ‘high load’ (strength/effort) Hungerford et al., 2003; O’Sullivan et al., 2002).
training starts to permeate research design and outcomes However, their findings have been somewhat mis-
(George et al., 2011; Escamilla et al., 2010). The misun- interpreted, such that transversus abdominis has been
derstanding becomes further entrenched. singled out as ‘the core muscle’ e transversus and ‘core’
Most people with spino-pelvic pain syndromes generally have become inextricably linked. This myth-conception is
have relatively low level function and cannot organize the propagated as the panacea for just about everything from
basic elements of ‘core control’. Subjecting them to indi- helping back pain, enhancing performance, to improving
vidual muscle group and ‘high load’ training strategies is your shape. Transversus abdominis dysfunction is only a
likely to further imprint perturbed motor patterns and in part of the problem.
many, symptom development or exacerbation. Joseph Pilates work has become linked with ‘the core’
Debate around ‘core stability’ has begun to surface although he didn’t use the term. His interest was “physical
PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

(McNeill, 2010), questioning the concept and the real value fitness and the complete coordination of body mind and
of ‘training the core’ (Allison and Morris, 2008; Allison spirit e good posture, flexibility and vitality” (Pilates and
et al., 2008; Lederman, 2010). Miller, 1945). He worked with the physically elite e gym-
nasts, dancers and circus performers, and many of his ex-
ercises are ‘high load’ strengthening with a strong focus on
A historical perspective on ‘core’ activating the abdominals (into lumbar flexion) and gluteals
with the breath.
In spite of all the interest in ‘the core’ it is difficult to find a Many of the moves are difficult to perform properly and
succinct definition of it. also risk provoking lumbo-pelvic pain symptoms e.g. ‘The
Long before ‘the core’ became fashionable, Ida Rolf Roll up’, ‘The Teaser’.
conceptualized the myofascial system as ‘intrinsic’ and Later disciples of his method use the term ‘the power-
‘extrinsic’. The intrinsic are the ‘core’, inner ‘being’ mus- house’ “. to describe the collective muscles of your ab-
cles. The extrinsic are the ‘sleeve’ e the large/superficial dominals, gluteals (buttock muscles) and lower back
‘doing’ muscles (Linn, 2004). She saw that inappropriate musculature. We define the powerhouse as the centre of
substitution by the ‘extrinsics’ for the ‘intrinsics’ e “living strength and control for the rest of your body. Pilates
in their extrinsics”, was a sign of somatic immaturity or practitioners also refer to this region as your ‘girdle of
dysfunction (Smith, 2008). These are useful concepts to strength’ or your ‘core muscles’” (Ungaro, 2002).
keep in mind. One starts to understand how the confusion begins to
The concept of ‘core stability’ probably emanated from occur e the shift in seeing ‘the girdle’ and the ‘abdominals’
Australian research into postural control in both healthy in becoming synonymous’ with ‘core’. Note also that this
and chronic low back pain (CLBP) populations. They were notion of the ‘powerhouse’ alludes to a more ‘extrinsic’
interested in the role of the motor system e how the ner- locus of control.
vous system organizes the appropriate responses to support The risk is that the ‘inner locus of control’ gets
the spine, give us the postural control to counteract gravity bypassed.
and balance while at the same time, also co-coordinating
important functions such as breathing and continence. The
evidence suggests that when spinal pain is present, the Examining the healthy ‘core’
strategies used by the central nervous system may be
altered (Hodges, 1999, 2000, 2001). Much of their research ‘Core’ structure
involved studying the feedforward anticipatory role played
by the intra-abdominal pressure (IAP) mechanism, an ‘Core’ is often simply construed as the muscles that wrap
important aspect of the antigravity postural control and around and ‘pull in the midriff’ e the transversus trap.
spinal stabilization system. They studied the roles of ‘Core’ is more complex.
various muscles contributing to a synergy of muscles The pelvis is the main centre of weight shift and ‘load
responsible for generating intra-abdominal pressure (IAP) e transfer’ in the body. The body’s centre of gravity is
transversus abdominis, the diaphragm, the pelvic floor anterior to the second sacral segment (S2) in the standing
muscles (PFM) and lumbar multifidus. anatomical position (Neumann, 2002) hence our mechanical
Hence it is appropriate to adopt the term ‘stabilization ‘core’ is principally around the front of the sacrum. Yet, as
synergy’. This affords ‘intrinsic’ control from the inside e the diaphragm and anterolateral abdomen are critical in
the ‘core’ of our being. ‘core support’ and movement control, structurally, ‘the
These researchers found that in healthy populations the core’ reaches from the ischial tuberosities up to the mid
individual elements of the ‘stabilization synergy’ sponta- thorax where the diaphragm and transversus abdominis
neously co-activate in advance of limb movement: e attach superiorly.
transversus abdominis (Hodges and Richardson, 1996, Energy expenditure is minimized when the head, thorax
1997); the diaphragm (Hodges et al., 1997a; Hodges and and pelvis are aligned in relation to the line of gravity e known
Gandevia, 2000a,b); the pelvic floor (Hodges et al., 2007; as the ‘neutral’ spinal posture. The rib cage, anterolateral
Smith et al., 2007a); deep fibres of lumbar multifidus abdominal wall (ALAW) and the pelvic ring form a framework
(Moseley et al., 2002). Yet, in CLBP and chronic pelvic gir- of ‘hoop bracing’ to the spinal column and enclose an internal
dle pain (CPGP), the pre-activation response of all these body chamber capable of volume change through expansion
‘The core’: Understanding it, and retraining its dysfunction 543

and contraction. The diaphragm divides this chamber into the Breathing and postural control in particular, are inex-
thoracic and thoraco-abdominal-pelvic cavities e the latter tricably linked and an important element common to
being our ‘core’. A balanced postural and functional rela- both mechanisms is the generation of appropriate levels
tionship between the thorax and pelvis affords ‘ideal’ inter- of IAP.
nal dimensions of ‘the core’ promoting optimal function
between the thoracic and pelvic diaphragms. ‘The core’ regulates internal pressure changes
The ability to appropriately pressurize the thoraco-
‘Core’ functional mechanisms abdomino-pelvic cavity and modulate its volumes and
shape not only underlies breathing and postural control but
also a range of other functions e.g. functional expiratory
In essence, healthy antigravity postural support and spino-
patterns e vocalisation, singing, laughing, sneezing; and
pelvic movement control can be distilled as consisting of
acts of elimination e coughing, nose blowing, vomiting,
three inter-dependent functions:
defecation, birthing etc.; e while also maintaining conti-

PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

nence during impact activities like running and jumping.
1. The breathing mechanism e plays a fundamental role
Like a suction pump, the diaphragm plays a crucial role
in the generation of IAP
in generating these internal pressure change mechanisms.
2. Postural control mechanisms of the axial column e a
IAP in variable measure is behind them all. The creation of
duality of:
each distinct function is achieved by differing timing onset
 Balanced yet adaptable co-activation between the
and proportional activity levels between the three principal
axial flexor and extensor muscle systems (Cholewicki
elements e the thoracic and pelvic diaphragms and trans-
et al., 1997) e helped by
versus abdominis.
 Appropriate levels of IAP for postural support
3. Sound posturo-movement control of the proximal limb
Breathing and postural control: the root mechanisms of
girdles e particularly the pelvis as its control directly
‘core control’
influences trunk flexor/extensor activation patterns.
Breathing is our most fundamental motor pattern. At birth
Space constraints do not allow an in-depth exploration
we have an abdominal breathing pattern e where dia-
of this aspect, which has been addressed elsewhere
phragm descent creates a negative intra-thoracic pressure
(Key et al., 2008; Key, 2010a).
drawing air into the lungs. To ‘get up’ against gravity we
need to develop postural control e the underlying platform
Coordinated activity between these 3 functional systems
supporting all our movements. In the developmental
is achieved by synergistic co-activation of many muscles, to
sequence, breathing becomes integrated into our evolving
provide adaptable and complex patterns of control. The
patterns of posturo-movement control. Breathing and
‘intrinsic system’ contribution is significant e those of
postural control are inextricably linked e each supports the
the ‘abdominal canister’ (diaphragm, PFM, transversus
other.
abdominis) and also lumbar multifidus, the interspinales
Consider the apparent ‘effortless’ yet protracted up-
and intertransversarii, psoas, medial fibres of quadratus
right posture adopted by the meditating Buddha e an
lumborum and the internal oblique (Hodges, 2003). Clini-
endurance activity sustained by breathing (Ong, 2007). This
cally, the iliacus and deep hip rotators are also important.
co-dependency between posture and breathing is
Excluding the intrinsic spinal extensors, these ‘deep’ mus-
considered.
cles form a continuous inner myofascial sleeve surrounding
Breathing sub serves the postural control mechanism:
the thoraco-abdominal-pelvic cavity e collectively termed
the ‘Lower Pelvic Unit’ (LPU) (Key, 2010a,b) (Fig. 1).
 Breathing transiently changes the volume and shape of
Variable patterns of activity within this provide the
the trunk creating slight postural disturbance which
adaptive underlying support in the modulation of these
when we are upright is counteracted by small angular
basic ‘mechanisms of core control’.
displacements through the lower trunk and legs
(Hodges et al., 2002). The sensori-motor activity from
these adjustments constantly ‘refuels’ the postural
reflex mechanism.
 A healthy breathing pattern is principally one of lateral
expansion of the lower rib cage. This only occurs if
there is sufficient generation of IAP acting through the
zone of apposition between the diaphragm and lower
pole of the thorax ‘to push the ribs out’ (Urmey et al.,
1988; De Troyer, 1997). This ‘respiratory generated IAP’
simultaneously contributes towards the postural sup-
port and stabilisation system.

