CORE

STABILITY
P. Ratan Khuman
M.P.T. (Ortho & Sports)

Contents

Terminology
Describe the functional approach to kinetic chain

rehab.
Explain the concept of the core.
Anatomical relationships between the
musculature of the core.
Review how the core functions to maintain
postural alignment and dynamic postural
equilibrium during functional activities.
Organize a procedure for assessing the core.
Create the rationale for core stabilization
training.
Set up the guidelines for core stabilization

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

Terminology
Function It is an integrated

multidimensional movement.
Functional strength It is the ability of the
neuromuscular system to reduce force, produce
force, and dynamically stabilize the kinetic
chain during functional movements, upon
demand, in a smooth coordinated fashion.
Neuromuscular efficiency It is the ability of
CNS to allow agonists, antagonists, synergists,
stabilizers, and neutralizers to work efficiently
and interdependently during dynamic kinetic
chain activities.
5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

Functional Approach To
Kinetic Chain Rehab
Traditionally, rehab has focused on isolated

absolute strength gains utilizing single planes of

motion.
However, all functional activities are tri-planar &
require acceleration, deceleration & dynamic
stabilization.
Movement might appear to be one-plane dominant,
but the other planes need to be dynamically
stabilized to allow for optimal neuromuscular
efficiency.
The fact is that we train force reduction, force
production and dynamic stabilization to occur
efficiently during all kinetic chain activities.
5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

Functional Approach To Kinetic

Chain Rehab Cont
A dynamic core-stabilization training program

should be a key component of all

comprehensive functional CKC rehabilitation
programs.
A core stabilization program will improve
dynamic postural control ensure appropriate
muscular balance and joint arthrokinematics
around the lumbo-pelvic-hip complex.
Allow for the expression of dynamic functional
strength and improve neuromuscular efficiency
throughout the entire kinetic chain.
5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

WHAT IS THE
CORE?
The CORE is defined as the lumbo-pelvic-

hip complex.
It is the location of our COG & where all movt
begins.

Efficient core allows for

Maintenance of normal length-tension

relationships
Maintenance of normal force couples
Maintenance of optimal arthrokinematics
Optimal efficiency in entire kinetic chain
during movement

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

Acceleration, deceleration, dynamic stabilization

The Core
Functions & operates as an

integrated unit

Entire kinetic chain operates

synergistically to produce force, reduce

force & dynamically stabilize against
abnormal force

In an efficient state

The CORE enables each of the

structural components to operate

optimally through:
Distribution

of weight
Absorption of force
Transfer of ground reaction forces

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

Neuromuscular efficiency
Ability of CNS to allow agonists, antagonists, synergists,

stabilizers & neutralizers to work efficiently &

interdependently
Established by combination of postural alignment & stability
strength
Optimizes bodys ability to generate & adapt to forces
Dynamic stabilization is critical for optimal neuromuscular
efficiency

Rehab generally focuses on isolated single plane strength gains in single

muscles
Functional activities are multi-planar requiring acceleration & stabilization

Inefficiency
Results in bodys inability to respond to demands
Can result in repetitive microtrauma, faulty biomechanics &

injury
Compensatory actions result
5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

Functional Anatomy
Global (dynamic, phasic) muscles
They are the large, torque-producing muscles.
Link the pelvis to the thoracic cage and provide general
trunk stabilization as well as movement.

Rectus abdominis, external oblique and the thoracic part of

lumbar iliocostalis

Local (postural, tonic) muscles

They attach directly to the lumbar vertebrae.
Responsible for providing segmental stability and

directly controlling the lumbar segments during

movement.