Postural control supports the breathing mechanism:

Figure 1 Schematic depiction of the myofascial elements of  By providing a spatially appropriate and stable base of
the Lower Pelvic Unit which contribute to ‘intrinsic’ mecha- support for the lower spinal column and pelvis and so,
nisms of spino-pelvic support and control. stability for the diaphragm’s crural attachments
 544 J. Key

 In ‘healthy posturo-movement’, the thorax is aligned in phasically with each step when walking (Grillner et al., 1978).
a balanced relationship to the pelvis, affording spatial A ‘heavy lift’ requires strong muscle splinting of the body wall
stability of the lower pole of the thorax and so for the and high levels of IAP as in Valsalva’s manoeuvre (McGill and
diaphragm’s costal attachments enabling optimal con- Sharratt, 1990) where breathing is temporarily sacrificed.
ditions for its descent. It isn’t possible to generate IAP without associated trunk
muscle co-activation and conversely trunk muscle co-
If the posture is ‘good’ so too is the breathing pattern activation is normally associated with IAP generation e
and conversely, if the breathing pattern is healthy, so is the each increases proportionally to the other and the higher
posture (Cumpelik 2008). In dysfunction, altered posture the forces, the stiffer the spine (Cholewicki et al., 2002). In
and compromised breathing patterns always go together dysfunction, this proportionality is lost - increased and
and are found almost universally in our clients. dominant ‘outer myo-fascial squeeze’ suffocates the ‘core
Lewit (2008) speculates that in essence, healthy response’.
breathing and postural patterns depend upon balanced Spinal stiffness also changes throughout the breathing
PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

activity levels and good coordination between the dia- cycle due to fluctuating IAP and trunk muscle activity
phragm, and the ALAW e in particular transversus (Shirley et al., 2003). Holding the breath at the end of
abdominis. This is further explored. inspiration during loading generates higher levels of IAP and
spinal stiffness (Hagins et al., 2004, 2006). However a
regular breathing pattern under loading conditions results
‘Core control’ and the intra-abdominal in ‘more optimal’ IAP levels reducing the risk of undue
pressure mechanism spinal compression (Beales et al., 2010b).
IAP also expands the lower rib cage three dimensionally
The spine like any column, risks buckling through non- e in particular laterally. Thus it ‘opens the centre’ body,
axially applied loading stresses e particularly those in the helping to maintain the optimal spatial alignment between
sagittal plane. Yet the spine is but the ‘backbone of the the thorax and pelvis and helping preserve the body’s lon-
trunk’ and other mechanisms come into play to assist its gitudinal integrity. Through it we can change the volumes
support and control. of the body cavities e contributing also to changes in body
IAP has long been regarded as important for the stabi- shape in posturo-movement.
lization and support of the back when exposed to lifting Importantly in healthy control, IAP is not a ‘rigid hold-
heavy loads. Early lifting studies mostly looked at maximal ing’! Instead, it affords a buoyancy and resilience to axial
effort with Valsalva’s manoeuvre with a closed glottis antigravity control. This promotes adaptable, flexible
(Hemborg and Moritz, 1985; Hemborg et al., 1985a,b; intersegmental control, and three-dimensional postural
Goldish et al., 1994). The focus then was on trunk muscle weight shifts and adjustments throughout the whole spine
strength rather than ‘control’. e necessary for optimal control and balance.
Later studies showed that low levels of IAP were also an Significantly, IAP provides internal stability to support
important part of the dynamic antigravity postural control in particular, the actions of psoas (Kolar, 2007), and the
and support mechanism during daily ‘functional activities’ large superficial ‘extrinsic’ trunk muscles involved in more
e moving a limb (Cresswell et al., 1992, 1994; Hodges and dynamic postural control e providing internal counter
Gandevia, 2000a,b; Kolar et al., 2010); lifting and support against the ‘yanking’ and ‘squeezing’ effects of
lowering (Cresswell and Thorstensson, 1994). their activity. This is important during functional load
IAP is generated when the diaphragm descends creating transfer between the pelvis and trunk as in the supine
a simultaneous reflex co-activation of the transversus Active Straight Leg Raise (ASLR) test (Beales et al., 2009a).
abdominis and the pelvic floor muscles. This positive intra- Microgravity studies are illuminating. Weightlessness of
abdominal pressure is an automatic, anticipatory or ‘pre- the abdominal contents dramatically removes tension in the
movement’ stabilizing response which acts like an inflated abdominal wall allowing the sternum and ribs to move upward
balloon providing internal ‘pneumatic support’ for the changing the rib cage shape and motion. When the resistance
anterior spine and pelvis and tensioning of the thor- provided by the abdominal fulcrum decreases, the di-
acolumbar fascia (Bartelink, 1957; Tesh et al., 1987; aphragm’s ability to generate IAP in the zone of apposition and
Cresswell et al., 1992; Hodges et al., 2001b). It is important expand the lower rib cage is compromised e and the scalenes
that the activity levels and timing onsets between the and parasternal intercostals show increased tonic activity
diaphragm and transversus with the PFM are well balanced. (Paiva et al., 1993). Conversely, in hyper gravity states, IAP
Problems arise when any element is overactive or under- increased and the lateral rib cage invariably expanded and
active thus disturbing the balanced pattern of coordination assumed a more caudal position. These researchers
and leading to ‘system blow outs’ and loss of optimal con- concluded that “IAP thus appears to be a major determinant
trol e postural, breathing, continence etc.. of the configuration of the related lower rib cage”.
In healthy function, the amount of IAP generated is at a So, when ‘up’ against gravity, low levels of IAP are al-
level appropriate to the task e to enable postural support ways present but vary in magnitude to accommodate the
and regular breathing patterns during functional activ- respiratory cycle and the fluctuating demands of axial
ities (Grillner et al., 1978; Hodges and Gandevia, 2000b; postural control (Cresswell and Thorstensson, 1994; Hodges
Kolar et al., 2010). Hence IAP increases in proportion to the and Richardson, 1997).
reactive forces created by limb movement (Hodges and To achieve this, the diaphragm, transversus abdominis
Gandevia, 2000b; Beales et al., 2010b) and more so with and the pelvic floor muscles need to be able to both co-
increasing respiratory demand (Beales et al., 2010a). It varies activate in patterns of low grade, sustained yet varying
‘The core’: Understanding it, and retraining its dysfunction 545

levels of tonic activity for postural uprightness and at the muscles and the diaphragm goes into respiratory mode
same time be able to generate superimposed phasic ac- Entrainment of the abdominals to the breathing cycle may
tivity to meet the prevailing demands of respiration and be apparent (McGill et al., 1995).
postural reflex adjustments and movements of the trunk
and limbs (Hodges and Gandevia, 2000a,b; Kolar et al.,
2010; Beales et al., 2010b). The abdominal muscles: more than just flexors
This is most important to appreciate.
Like the fairy story character Goldilocks’ porridge, the ‘The abdominals’, a group of myofascial layers forming the
amount of IAP needs to be not too high; not too low e but anterolateral abdominal wall (ALAW) do not work alone but
‘just right’. This is not only dependent upon balanced ac- in complex synergies of control which contribute to both
tivity within the deep ‘intrinsic’ system but is also reliant breathing and three dimensional posturo-movement
upon balanced activity levels between the ‘deep’ and su- control.
perficial ‘extrinsic’ myofascial systems. It is important that training the ALAW is done in a way

PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

It is clinically apparent that in general, patient pop- that is both safe for the spine and promotes functional
ulations have difficulty achieving and modulating this bal- capacity.
ance where the amount of IAP is either deficient or Postural perturbation (Hodges and Richardson, 1997,
excessive. Either way the quality of breathing and postural 1999a) and respiratory studies (Hodges et al., 1997b) sug-
control suffers. gest that there is independent control between the deeply
placed transversus and the more superficial abdominals e
The principal elements contributing to ‘core the obliques and rectus abdominis. Transversus activates in
advance of the superficial abdominals (Hodges and
control’ Richardson, 1999b) and is more tonically yet adaptively
involved in the generation and modulation of IAP for the
The diaphragm: the forgotten element in ‘core fluctuating demands of respiration and postural control
control’? (Eriksson et al., 2011).
More task dependent, the obliques and rectus work more
Long acknowledged as ‘the’ principal muscle of respiration, phasically to control the imposed torques and the spatial
we now know that the diaphragm is also important in relationship between the thorax, pelvis and the axial spine
postural control (Allison et al., 1998; Hodges et al., 2001b, in posturo-movement (Bergmark, 1989; Hodges, 2003;
2003; Kolar et al., 2009, 2010) through its contribution to Saunders et al., 2004; McCook et al., 2009). Their activity is
the generation of IAP (Hodges et al., 1997a; Hodges and low grade for most ordinary activities of daily living and it is
Gandevia, 2000a,b). only during ‘high load’ activities where they strongly splint
The crural and costal parts of the diaphragm simulta- the body wall e stiffening the body and limiting breathing.
neously co-activate with transversus and the PFM to create Importantly, transversus activity does not occur in
IAP as part of the feedforward postural responses prior to isolation but as part of the coordinated pre-movement’
limb movement (Hodges et al., 1997a; Kolar et al., 2010). ‘stabilizing synergy’ creating IAP. Some researchers
The diaphragm is non-uniformly recruited responding concluded that it is transversus activity which is most
differently to postural and respiratory demands. The consistently related to changes in IAP (Cresswell et al.,
increased descent in response to limb load postural challenge 1992; Cresswell and Thorstensson, 1994) while others
is greater than during tidal breathing alone and is more thought it was the diaphragm (Hemborg et al., 1985b).
marked during lower extremity challenges e.g. supine resis- However, this differential function between the deep
ted hip flexion. The contraction occurs mostly at the dome and superficial abdominals is generally overlooked by
apex and the crural (posterior) sections (Kolar et al., 2010). trainers. Instead of specific activation and building control
While diaphragmatic activity is largely reflexive, its and endurance in the deep ‘stabilizing synergy’ to support
postural function can be activated voluntarily independent ‘uprightness’, much of the ‘core training’ offered simply
of respiration. Subjects were able to increase the degree of becomes ‘strengthening the abs’ as a group e principally
diaphragm descent while breath holding beyond that seen the superficial abdominals e invariably in supine into
in tidal breathing e with varying individual response pat- repeated cycles of spinal flexion: crunches, curls, sit-ups
terns (Kolar et al., 2009). etc with predictable adverse consequences on the discs
As the crura are attached between T12 to L2-3 the dia- and spinal health and wellbeing.
phragm directly affects upper lumbar stiffness (Richardson Abdominal activation patterns change depending upon
et al., 2004). Experimental stimulation of the diaphragm whether the prime purpose is to control pelvis motion or
without concurrent activity of the abdominal or back thorax motion: the obliques are most active particularly the
extensor muscles creates an extensor torque in the spine internal oblique, and more so when the pelvis initiates the
(Hodges et al., 2001b). movement (Vera-Garcia et al., 2011). During a supine ASLR,
When respiratory demand is substantially increased the lower internal obliques are generally more active
(during hypercapnoea; taxing exercise; or respiratory dis- (particularly ipsilaterally) than the external obliques
ease) respiration wins over postural control. The diaphragm (Beales et al., 2009a).
(and transversus and the PFM) show diminished tonic activity Regional variations in the morphology and recruitment
and postural IAP may be degraded (Hodges et al., 2001a). of transversus and internal oblique have also been shown.
With added significant spinal loading and ventilatory The greatest tonic postural activity occurs in the lower
challenge the trunk becomes stabilized by the large axial section; the least in the upper sections while the middle
 546 J. Key

was most associated with respiratory activity. Activation of affording little stability for the diaphragm and the rest of
the lower and middle sections was independent of the the ‘stabilizing synergy’ in the creation of optimal IAP.
upper region (Urquhart et al., 2005). Conversely, when the superficial abdominals are ‘too
Clinically, differing activity levels between the ‘upper’ strong’, the ‘neutral’ spino-pelvic ‘posture is also lost, the
and ‘lower’ abdominals have been long reported with inferior thoracic opening is constricted, inhibiting dia-
‘upper’ strong and ‘lower’ weak the most common, fol- phragm descent and so, disturbing the associated reflex
lowed by both ‘upper’ and ‘lower’ weak (Kendall et al., function between the diaphragm, transversus and pelvic
1993). floor e again IAP generation is compromised.
Significantly, the abdominal muscles particularly trans- Balanced activity between all muscles in the abdominal
versus, are important when antigravity for efficient dia- group ensures an ‘ideal’ thoraco-pelvic alignment and a
phragm activity: on inspiration they provide both stability stable, ‘open centre’ for the generation of optimum IAP
of the lower rib cage to support diaphragmatic descent and and postural control. To achieve this, transversus (and the
counter support for the abdominal contents e and so the diaphragm) via the ‘stabilization synergy’ needs to have
PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

generation of IAP. Transversus is more eccentrically active the capacity to match the activity of the more superficial
on inspiration and concentrically active on exhalation rectus and the obliques. This is important to appreciate.
(Hodges and Gandevia, 2000b). As respiratory demand in- Abdominal postscript: an ‘hour glass figure’ is a beauty
creases the whole abdominal group becomes increasingly myth and non-functional! Just observe the torso of a singer,
involved in active exhalation to assist diaphragm ascent in an elite track and field athlete or a professional dancer e
readiness for the next diaphragm descent and inhalation. the thorax is balanced over the pelvis, the ‘centre is open’
However individual strategies vary and some may show with balanced activity in the ALAW (Fig. 2.) and the
greater activity synchronised to inspiration (Beales et al., extensor system (Fig. 3.). The waist is subtle.
2010a). During hypoxic hypercapnic breathing studies,
transversus activity occurs well before activity in the other
abdominals (De Troyer et al., 1990). The pelvic floor: the seat of breathing and postural
The ‘Abdominal Drawing in Maneuver’ (ADIM) or control
‘Abdominal Hollowing’ is a suggested strategy to activate
the ‘deep muscle corset’ which aims to preferentially re- The PFM must contract during tasks that elevate IAP to both
cruit the lower transversus while minimally contracting the contribute to pressure increase and to maintain continence
obliques. Subjects are asked ‘to pull in the lower abdomen’ (Sapsford and Hodges, 2001). Avoiding bladder neck
keeping a ‘neutral spine’ (Richardson et al., 2004). The depression requires the PFM activity to be high relative to
quality of the response is important and substitution pat- the IAP increase (Junginger et al., 2010). Increasingly, there
terns avoided. The lower internal oblique is also consid- is an evident association between CLBP, continence and
ered part of the ‘deep corset’ by some and the ability to breathing disorders (Smith et al., 2006; Eliasson et al.,
isolate it from the upper rectus and external oblique in the 2008; Smith et al., 2009). If you don’t breathe well and
ADIM has been demonstrated (O’Sullivan et al., 1997a). posture well, you are more likely to get CLBP and develop
Correct performance of the ADIM also recruits the dia- incontinence.
phragm (Allison et al., 1998) and PFM (Sapsford and The PFM are tonically active as part of the ‘stabilization
Hodges, 2001). Positive treatment effects have been synergy’ and demonstrate respiratory modulation e
demonstrated utilizing the ADIM combined with co- showing more activity on exhalation (Hodges et al., 2007).
activation of lumbar multifidus in a CLBP subgroup Upright unsupported sitting postures recruit greater PFM
(O’Sullivan et al., 1997). activity than slumped supported postures (Sapsford et al.,
However, achieving the correct action can be difficult 2006, 2008). Resting PFM activity is also higher in standing
for many ‘healthy’ subjects (Beith et al., 2001). Ishida et al. and is affected by the lumbo-pelvic posture being highest in
(2012) demonstrated that a maximum voluntary exhalation a hypo-lordotic posture (Capson et al., 2011) e not neces-
recruits transversus and internal oblique e followed by sarily a good thing as continence disorders have been linked
external oblique, significantly more than during the ADIM. to increased PFM and external oblique activity (Smith
‘Bracing’ the whole ALAW has been shown to be more et al., 2007a,b). Over-training the PFM and abdominals
effective in increasing lumbar stiffness or ‘stability’ than can be deleterious!
the ADIM (Grenier and McGill, 2007). However, it’s also Voluntary activation of the PFM normally creates a co-
important to keep in mind that this can create ‘too much contraction in the abdominal muscles (Sapsford et al.,
stability’, rigidity and stiffness for healthy spinal control. 2001) e here, transversus activation was greatest with
While the obliques and rectus help to anchor the thorax the spine in extension; external oblique when the spine was
caudally their excessive activity also constricts the inferior flexed. Similarly, voluntary lower abdominal activation re-
thorax interfering with diaphragm descent. Conversely, sults in a reflex activation of the PFM which occurred in
transversus activity through IAP increases the transverse advance of IAP (Sapsford and Hodges, 2001).
diameter of the lower rib cage. The PFM also contribute to intrapelvic myomechanics
(Bendova et al., 2007). Bear in mind that their (over) ac-
Underactive or overactive abdominals compromise the tivity counternutates the sacrum and coccyx which places
diaphragm’s function the sacroiliac joint in its less stable position. The ability to
When the ALAW is underactive, the abdomen protrudes, the eccentrically lengthen the PFM is important in ‘funda-
‘neutral’ spino-pelvic posture is lost and so also control of mental patterns of pelvic control’ (Key, 2010a) which sup-
the functional relationship between the thorax and pelvis, port healthy axial control mechanisms.
‘The core’: Understanding it, and retraining its dysfunction 547

PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

Figure 2 Balanced activity in the ALAW is evident in these two professional dancers.

‘Core control’: It’s about coordination rather This suggests a definition of ‘core control’: “The ability
than strength to generate optimal IAP to support both breathing and the
provision of three dimensional postural and movement
control of the torso e particularly control of the pelvis on
As research has demonstrated, the ‘core response’ is about
the legs”.
muscle co-activation and coordination. Reliant upon input
Real ‘core control’ comes from inside. Most people try
from the sensory system, it is the accurate interplay of
to train it from the outside.
many muscles working in synergies to produce complex
patterns of control and movement rather than the strength
of individual muscles (Hodges, 2003). No muscle works
What goes wrong with ‘the core’?
alone. Activating single muscles is impossible e trying to,
creates dysfunctional spines (McGill, 2004). Retraining
‘core control’ involves relearning basic motor skills. Dysfunction of ‘the core’ involves subtle to overt shifts in
Functional control requires the ability to coordinate the the pattern of motor activity. There is both dys-
postural and respiratory functions of the trunk muscles. To coordination in the deep system and imbalance between
achieve this, a well-coordinated IAP mechanism contributes ‘inside’ and ‘outside’ control e too little, too late deep
much towards our ability to operate well in a gravity-based system control necessitates substitution strategies by
environment. various superficial muscles (Hodges, 2003) which show
distinct patterns of tonic and/or phasic overactivity. Their
overactivity involves both timing (too early) and degree of
activity (too much) e further interfering with the mecha-
nisms of deep system control. This augmented muscle ac-
tivity is being increasingly reported (Hodges et al., 2009;
Van der Hulst et al., 2010; Jones et al., 2012). This creates
greater trunk stiffness e and so, and contrary to popular
belief CLBP subjects actually move their spines less (Mok
et al., 2007) and move with excess muscle tension and
effort e and breath holding.
Importantly, the deep system ‘stabilization synergy’ is
not coordinated. The principal problem is more one of poor
coordination and endurance than reduced strength.
CLBP and related research now provides ample evidence
showing delayed and/or reduced activity of the individual
deep system elements which contribute to IAP and control e
transversus abdominis (Hodges and Richardson, 1997, 1998,
1999a,b; Ferreira et al., 2004; Hides et al., 2010); lumbar
multifidus (Hides et al., 1994, 2008; MacDonald et al., 2009)
transversus and lumbar multifidus (Hides et al., 2011b); PFM
Figure 3 Balanced activity in the extensor system in a pro- e delayed yet increased activity in incontinent women
fessional dancer. (Smith et al., 2007a; Madill et al., 2010).
 548 J. Key

Similarly, altered postural function of the diaphragm has The body shape and its functions change resulting in
been shown. In a CPGP cohort, an ASLR on the painful side disturbed regulation of internal pressure change mecha-
resulted in increased bilateral oblique muscle ‘bracing’ of nisms because of compromised diaphragmatic function.
the abdominal and chest wall associated with diaphragm The IAP generated provides suboptimal support for
‘splinting’ and reduced excursion while PFM descent was breathing and postural control (Fig. 4).
increased (O’Sullivan et al., 2002; Beales et al., 2009b). This The necessary compensatory control strategies actually
was associated with an increased baseline shift in IAP, stiffen and bother the spine and pelvis in differing ways.
increased minute ventilation and a high variability of respi-
ratory patterns including accessory breathing patterns and
Two subgroups are apparent e the
transient breath holding. Significantly, in the O’Sullivan
study, over half the sacroiliac pain cohort showed zero dia- architecture of ‘the core’ and its control are
phragmatic motion! It is important to note that with this differently compromised
‘inversion function’ of the diaphragm, the automatic reflex
PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

relationship between it, transversus and the PFM is lost, Based upon the altered postural alignment and changed
hence the non-optimal IAP generated by superficial abdom- regional myofascial activation patterns, two main sub-
inal splinting was associated with increased PFM descent. groups are clinically apparent which have been described as
Another CLBP study found a higher resting position of the the Pelvic Crossed Syndromes (Key et al., 2008; Key,
diaphragm and in response to postural tasks in supine 2010a,b).
(resisted bilateral arm or hip flexion) there was significantly Simply looking at the client as he sits or stands in front of
less diaphragmatic excursion (Kolar et al., 2012). you tells you his problems. In particular, observing the ar-
chitecture of the lower pole of the thorax and the ALAW
How can we see what goes wrong with the ‘core’? informs as to the activity level and balance between the
diaphragm and transversus abdominis.
Imbalance in the ALAW is common yet differs between
Altered neuromotor control results in common observable
groups. In general there is underactivity of the deep
effects e in essence:
transversus associated with either increased or decreased
superficial activity in the obliques and rectus. The
 Altered sagittal spatial pelvic position (and intrapelvic increased activity is more apparent in the ‘upper’ ALAW
control) and related. while the ‘lower’ ALAW is generally deficient.
 Altered spinal alignment
 Deficient ‘intrinsic’ control e including the ‘stabilizing
synergy’ and The posterior pelvic crossed syndrome (PPXS)
 A compensatory over-reliance on ‘extrinsic’ control in
distinct patterns of myofascial ‘holding’ or ‘cinching’e This subgroup is more axial extensor dominant. This is
creating regional segmental ‘hyper-stability’ while in non-uniform, principally occurring in the extensor system
other regions, spinal segmental control is inadequate. over the thoracolumbar junction between the dorsal hinge