5/18/15

Lumbar multifidus, psoas major, quadratus lumborum, the

lumbar parts of iliocostalis and longisimus, transversus
abdominis, the diaphragm and the posterior fibers of internal
Oblique
Ratankhuman M.P.T. (Ortho & Sports)

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

10

Functional Anatomy
Cont
29 muscles attach to core
Lumbar Spine Muscles
Erector spinae
Transversospinalis
Iliocostalis
group
Longissimus
Rotatores

Interspinales
Intertransversarii
Semispinalis
Multifidus
5/18/15

Spinalis

Quadratus

lumborum
Latissimus Dorsi

Ratankhuman M.P.T. (Ortho & Sports)

11

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

12

Transversospinalis group
Poor mechanical advantage relative to

movement production
Primarily Type-I muscle fibers with high of
muscle spindles
Optimal for providing proprioceptive
information to CNS
Inter/intra-segmental stabilization

Erector spinae
Provide inter-segmental stabilization
Eccentrically decelerate trunk flexion &

rotation

Quadratus Lumborum
Frontal plane stabilizer
Works in conjunction with gluteus medius &

5/18/15

TFL

Ratankhuman M.P.T. (Ortho & Sports)

13

Functional Anatomy
Cont
Abdominal Muscles
Rectus abdominus
External obliques
Internal obliques
Transverse abdominus
Work to optimize spinal mechanics
Provide sagittal, frontal & transverse plane

stabilization

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

14

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

15

Functional Anatomy
Cont
Hip Musculature
Psoas

Closed chain vs. open chain

functioning

Works with erector spinae,

multifidus & deep abdominal wall

Works to balance anterior shear

forces of lumbar

Can reciprocally inhibit gluteus

maximus, multifidus, deep

erector spinae, internal oblique &
transverse abdominus when tight

Extensor mechanism dysfunction

Synergistic dominance during hip

extension

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

16

Hip Musculature cont

Gluteus medius

Frontal plane stabilizer

Weakness increases frontal &
transverse plane stresses
(patellofemoral stress)
Controls femoral adduction & IR
Weakness results in synergistic

dominance of TFL & quadratus

lumborum

Gluteus maximus

Hip extension & ER during OKC,

concentrically

Eccentrically hip flexion & IR

Decelerates tibial IR with TFL
Stabilizes SI joint
Faulty firing
results
in decreased
5/18/15
Ratankhuman
M.P.T. (Ortho
& Sports)

17

Hip Musculature cont

Hamstrings
Concentrically flex the knee, extend the hip &

rotate the tibia

Eccentrically decelerate knee extension, hip
flexion & tibial rotation
Work synergistically with the ACL to stabilize
tibial translation

All muscles produce & control forces in

multiple planes
5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

18

Diaphragm and pelvic

floor
Diaphragm serves as the roof of the core.
Stability is imparted to the lumbar spine by

contraction of the diaphragm and increasing

intra-abdominal pressure.
Ventilatory challenges on the body may cause
further diaphragm dysfunction and lead to
more compressive loads on the lumbar spine.
Thus, diaphragmatic breathing techniques
may be an important part of a core
strengthening program.
5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

19

CORE STABILIZATION
TRAINING CONCEPTS
A specific core strengthening program can:
IMPROVE dynamic postural control

Ensure appropriate muscular balance & joint

arthrokinematics in the lumbo-pelvic-hip complex

Allow for expression of dynamic functional
performance throughout the entire kinetic chain
Increase neuromuscular efficiency throughout the
entire body
Spinal stabilization
Must effectively utilize strength, power, neuromuscular control &

endurance of the prime movers

Weak core = decreased force production & efficiency

Protective mechanism for the spine

Facilitates balanced muscular functioning of the entire kinetic
chain
Enhances neuromuscular control to provide a more efficient
body positioning
5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

20

Postural Considerations
Core functions to maintain postural

alignment & dynamic postural equilibrium

Optimal alignment = optimal functional

training and rehabilitation

Segmental deficit results in predictable

dysfunction
Serial distortion patterns
Structural integrity of body is compromised due to
malalignment
Abnormal forces are distributed above and below
misaligned segment