Figure 4 Schematic depiction of ‘healthy alignment’ (centre) and the apparent altered body shape including that of the thoraco-
abdomino-pelvic cavity in the crossed syndromes: Posterior Pelvic Crossed Syndrome (PPXS) (left) and Anterior Pelvic Crossed
Syndrome (APXS) (right).
‘The core’: Understanding it, and retraining its dysfunction 549

and the mid lumbar spine. Termed a ‘Central Posterior

Cinch’ (Key, 2010a), this automatic reflex hyperactivity is a
tonic, bilateral, posterior ‘bracing’ response (Fig. 5) char-
acteristically co-associated with observable underactivity
of the entire anterolateral abdominal wall (Fig. 6).
The quality of breathing and postural control patterns
suffers in a typical manner.
Thoraco-pelvic alignment alters e the pelvis moves back
and the thorax moves forward assuming a more oblique
relationship to each other. Importantly the whole thorax
also moves up because of the poor inferior stabilisation
afforded from the abdominals. The infra-sternal angle is
increased being generally greater than 90 while the

PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

postero-inferior thorax is hyper-stabilized and ‘drawn in’
limiting postero-lateral costo-vertebral movement. The
person principally relies upon habitual ‘Central Posterior
Cinch’ (CPC) behaviour for antigravity postures and move-
ment control (Dankaerts et al., 2006a,b). The resulting
more anterior and elevated position of the thorax in-
terferes with the functional relationship between the
thoracic and pelvic diaphragms disturbing Lower Pelvic Unit
‘stabilization synergies’.
As a result the person lifts the thorax on inspiration
through a synergy of pectoral ‘lift’ and ‘CPC’ adopting an
upper chest breathing pattern. Active exhalation is difficult
as abdominal activation is inadequate to bring the thorax Figure 6 Typical appearance of underactivity in the whole
down and back into the more ‘expiratory’ caudal, or ALAW in a PPXS picture.
‘neutral’ position, as well as generate the necessary IAP.
breath holding is common. The important co-activation and
The expiratory phase is shortened. Breathing pattern dis-
coordination, between transversus and the diaphragm is
orders are common. In general, the person cannot achieve
missing e the abdominal underactivity is paramount. He is
posterior basal expansion and a lateral widening of the
forced to rely upon ‘CPC’ behaviour which is co-associated
lower rib cage and he cannot generate appropriate IAP
with overactivity in the psoas and probably the crural dia-
when antigravity e let alone during movement where
phragm, further disturbing patterns of control.

Retraining the PPXS client

In rehabilitation, this group certainly need to generate

more activity in the ALAW! However, ‘sit-ups’, ‘crunches’
‘curls’ etc are not the answer! These create large flexion
loading stresses on the spine (McGill, 2002) and do not
restore the function actually needed. Multiple, deleterious
segmental effects ensue from over-flexing spinal tissues
(Solomonow, 2012).
The best way to initially activate the ALAW in particular
transversus is through improving active exhalation (Ishida
et al., 2012; Ishida and Watanabe, 2013) to bring the tho-
rax caudally on a stable pelvis. Initially the client may need
assistance with this (Figs, 7 and 8). He then has to learn to
maintain this more ‘neutral’ position through ALAW acti-
vation while also breathing down not up! (Fig. 9) And then
further, to be able to maintain the above while generating
sustained LPU activity and IAP with a regular basal
breathing pattern e in particular a more extended exha-
lation (Fig. 10). The IAP is monitored low down at the
lateral iliac fossa (Fig. 11) where a sustained firming should
be felt. This pressure can only be developed if all elements
of the ‘stabilization synergy’ are co-activated.
Applicable to both subgroups albeit with differing
emphasis, this is ‘The Fundamental Pattern of Control’
Figure 5 Typical appearance of a ‘Central posterior Cinch’ which simultaneously trains both the postural and respira-
activity in a PPXS picture. tory aspects of the ‘stabilization synergy’. It is easiest to
 550 J. Key
PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

Figure 7 In supine supported hip flexion, the ‘inspiratory’ Figure 9 The practitioner helps to maintain the caudal
more cephalad position of the thorax is apparent. Note the thorax while asking the patient to ‘breathe down to my lower
reduced abdominal tone and wide infra-sternal angle. hand’. Encouraging an active and longer exhalation helps
activate the ALAW and facilitate a firming in the ‘Lower Pelvic
Unit’ giving him ‘the sense of’ the required action which he
first establish with the hips in supported flexion, gravity also monitors with his (R) hand.
eliminated. When the correct pattern is mastered it is
increasingly sustained to build endurance and capacity in
the ‘stabilization synergy’. This is further progressed into behaviour when antigravity. Once this is mastered, appro-
unsupported hip flexion (Fig. 12), progressing to various priate limb load challenge can be judiciously applied pro-
limb load challenges and sustained antigravity control in vided that control of the ‘fundamental pattern’ affording
sitting and standing. thoraco-lumbo-pelvic stabilization, IAP and a regular dia-
Postero-lateral expansion of the lower rib cage can only phragmatic breathing pattern are maintained. If lost, we
be achieved by ALAW activation with an appropriate need to go back and reestablish better ‘fundamental con-
pattern of IAP hence we simply work for this. This is pro- trol’, reduce the challenge such that it can be properly
gressed from recumbent (to ‘re-groove’ the postural sustained.
response) to upright. ‘Opening the centre’ is achieved by Abdominal ‘bracing’ strategies in a ‘neutral’ thoraco-
‘pushing the ribs wide and back’ without lifting the thorax pelvic position are more appropriate for this group but need
while continuing a regular basal breathing pattern to be carefully applied while ensuring correct and
(Fig. 13). Developing capacity in the ‘stabilizing synergy’ adequate pre-activation of the ‘stabilizing synergy’.
helps overcome the tendency to ‘Central Cinch Pattern’

Figure 10 He is now managing to control the thorax position

Figure 8 The thorax is passively brought into the caudal and generate sustained IAP while continuing to regularly
‘expiratory position’ to help give the client the sense of the ‘breathe down not up’. He needs to keep focusing upon a
‘neutral’ thoraco-pelvic position. Holding it so helps him inhibit longer exhalation and holding the lower ribs down and back in
lifting the thorax on inspiration and also facilitates better contact with the support surface. Sustaining the action for
diaphragmatic and ALAW activity so that he can experience the increasing periods of time builds capacity and endurance in the
‘feel of it’. ‘stabilizing synergy’.
‘The core’: Understanding it, and retraining its dysfunction 551

PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

Figure 11 Sustained Lower Pelvic Unit ‘switch on’ is moni-
tored low down in the ‘lateral valley’ of the iliac fossa e not
centrally over rectus abdominis.

Otherwise, overdeveloping abdominal ‘bracing’ risks

compromising diaphragm descent and creates hyper-
stability and spinal compression (Reeves et al., 2006)
limiting movement through the spine and degrading
posturo-movement control and balance (Grὔneberg et al.,
2004).
‘Planks’, ‘side bridge’ ‘stir the pot’ etc. are way too
much for many and encourage superficial ‘lock down’ e in
particular reinforced ‘Central Cinch Pattern’ behaviour,
‘pectoral armouring’, and further deep system inhibition.
Figure 13 The client is being asked to ‘push out sideways
Attempting ‘abdominal hollowing’ invariably results in a
and back into my hands’. She can only do this by adequate
‘suck in’ and lift of the thorax and/or a posterior pelvic tilt
activation of the ‘stabilization synergy’. Note the ‘Central
with lumbosacral flexion. This just further imprints patterns
Posterior Cinch’ hyperactivity which will lessen as she improves
of non-optimal control.
internal control.

Anterior pelvic crossed syndrome (APXS)

This subgroup is more axial flexor dominant with

overactivity of the upper anterolateral abdominal wall
between the umbilicus and the xiphoid. Termed a ‘Central
Anterior Cinch’ (Key, 2010a), this automatic reflex hyper-
activity is a bilateral, tonic anterolateral ‘bracing’ response
which is co-associated with underactivity in the lower
ALAW and relative underactivity in the axial extensor sys-
tem. A crease and/or a hollow are generally apparent above
the umbilicus (Fig. 14). However, transient ‘Central Poste-
rior Cinch’ (CPC) behaviour occurs when the postural system
is challenged e and more so in pain states. This combined
with the Central Anterior Cinch (CAC) behaviour, hyper-
stabilises and ‘draws in’ the whole lower pole of the tho-
rax (Fig. 15). Regional joint function is suffocated.
The quality of breathing and postural control patterns
suffers in a typical manner.
Figure 12 When the correct pattern is mastered it is further Thoraco-pelvic alignment again shows an oblique rela-
progressed to no support for the legs. Care must be exercised tionship e the pelvis moves forward and the thorax back,
in not over challenging the client beyond his abilities. Note assuming a more ‘expiratory’ position further constricting
that the subject’s lower ribs have lifted slightly of the support the lower pole of the thorax. The infra-sternal angle is
surface hence ‘going back’ and spending longer time devel- usually less than 90 .
oping and sustaining a better pattern of control in the ‘legs Static antigravity strategies invariably involve axial
supported position’ is indicated. collapse and ‘slumping’ relying upon passive end range
 552 J. Key

loading of the spinal joints and posterior myofascial tissues

into flexion (Dankaerts et al., 2006a,b). This postural mal-
alignment and the associated ‘Central Cinch Pattern’
behaviour interfere with the diaphragm’s ability to descend.
Without diaphragmatic descent, the reflex relationship be-
tween it and the PFM and transversus is lost (O’Sullivan
et al., 2002). Without this co-activation, the ability to
generate IAP is compromised and so suboptimal breathing
and postural control ensues. Kolar suggests (2008) that when
this ‘inversion function’ of the diaphragm occurs (it goes up
instead of down) and IAP is deficient, the central tendon
necessarily becomes the compensatory ‘place of stability’,
further pulling in the lower pole of the thorax.
PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

Posturo-movement challenges result in increased ‘CAC’

behaviour, transient ‘CPC’ behaviour and breath holding.
Restricted chest wall expansion during exercise has been
shown to increase diaphragmatic fatigue, reducing its
endurance (Hussain et al., 1985; Hussain and Pardy, 1985).
The person further compensates with an upper chest
breathing pattern as they find it difficult to relax the upper
ALAW and ‘push’ the diaphragm down and so, lateral expansion
of the lower rib cage and ‘opening the centre’ again suffers.
Breathing pattern disorders and poor energy levels are
common.
While the thoracic diaphragm is relatively underactive,
the pelvic diaphragm and related myofascial tissues over
the posterior inferior pelvis are characteristically tight e
yet may show timing delays (Smith et al., 2007a,b) further
disturbing control. This is part of an ‘inferior tether’
pattern of dysfunction in the pelvis (Key, 2010a).
Pelvic girdle pain syndromes are a common feature in
Figure 14 Typical appearance of ‘Central Anterior Cinch’
this subgroup.
activity in an APXS picture.

Retraining the APXS client

In rehabilitation, it is important to understand and recog-

nise the real needs of this subgroup. Their real difficulty is
the diaphragm e too little too late. Obtaining balanced and
coordinated activity between the ALAW and diaphragm can
be tricky. The ‘CAC’ reflex hyperactivity means that
attempting the ADIM predictably results in early ‘upper’
ALAW over-activation (Lee et al., 2008) often involving a
‘suck in’ and thorax lift and breath holding, further aug-
menting the CAC response (Fig. 16) e and difficulty acti-
vating the ‘lower’ ALAW (Hides et al., 2011a). Similarly,
because the ‘upper’ ALAW is already overactive, abdominal
‘bracing’ strategies are inappropriate.
The increased external oblique activity common in this
group is often associated with increased PFM activity (Smith
et al., 2007b). Like squeezing a tube of toothpaste in the
centre, this Central Cinch Pattern behaviour constricts the
waist, creating undue pressure on both diaphragms.
Instead, we need to ‘down train’ the ‘Central Cinch
pattern’ activity e in particular the CAC behaviour; and
really encourage better diaphragm activity towards
achieving good co-activation and balanced activity within
the whole ‘stabilization synergy’. Establishing this also
Figure 15 Combined anterior and posterior Central Cinch helps to relax the upper ALAW and gain better lateral
Pattern behaviour constricts the lower pole of the thorax. The expansion of the lower pole of the thorax (Fig. 17). With
subject is a 19-year-old ‘gym junkie’ who presented with a this, it’s helpful to think of IAP as a balloon: e if you
right femoral nerve irritation. squeeze the bottom (co-active PFM and lower transversus
‘The core’: Understanding it, and retraining its dysfunction 553

Each person has an individual presentation yet there are

common subgroup patterns.
In the PPXS group the ALAW deficit is paramount causing
them to rely on CPC behaviour and related overactivity of
psoas.
In the APXS group, reduced diaphragm activity necessi-
tates reliance upon CAC behaviour and ‘locking’ the
postero-inferior pelvis.
The dysbalance may be subtle or marked where more
compromised function occurs.

The crux of the problem

PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

‘Core problems’ are apparent in our clients as a
common difficulty in simply ‘sitting up’ and breathing
properly!: e achieving antigravity ‘neutral’ thoraco-pelvic
postural alignment with a regular diaphragmatic breathing
pattern (O’Sullivan et al., 2002; Beales et al., 2009a;
Roussel et al., 2009). This is basic to all their other
problems in achieving healthy spino-pelvic movement
control. These include diminished triplanar weight shift and
rotation through the spine and pelvis and so, reduced
variability of postural strategies (Moseley and Hodges,
2006), impaired postural compensations (Grimstone and
Hodges, 2003) and reduced postural adjustments through
Figure 16 Asking for “draw the lower abdomen up and in”
the pelvis/hip affecting balance (Mok et al., 2004, 2011;
results augmented CAC behaviour and breath holding. Note the
Smith et al., 2008).
asymmetry of the lower pole of the thorax.
The Pelvic Crossed Syndromes are an expression of
deficient deep system control.
in response to diaphragm descent) e the top expands In addition, a ‘Key Sign’ over the lower postero-lateral
(pushing the ribs out), ‘opening the centre’. thorax is further indicative of an incapacity of the deep
Cueing the PFM to help re activate the lower transversus ‘stabilizing synergy’ to match the degree of superficial
isn’t necessarily helpful as this can still result in augmented (over) activity seen in the ‘Central Cinch Patterns’ e where
CAC behaviour. Getting better ‘push down’ of the dia- internal counter support, ‘opening the centre’ and it’s
phragm and re-establishing the ‘stabilising synergy’ helps three dimensional control is wanting (Fig. 18 e and also
normalize PFM function. Figs. 5, 15 and 22). It is usually more marked on the
symptomatic side.
Discussion Correct breathing patterns are ‘the’ basic building block
of ‘core control’. Retraining faulty breathing is multifac-
Improper coordination between the abdominal wall and the eted (Chaitow et al., 2002; McLaughlin, 2009) and may
diaphragm results in compromised breathing and ‘internal
support’ and spinal stability mechanisms.

Figure 17 ‘Letting go’ the upper ALAW, establishing better Figure 18 A ‘Key Sign’ might be construed as a ‘roll of fat’
diaphragm descent and its co-activation within the ‘stabilizing but is indicative of inadequate and ‘empty’ intrinsic control
synergy’ now enables ‘opening the centre’. and compensatory extrinsic hyperactivity.
 554 J. Key
PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

Figure 19 The ability to ‘fill out’ sideways and back under

the subjects hands and sustain ‘opening the centre’ with a Figure 21 Habitual ‘slumping’ switches off the deep system
regular basal breathing pattern when antigravity requires ca- and feels ‘normal’ over time.
pacity and endurance in the ‘stabilizing synergy’ and helps
remedy a ‘Key Sign’.
postural control (O’Sullivan and Beales, 2007) and conti-
nence (Hung et al., 2010).
require quite some work in order to reestablish healthy
The desirable Fundamental Pattern of Control is always
patterns. Once mastered, it is important that they then
one of correct thoraco-pelvic relationship with regular
become incorporated through the ‘stabilizing synergy’ into
diaphragmatic breathing, IAP generation and ‘opening the
sustained antigravity postures (Fig. 19) and functional
centre’ and the ability to maintain this while integrating
patterns of posturo-movement control. In this regard, Kolar
appropriate incremental limb load challenge. In general,
(2007) offers an excellent protocol.
the PPXS group need to master ‘opening the centre’ side-
Skilled assessment will delineate if any one element e
ways and backwards; the APXS sidewayse- and possibly
the diaphragm, PFM, multifidus or transversus requires
particular individual attention in order to achieve co-
activation of the whole ‘stabilization synergy’. This re-
quires practitioner intuition, skill, patience and a pre-
paredness to ‘play around’ to achieve the correct response.
Retraining the coordination between the diaphragm,
transversus and PFM has demonstrated improvements in

Figure 20 The practitioner is providing tactile feedback to

help the client inhibit lifting the chest on inspiration; while at Figure 22 ‘Sitting up straight’ involves Central Posterior
the same time directing his awareness to bringing the lower Cinching and throwing the lower ribs forward because of
ribs down and back; and then expanding them sideways and reduced intrinsic control. This strategy will be short lived. Note
back while also sustaining Lower Pelvic Unit engagement and a the inability to achieve a lumbosacral lordosis and the ‘Key
regular basal breathing pattern. Sign’.
‘The core’: Understanding it, and retraining its dysfunction 555

forward. Otherwise, without adequate ‘control of the

centre’, proximal limb girdle activity predictably results in
further ‘Central Cinch Pattern’ behaviour.
Overly focusing upon ‘the abdominals’ e particularly
with cues to ‘tummy tuck’ or ‘tail tuck’ degrades control of
the lumbosacral ‘neutral’ and disturbs diaphragmatic and
PFM kinematics e particularly so in the APXS group. The
diaphragm has to come first (Kolar, 2008) with co-activation
of transversus and the PFM.
Commonly, breathing instruction is delivered as an
afterthought and so does not involve the correct pattern of
lateral basal expansion. This is not possible if appropriate
IAP is not generated and/or the chest lifts on inspiration.

PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

Focusing on the PFM alone risks compromising spino-
pelvic postural control e yet activating the PFM (with the
lower transversus) and diaphragm improves postural control
(O’Sullivan and Beales, 2007).
The correct pattern of IAP and stable control can only be
achieved if all elements in the ‘stabilizing synergy’ are
equally co-active.
Current approaches to ‘stability retraining’ seem to vie
between either ‘abdominal hollowing’ or ‘bracing’ strate-
gies. Re-establishing the ‘stabilizing synergy’ as described
incorporates aspects of both approaches towards achieving
better functional control. It is important to ensure that the
principal activity is in the Lower Pelvic Unit, with postero-
lateral costal expansion while the pelvis and thorax position
are appropriately controlled (Fig. 20). Undesirable compen-
sations such as upper chest breathing; breath holding; push-
ing with the feet; clenching the buttocks; posterior pelvic tilt,
increased ‘Central Anterior Cinch’ behaviour; ‘ballooning the
belly’; abdominal ‘suck in’ and lifting the thorax need to be
anticipated. Appreciating the typical features of the Pelvic Figure 23 Activating the ‘stabilizing synergy’ helps achieve
Crossed Syndromes helps predict the likely strategies to a ‘neutral’ thoraco-pelvic alignment and removes the ‘Key
overcome. Sign’.
Remember that increasing the force or load increases
superficial myofascial activity. If the client is ‘over-chal- with poor intrapelvic control and so, have difficulty
lenged’ beyond his ‘deep system’ ability he will have assuming a lumbosacral ‘neutral’ lordotic posture (Claus
compensate with Central Cinch Patterns e the reverse of et al., 2009b) e even the young. This, coupled with inad-
what we want! Clients need to ‘work smarter’, not ‘harder’. equate IAP generation means that attempts by the subject
High load ‘bracing’ strategies aimed at ‘not letting it move’ to improve his posture and ‘sit up’ will usually result in
risk developing ‘corsets of concrete’ which compress the increased ‘CPC’ behaviour (marked in the PPXS group) and
spine and stiffen the body wall, limiting inner movement. possibly ‘CAC’ strategies (in the APXS group) which may
Thus, it is important that the deep ‘stabilizing synergy’ is well exacerbate symptoms (Fig. 22). Conversely, estab-
first established and has the capacity to match the activity lishing and improving the capacity of the ‘stabilising syn-
level of the superficial muscles to allow stable yet adaptable ergy’ helps to regain a neutral thoraco-pelvic position and
patterns of spino-pelvic control. This is important. reduce this superficial global muscle hyperactivity and
tension when antigravity (Fig. 23).

Sitting and ‘the core’

Conclusion
Most people these days habitually sit in lumbo-pelvic
flexion (O’Sullivan et al., 2010) eswitching off their deep ‘Retraining the core’ should redress the client’s actual
system! e particularly the APXS group (Fig. 21). Normally, functional deficits and promote functional capacity.
adopting ‘neutral’ thoraco-pelvic postures in sitting and Understanding healthy ‘core control’ is a prerequisite to
standing automatically facilitates better deep system ac- seeing it’s dysfunction.
tivity without activating the large superficial muscles ‘Core dysfunction’ is both a reflection of inadequate
(O’Sullivan et al., 2002a, 2006; Claus et al., 2009a; Reeve ‘intrinsic’ neuro-myofascial system control and the related,
and Dilley, 2009; Pinto et al., 2011). However, there is necessary compensatory ‘extrinsic’ motor behaviour.
non-uniform agreement between physiotherapists as to Two basic subgroups are clinically apparent, each dis-
what constitutes a ‘neutral spinal posture’ (O’Sullivan playing common features and distinct difficulties with ‘core
et al., 2012) Also bear in mind that most people are stiff control’. Posture and movement control of the spine are
 556 J. Key

compromised, contributing to both the cause and perpet- Claus, A.P., Hides, J.A., Moseley, G.L., Hodges, P.W., 2009a.
uation of many spino-pelvic pain syndromes. Different ways to balance the spine: subtle changes in sagittal
It is important that the practitioner can appreciate and spinal curves affect regional muscle activity. Spine 34 (6),
recognise these subgroup patterns as each dictates a E208eE214.
Claus, A.P., Hides, J.A., Moseley, G.L., Hodges, P.W., 2009b. Is
different emphasis in therapeutic movement retraining.
‘ideal’ sitting posture real?: measurement of spinal curves in
Re-establishing the ‘stabilizing synergy’ helps restore four sitting postures. Man. Ther. 14 (4), 404e408.
fundamental control and has been described for each Cresswell, A.G., Thorstensson, A., 1994. Changes in intra-
group. abdominal pressure, trunk muscle activation and force during
isokinetic lifting and lowering. Eur. J. Appl. Physiol. Occup.
Physiol. 68 (4), 315e321.
Acknowledgement Cresswell, A.G., Grundstrom, H., Thorstensson, A., 1992. Observa-
tions on intra-abdominal pressure and patterns of abdominal
The author would like to thank her senior colleagues at intramuscular activity in man. Acta Physiol. Scand. 144, 409e418.
PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

Edgecliff Physiotherapy Sports and Spinal Centre for their Cumpelik, J., 2008. Breathing mechanics in postural stabilisation.
support and valuable contributions to this paper and in In: Workshop hosted by Chiropractic Education Australia Sydney
particular Andrea Clift co-principal. June 2008.
Dankaerts, W., O’Sullivan, P.B., Burnett, A., Straker, L., 2006a.
Differences in sitting posture are associated with nonspecific
References chronic low back pain disorders when patients are subclassified.
Spine 31 (6), 698e704.
Allison, G.T., Morris, S.L., 2008. Transversus abdominis and core Dankaerts, W., O’Sullivan, P.B., Burnett, A., Straker, L., 2006b.
stability e has the pendulum swung? Br. J. Sports Med. 42, Altered patterns of superficial trunk muscle activation during
930e931. sitting in nonspecific chronic low back pain patients. Spine 31
Allison, G., Kendle, K., Roll, S., Schupelius, J., Scott, Q., (17), 2017e2023.
Panizza, J., 1998. The role of the diaphragm during abdominal De Troyer, A., Estenne, M., Ninane, V., Van Gansbeke, D., Gorini,
hollowing exercises. Aust. J. Physiother. 44 (2), 95e102. 1990. Transversus abdominis muscle function in humans. J.
Allison, G.T., et al., 2008. Feedforward responses of transversus Appl. Physiol. 68 (3), 1010e1016.
abdominis are directionally specific and act symmetrically: De Troyer, A., 1997. Effect of hyperinflation on the diaphragm. Eur.
Implications for core stability theories. J. Orthop. Sports Phys. Respir. J. 10, 708e713.
Ther. 38 (5), 228e237. Eliasson, K., Elfving, B., Nordgren, B., Mattsson, E., 2008. Urinary
Bartelink, D.L., 1957. The role of intra-abdominal pressure in incontinence in women with low back pain. Man. Ther. 13 (3),
relieving the pressure on the lumbar vertebral discs. J. Bone 206e212.
Joint Surg. Br. 398, 718e725. Eriksson, I., Ekblom, M.M., Thorstensson, A., 2011. Activation of
Beales, D.J., O’Sullivan, P.B., Briffa, N.K., 2009a. Motor control transversus abdominis varies with postural demand in standing.
patterns during an active straight leg raise in pain-free sub- Gait and Posture 33 (3), 473e477.
jects. Spine 34 (1), E1eE8. Escamilla, R.F., Lewis, C., Bell, D., Bramblet, G., Daffron, J.,
Beales, D.J., O’Sullivan, P.B., Briffa, N.K., 2009b. Motor control Lamberts, S., Pecson, A., Imamura, R., Paulos, L.,
patterns during an active straight leg raiser in chronic pelvic Andrews, J.R., 2010. Core muscle activation during Swiss ball
girdle pain subjects. Spine 34 (9), 861e870. and traditional abdominal exercises. J. Orthop. Sports Phys.
Beales, D.J., O’Sullivan, P.B., Briffa, N.K., 2010a. The effect of Ther. 40 (5), 265e276.
resisted inspiration during active straight leg raise in pain-free Ferreira, P.H., Ferreira, M.L., Hodges, P.W., 2004. Changes in the
subjects. J. Electromyogr. Kinesiol. 20, 313e321. recruitment of the abdominal muscles in people with low back
Beales, D.J., O’Sullivan, P.B., Briffa, N.K., 2010b. The effect of pain: ultrasound measurement of muscle activity. Spine 29 (22),
increased physical load during an active straight leg raise in 2560e2566.
pain-free subjects. J. Electromyogr. Kinesiol. 20, 710e718. George, S.Z., Childs, J.D., Teyhen, D.S., Wu, S.S., Wright, A.C.,
Beith, I.D., Synnott, R.E., Newman, S.A., 2001. Abdominal muscle Dugan, J.L., Robinson, M.E., 2011. Brief psychosocial educa-
activity during abdominal hollowing manoeuvre in the four point tion, not core stabilization, reduced incidence of low back pain:
kneeling and prone positions. Man. Ther. 6 (2), 82e87. results from the prevention of low back pain in the military
Bendová, P., Rùzicka, P., Peterová, V., Fricová, M., Springrová, I., (POLM) cluster randomized trial. BMC Med. 9, 128.
2007. MRI-based registration of pelvic alignment affected by Goldish, G.D., Quast, J.E., Blow, J.J., Kuskowski, M.A., 1994.
altered pelvic floor muscle characteristics. Clin. Biomech. Postural effects on intra-abdominal pressure during Valsalva
(Bristol, Avon) 22 (9), 980e987. maneuver. Arch. Phys. Med. Rehabil. 75 (3), 324e327.
Bergmark, A., 1989. Stability of the lumbar spine: a study in me- Grenier, S.G., McGill, S.M., 2007. Quantification of lumbar stability
chanical engineering. Acta Orthop. Scand. Suppl. 230, 60. by using 2 different abdominal activation strategies. Arch. Phys.
Capson, A.C., Nashed, J., McLean, L., 2011. The role of lumbo- Med. Rehabil. 88 (1), 54e62.
pelvic posture in pelvic floor muscle activation in continent Grillner, S., Nilsson, J., Thorstensson, A., 1978. Intra-abdominal
women. J. Electromyogr. Kinesiol. 21 (1), 166e177. pressure changes during natural movements in man. Acta
Chaitow, L., Bradley, D., Gilbert, C., 2002. Multidisciplinary Ap- Physiol. Scand. 103 (3), 275e283.
proaches to Breathing Pattern Disorders. Churchill Livingstone, Grimstone, S.K., Hodges, P.W., 2003. Impaired postural compen-
Harcourt. sation for respiration in people with recurrent LBP. Exp. Brain
Cholewicki, J., Panjabi, M., Khachatryan, A., 1997. Stabilizing Res. 151, 218e224.
function of trunk flexor-extensor muscles around a neutral spine Grὔneberg, C., Bloem, B.R., Honegger, F., Allum, J.H.J., 2004. The
posture. Spine 22 (19), 2207e2212. influence of artificially increased hip and trunk stiffness on
Cholewicki, J., Ivancic, P.C., Radebold, A., 2002. Can increased balance control in man. Exp. Brain Res. 157 (4), 472e485.
intra-abdominal pressure in humans be decoupled from trunk Hagins, M., Pietrek, M., Sheikhzadeh, A., Nordin, M., Axen, K.,
muscle co-contraction during steady state isometric exertions? 2004. The effects of breath control on intra-abdominal pressure
Eur. J. Appl. Physiol. 87 (2), 127e133. during lifting tasks. Spine 29 (4), 464e469.
‘The core’: Understanding it, and retraining its dysfunction 557

Hagins, M., Pietrek, M., Sheikhzadeh, A., Nordin, M., 2006. The Hodges, P.W., Heijnen, I., Gandevia, S.C., 2001a. Postural activity
effects of breath control on maximum force and IAP during a of the diaphragm is reduced in humans when respiratory de-
maximum isometric lifting task. Clin. Biomech. (Bristol, Avon) mand increases. J. Physiol. 15, 999e1008.
21 (8), 775e780. Hodges, P.W., Cresswell, A.G., Daggfeldt, K., Thorstensson, A.,
Hemborg, B., Moritz, U., 1985. Intra-abdominal pressure and trunk 2001b. In vivo measurement of the effect of intra-abdominal
muscle activity during lifting, 11. Chronic low back pain pa- pressure on the human spine. J. Biomech. 34 (3), 347e353.
tients. Scand. J. Rehabil. Med. 17 (1), 5e13. Hodges, P.W., Gurfinkel, V.S., Brumagne, S., Smith, T.C.,
Hemborg, b, Moritz, U., Hamberg, J., Holmström, E., Löwing, H., Cordo, P.C., 2002. Coexistence of stability and mobility in
Akesson, I., 1985a. Intra-abdominal pressure and trunk muscle postural control: evidence from postural compensation for
activity during lifting 111: effect of abdominal muscle training respiration. Exp. Brain Res. 144 (3), 293e302.
in chronic low back pain patients. Scand. J. Rehabil. Med. 17 Hodges, P.W., Kaigle Holm, A., Holm, S., Ekström, L., Cresswell, A.,
(1), 15e24. Hansson, T., Thorstensson, A., 2003. Intervertebral stiffness of
Hemborg, B., Moritz, U., Löwing, H., 1985b. Intra-abdominal the spine is increased by evoked contraction of the transversus
pressure and trunk muscle activity during lifting. IV. The causal abdominis and the diaphragm: In vivo porcine studies. Spine 28

PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

factors of the intra-abdominal pressure rise. Scand. J. Rehabil. (23), 2594e2601.
Med. 17 (1), 25e38. Hodges, P.W., Sapsford, R., Pengel, L.H.M., 2007. Postural and
Hides, J.A., Stokes, M.J., Saide, M., Jull, G.A., Cooper, D.H., 1994. respiratory functions of the pelvic floor muscles. Neurourol.
Evidence of lumbar multifidus wasting ipsilateral to symptoms Urodyn. 26 (3), 362e371.
in patients with acute/subacute low back pain. Spine 19 (2), Hodges, P.W., van den Hoorn, W., Dawson, A., Cholewicki, J.,
165e172. 2009. Changes in the mechanical properties of the trunk in low
Hides, J.A., Stanton, W.R., McMahon, S., Sims, K., back pain may be associated with recurrence. J. Biomech. 42
Richardson, C.A., 2008. Effect of stabilisation training on (1), 61e66.
multifidus cross sectional area among young elite cricketers Hodges, P.W., 1999. Is there a role for transversus abdominis in
with low back pain. J. Orthop. Sports Phys. Ther. 38 (3), lumbo-pelvic stability? Man. Ther. 4 (2), 74e86.
101e108. Hodges, P.W., Sept 2000. The role of the motor system in spinal
Hides, J.A., Boughen, C.L., Stanton, W.R., Strudwick, M.W., pain: implications for rehabilitation of the athlete following low
Wilson, S.J., 2010. A magnetic resonance imaging investigation of back pain. J. Sci. Med. Sport 3 (3), 243e253.
transversus abdominis muscle during drawing-in of the abdominal Hodges, P.W., Nov 2001. Changes in motor planning of feedforward
wall in elite Australian Football League players with and without postural responses of the trunk muscles in low back pain. Exp.
back pain. J. Orthop. Sports Physiother. 40 (1), 4e10. Brain Res. 141 (2), 261e266.
Hides, J., Hughes, B., Stanton, W., 2011a. Magnetic resonance Hodges, P.W., 2003. Core stability exercise in chronic low back
imaging assessment of regional abdominal muscle function in pain. Orthop. Clin. N. Am. 34, 245e254.
elite AFL players with and without low back pain. Man. Ther. 16 Hung, H.-S., Hsiao, S.-M., Chih, S.-Y., Lin, H.-H., Tsauo, J.-Y., 2010.
(3), 279e284. An alternative intervention for urinary incontinence: retraining
Hides, J., Stanton, W., Dilani-Mendis, M., Sexton, M., 2011b. The diaphragmatic, deep abdominal and pelvic floor coordinated
relationship of transversus abdominis and lumbar multifidus function. Man. Ther. 15 (3), 273e279.
clinical muscle tests in patients with chronic low back pain. Hungerford, B., Gilleard, W., Hodges, P.W., 2003. Evidence of
Man. Ther. 16 (6), 573e577. altered lumbopelvic muscle recruitment in the presence of
Hodges, P.W., Gandevia, S.C., 2000a. Activation of the human sacroiliac joint pain. Spine 28 (14), 1593e1600.
diaphragm during a repetitive postural task. J. Physiol. 522.1, Hussain, S.N., Pardy, R.L., 1985. Inspiratory muscle function with
165e175. restrictive chest wall loading during exercise in normal humans.
Hodges, P.W., Gandevia, S.C., 2000b. Changes in intra-abdominal J. Appl. Physiol. 58 (6), 2027e2032.
pressure during postural and respiratory activation of the Hussain, S.N., Rabinovitch, B., Macklem, P.T., Pardy, R.L., 1985.
human diaphragm. J. Appl. Physiol. 89 (3), 967e976. Effects of separate rib cage and abdominal restriction on ex-
Hodges, P.W., Richardson, C.A., 1996. Inefficient muscular stabi- ercise performance in normal humans. J. Appl. Physiol. 58 (6),
lization of the lumbar spine associated with low back pain: a 220e226.
motor control evaluation of transversus abdominis. Spine 21 Ishida, H., Watanabe, S., 2013. Changes in lateral abdominal
(22), 2640e2650. muscles’ thickness immediately after the abdominal drawing-in
Hodges, P.W., Richardson, C.A., 1997. Feedforward contraction of maneuver and maximum expiration. J. Bodyw. Move. Ther. 17
transversus abdominis is not influenced by direction of arm (2), 254e258.
movement. Exp. Brain Res. 114 (2), 362e370. Ishida, H., Hirose, R., Watanabe, S., 2012. Comparison of changes
Hodges, P.W., Richardson, C.A., 1998. Delayed postural contraction in the contraction of the lateral abdominal muscles between
of transversus abdominis in low back pain associated the abdominal drawing-in maneuver and breathe held at the
with movement of the lower limb. J. Spine Disord. 11 (1), maximum expiratory level. Man. Ther. 17 (5), 427e431.
46e56. Jones, S.L., Henry, S.M., Raasch, C.C., Hitt, J.R., Bunn, J.Y., 2012.
Hodges, P.W., Richardson, C.A., 1999a. Altered trunk muscle Individuals with non-specific low back pain use a trunk stiff-
recruitment in people with low back pain with upper limb ening strategy to maintain upright posture. J. Electromyogr.
movement at different speeds. Arch. Phys. Med. Rehabil. 80 (9), Kinesiol. 22 (1), 13e20.
1005e1012. Junginger, B., Baessler, Sapsford, R., Hodges, P.W., 2010. Effect of
Hodges, P.W., Richardson, C.A., 1999b. Transversus abdominis and abdominal and pelvic floor tasks on muscle activity, abdominal
superficial abdominal muscles are controlled independently in a pressure and bladder neck. Int. Urogynecol. J. 21 (1), 69e77.
postural task. Neurosci. Lett. 265 (2), 91e94. Kendall, F.P., McCreary, E.K., Provance, P.G., 1993. Muscles: Testing
Hodges, P.W., Butler, J.E., McKenzie, D.K., Gandevia, S.C., 1997a. and Function, fourth ed. Williams and Wilkins, Baltimore.
Contraction of the human diaphragm during rapid postural ad- Key, J., Clift, A., Condie, F., Harley, C., 2008. A model of move-
justments. J. Physiol. 505.2, 539e548. ment dysfunction provides a classification system guiding diag-
Hodges, P.W., Gandevia, S.C., Richardson, C.A., 1997b. Contrac- nosis and therapeutic care in spinal pain and related
tions of specific abdominal muscles in postural tasks are effected musculoskeletal pain disorders: a paradigm shift e part 2. J.
by respiratory maneuvers. J. Appl. Physiol. 83 (3), 753e760. Bodyw. Move. Ther. 12, 105e120.
 558 J. Key

Key, J., 2010a. Back Pain: A Movement Problem. A Clinical Moseley, G.L., Hodges, P.W., 2006. Reduced variability of postural
Approach Incorporating Relevant Research and Practice. strategy prevents normalization of motor changes induced by
Churchill Livingstone, Edinburgh. back pain: a risk factor for chronic trouble? Behav. Neurosci.
Key, J., 2010b. The pelvic crossed syndromes: a reflection of 120 (2), 474e476.
imbalanced function in the myofascial envelope; a further Moseley, G.L., Hodges, P.W., Gandevia, S.C., 2002. Deep and su-
exploration of Janda’s work. J. Bodyw. Move. Ther. 14, 299e301. perficial fibers of the lumbar multifidus muscle are differen-
Kolar, P., Neuwirth, J., Sanda, J., Suchanek, V., Svata, Z., Voljnik, J., tially active during voluntary arm movements. Spine 27 (2),
Pivec, M., 2009. Analysis of diaphragm movement during tidal E29eE36.
breathing and during its activation while breath holding using MRI Neumann, D.A., 2002. Kinesiology of the Musculo-skeletal System:
synchronized with spirometry. Physiol. Res. 58, 383e392. Foundations for Physical Rehabilitation. Mosby, Missouri.
Kolar, P., Sulc, J., Kyncl, M., Sanda, J., Neuwirth, J., Ong, L., 2007. The kinesthetic Buddha, human form and function e
Bokarius, A.V., Kriz, J., Kobesova, A., 2010. Stabilizing function part 1: breathing torso. J. Bodyw. Move. Ther. 11 (3), 214e222.
of the diaphragm: dynamic MRI and synchronized spirometric O’Sullivan, P., Twomey, L., Allison, G., 1997. Evaluation of a spe-
assessment. J. Appl. Physiol. 109, 1064e1071. cific stabilising exercise in the treatment of chronic low back
PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

Kolar, P., Sulc, J., Kyncl, M., Sanda, J., Cakrt, O., Andel, R., pain with radiological diagnosis of spondylolysis and spondylo-
Kumagai, K., Kobesova, A., 2012. Postural function of the dia- listhesis. Spine 15 (24), 2959e2967.
phragm in persons with and without chronic low back pain. J. O’Sullivan, P., Twomey, L., Allison, G., Sinclair, J., Milleer, K.,
Orthop. Sports Phys. Ther. 42 (4), 352e362. Knox, J., 1997a. Altered patterns of abdominal muscle activa-
Kolar, P., 2007. Facilitation of agonisteantagonist co-activation by tion in patients with chronic low back pain. Aust. J. Physiother.
reflex stimulation methods. In: Liebenson, C. (Ed.), Rehabili- 43 (2), 91e98.
tation of the Spine: A Practitioner’s Manual, second ed. Lip- O’Sullivan, P.B., Beales, D.J., Beetham, J.A., Cripps, J., Graf, F.,
pincott Williams & Wilkins, Baltimore. Lin, I., Tucker, B., Avery, A., 2002. Altered motor control
Kolar, P., 2008. “Dynamic neuromuscular stabilisation” e Practical strategies in subjects with sacroiliac joint pain during active
Workshops A &B Chiropractic Education Australia eSydney. straight leg raise test. Spine 27 (1), E1eE8.
Lederman, E., 2010. The myth of core stability. J. Bodyw. Move. O’Sullivan, P.B., Grahamslaw, K.M., Kendell, M., Lapenske, S.C.,
Ther. 14 (1), 84e98. Mὂller, N.E., Richards, K.V.M., 2002a. The effect of different
Lee, D.G., Lee, L.J., McLaughlin, L., 2008. Stability, continence standing and sitting postures on trunk muscle activity in a pain-
and breathing: the role of fascia following pregnancy and de- free population. Spine 27 (11), 1238e1244.
livery. J. Bodyw. Move. Ther. 12 (4), 333e348. O’Sullivan, P.B., Dankaerts, W., Burnett, A.F., Farrell, G.T.,
Lewit, K., 2008. Lessons for the future. Int. Musculoskelet. Med. 30 Jefford, Y., Naylor, C.S., O’Sullivan, K.J., 2006. Effect of different
(3), 133e140. upright sitting postures on spinal-pelvic curvature and trunk mus-
Linn, J., 2004. The Core of the Matter: Core and Sleeve in the cle activation in a pain free population. Spine 31 (19), E707eE712.
Rolfian Paradigm. http://www.somatics.de/Linn/Core.htm. O’Sullivan, P.B., Beales, D.J., 2007. Changes in pelvic floor and
MacDonald, D., Moseley, G.L., Hodges, P.W., 2009. Why do some diaphragm kinematics and respiratory patterns in subjects with
patients keep hurting their back? Evidence of ongoing back sacroiliac joint pain following a motor learning intervention: a
muscle dysfunction during remission from recurrent back pain. case series. Man. Ther. 12 (3), 209e218.
Pain 142 (3), 183e188. O’Sullivan, K., O’Dea, P., Dankaerts, W., O’Sullivan, P.,
Madill, S.J., Harvey, M.-A., McLean, L., 2010. Women with stress Clifford, A., O’Sullivan, L., 2010. Neutral lumbar spine sitting
urinary incontinence demonstrate motor control differences posture in pain free subjects. Man. Ther. 15 (6), 557e561.
during coughing. J. Electromyogr. Kinesiol. 20 (5), 804e812. O’Sullivan, K., O’Sullivan, P., O’Sullivan, L., Dankaerts, W., 2012.
McCook, D.T., Vicenzino, B., Hodges, P.W., 2009. Activity of deep What do physiotherapists consider to be the best sitting spinal
abdominal muscles increases during submaximal flexion and posture? Man. Ther. 17 (5), 432e437.
extension efforts but antagonist co-contraction remains un- Paiva, M., Verbanck, S., Estenne, M., 1993. Chest wall mechanics in
changed. J. Electromyogr. Kinesiol. 19 (5), 754e762. microgravity: results from parabolic flights. In: Proc. 5th Euro-
McGill, S.M., Sharratt, M.T., 1990. Relationship between intra- pean Symposium on “Life Sciences Research in Space”, Arca-
abdominal pressure and trunk EMG. Clin. Biomech. 5 (2), 59e67. chon, France Sept. 26e1st Oct (ESA SP-366 Aug 1994).
McGill, S.M., Sharratt, M.T., Seguin, J.P., 1995. Loads on spinal Pilates, J.H., Miller, W.J., 1945. Pilate’s Return to Life through
tissues during simultaneous lifting and ventilatory challenge. Contrology. Presentation Dynamics Inc..
Ergonomics 38 (9), 1772e1792. Pinto, R.Z., Ferreira, P.H., Franco, M.R., Ferreira, M.C.,
McGill, S.M., 2002. Low Back Disorders. Human Kinetics, Cham- Ferreira, M.L., Teixeira-Salmela, L.F., Oliveira, V., Maher, C.,
pagne, Illinois. 2011. The effect of lumbar posture on abdominal
McGill, S.M., 2004. Ultimate Back Fitness. Wabuno Publishers, muscle thickness during an isometric leg task in people with
Waterloo, Canada. and without non-specific low back pain. Man. Ther. 16 (6),
McGill, S.M., 2009. Quoted In: Reynolds G. “Is Your Ab Workout 578e584.
Hurting You Back?”. New York Times June 17, 2009. Reeve, A., Dilley, A., 2009. Effects of posture on the thickness of
McLaughlin, L., 2009. Breathing evaluation and retraining in transversus abdominis in pain-free subjects. Man. Ther. 14 (16),
manual therapy. J. Bodyw. Move. Ther. 13 (3), 276e282. 679e684.
McNeill, W., 2010. Editorial: core stability is a subset of motor Reeves, N.P., Everding, V.Q., Cholewicki, J., Morrisette, D.C.,
control. J. Bodyw. Move. Ther. 14 (1), 80e83. 2006. The effects of trunk stiffness on postural control during
Mok, N.W., Brauer, S.G., Hodges, P.W., 2004. Hip strategy for unstable seated balance. Exp. Brain Res. 174 (4), 694e700.
balance control in quiet standing is reduced in people with low Richardson, C.A., Hodges, P.W., Hides, J., 2004. Therapeutic Ex-
back pain. Spine 29 (6), E107eE112. ercise for Lumbopelvic Stabilisation: a Motor Control Approach
Mok, N.W., Brauer, S.G., Hodges, P.W., 2007. Failure to use for the Treatment and Prevention of Low Back Pain, second ed.
movement in postural strategies leads to increased spinal Churchill Livingstone, pp. 185e220.
displacement in low back pain. Spine 32 (19), E537eE543. Roussel, N., Nijs, J., Truijen, S., Vervecken, L., Mottram, S.,
Mok, N.W., Brauer, S.G., Hodges, P.W., 2011. Changes in lumbar Stassijns, G., 2009. Altered breathing patterns during lumbo-
movement in people with low back pain are related to pelvic motor control tests in chronic low back pain: a case-
compromised balance. Spine 36 (1), E45eE52. control study. Eur. Spine J. 18 (7), 1066e1073.
‘The core’: Understanding it, and retraining its dysfunction 559

Sapsford, R.R., Hodges, P.W., Aug 2001. Contraction of the pelvic Smith, M.D., Coppieters, M.W., Hodges, P.W., 2008. Is balance
floor muscles during abdominal maneuvers. Arch. Phys. Med. different in women with and without stress urinary inconti-
Rehabil. 82. nence? Neurourol. Urodyn. 27 (1), 71e78.
Sapsford, R.R., Hodges, P.W., Richardson, C.A., Cooper, D.H., Smith, M.D., Russell, A., Hodges, P.W., 2009. Do incontinence,
Markwell, S.J., Jull, G.A., 2001. Co-activation of the abdominal breathing difficulties, and gastrointestinal symptoms increase
and pelvic floor muscles during voluntary exercises. Neurourol. the risk of future back pain? J. Pain 10 (8), 876e886.
Urodyn. 20 (1), 31e42. Smith, J., June 2008. The Core as Coordination. Structural Inte-
Sapsford, R.R., Richardson, C.A., Stanton, W.R., 2006. Sitting gration, pp. 27e31.
posture affects pelvic floor muscle activity in parous women: an Solomonow, M., 2012. Neuromuscular manifestations of visco-
observational study. Aust. J. Physiother. 52, 219e222. elastic tissue degradation following high and low risk repetitive
Sapsford, R.R., Richardson, C.A., Maher, C.F., Hodges, P.W., Sept lumbar flexion. J. Electromyogr. Kinesiol. 22 (2), 155e175.
2008. Pelvic floor muscle activity in different sitting postures in Tesh, K.M., Dunn, J.S., Evans, J.H., 1987. The abdominal muscles
continent and incontinent women. Arch. Phys. Med. Rehabil. 89 and vertebral stability. Spine 12 (5), 501e508.
(9), 1741e1747. Ungaro, A., 2002. Pilates: Body in Motion. Dorling Kindersley,

PREVENTION & REHABILITATION: CLINICAL AND RESEARCH REVIEW

Saunders, S.W., Rath, D., Hodges, P.W., 2004. Postural and respi- London.
ratory activation of the trunk muscles changes with the mode Urmey, W.F., De Troyer, A., Kelly, K.B., Loring, S.H., 1988. Pleural
and speed of locomotion. Gait Posture 20 (3), 280e290. pressure increases during inspiration in the zone of apposition
Shirley, D., Hodges, P.W., Eriksson, A.E.M., Gandevia, S.C., 2003. of diaphragm to rib cage. J. Appl. Physiol. 65 (5), 2207e2212.
Spinal stiffness changes throughout the respiratory cycle. J. Urquhart, D., Hodges, P.W., Story, J.H., 2005. Postural activity of
Appl. Physiol. 95 (4), 1467e1475. the abdominal regions varies between regions of these muscles
Smith, M.D., Russell, A., Hodges, P.W., 2006. Disorders of breathing and between body positions. Gait Posture 2 (4), 295e301.
and continence have a stronger association with back pain than Van der Hulst, M., Vollenbroek-Hutton, M.M., Rietman, J.S.,
obesity and physical activity. Aust. J. Physiother. 52, 11e16. Hermens, H.J., 2010. Lumbar and abdominal muscle activity
Smith, M.D., Coppieters, M.W., Hodges, P.W., 2007a. Postural ac- during walking in subjects with chronic low back pain: support
tivity of the pelvic floor muscles is delayed during rapid arm of the ‘guarding’ hypothesis? J. Electromyogr. Kinesiol. 20 (1),
movements in women with stress urinary incontinence. Int 31e38.
Urogynecol. J. Pelvic Floor Dysfunct. 18 (8), 901e911. Vera-Garcia, F.J., Moreside, J.M., McGill, S.M., 2011. Abdominal
Smith, M.D., Coppieters, M.W., Hodges, P.W., 2007b. Postural muscle activation changes if the purpose is to control thorax
response of the pelvic floor and abdominal muscles in women with motion or pelvis motion. J. Electromyogr. Kinesiol. 21 (6),
and without incontinence. Neurourol. Urodyn. 26 (3), 377e385. 893e903.