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

21

Neuromuscular
Considerations
Enhance dynamic postural control with strong

stable core
Kinetic chain imbalances = deficient
neuromuscular control
Impact of low back pain on neuromuscular control
Joint/ligament injury neuromuscular deficits

Arthrokinetic reflex
Reflexes mediated by joint receptor activity
Altered arthrokinetic reflex can result in arthrogenic

muscle inhibition

5/18/15

Disrupted muscle function due to altered joint functioning

Ratankhuman M.P.T. (Ortho & Sports)

22

Assessment of The Core

Muscle imbalances
Arthrokinematic deficits
Core
Endurance
Neuromuscular control
Strength
Power
Real-time Ultrasound Imaging

Overall function of lower extremity kinetic

chain
5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

23

CORE
ENDURANCE TEST

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

24

Core Endurance Tests

4 endurance tests advocated are
Prone bridges
Lateral bridges
Torso flexor
Torso extensor

Other Test
Single-legged squat Test
The bridge tests are functional.
They assess strength, muscle endurance and how is

the ability to control the trunk by the synchronous

activation of many muscles.
5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

25

Prone Bridge Endurance

Test
Primarily assesses the anterior and posterior

core muscles.
It is performed by supporting the body's
weight between the forearms and toes
The pelvis in the neutral position and the
body straight
Failure occurs when client loses neutral
pelvis and falls into a lordotic position with
anterior rotation of the pelvis.

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

26

Lateral Bridge
Endurance Test
It assesses the lateral core muscles.
Legs are extended and the top foot placed in

front of the lower foot for support.

Support themselves on one elbow & feet while
lifting hips off the floor to create a straight line
over their body length.
The uninvolved arm is held across the chest with
the hand placed on the opposite shoulder
Failure occurs when the patient loses the straight
posture and the hip falls towards the table.

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

27

Torso Flexor Endurance Test

It is time based test, how long the patient can

hold a position of seated torso flexion at 60.

The client sits at 60 with both hips & knees
at 90, arms folded across chest with the
hands placed on the opposite shoulder, & toes
secured under toe straps or by examiner
Failure occurs when the athlete's torso falls
below 60.

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

28

Torso Extensors Endurance test

The test is performed in prone position of the

client.
The client is at the edge with upper body out
of the table while securing pelvic & leg.
Failure occurs when the upper body falls
from horizontal into a flexed position.

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

29

Mean Endurance times (in sec) in

Young Healthy Subjects (mean age
21 yrs)
Men
Women
Extension
161
185
Flexion
136
134
Side Bridge (R)
95
75
Side Bridge (L)
99
78
Flexion/Extension
0.84
0.72
Ratio
5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

30

Single-legged Squat Test

The test is used as an indicator

of lumbo-pelvic-hip stability.
It is functional test, requires
control the body over a Single
weight-bearing lower limb
It is frequently used clinically
to assess hip and trunk
muscular coordination and/or
control.

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

31

CORE
NEUROMUSCULAR TEST

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

32

Abdominal Neuromuscular Control

Test
Supine with hips & knees in 90
Pressure cuff placed under lumbar spine (L 4-5) &

raised to 40 mmHg
Performs drawing in maneuver (belly button to spine)
Lower legs until pressure decreases
Assesses lumbar spine moving into extension (ability
of lower abs wall to stabilize the lumbo-pelvic-hip
complex)
Hip flexors begin to work as stabilizers
Increases anterior shear forces & compressive forces at L4-

L5
Inhibits transversus abdominis, internal oblique &
multifidus
5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

33

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

34

CORE STRENGTH
TEST

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

35

Straight-Leg Lowering
Test
Supine with knees in extension
Pressure cuff placed under lumbar spine (L4-L5) &

raised to 40 mmHg with knees extended, hips to 90

Performs drawing in maneuver (belly button to
spine) & then flattens back maximally into the table
& cuff
Gradually lower legs to table while maintaining flat
back
The test is over when the pressure in the cuff
decreases.
The hip angle is then measured with a goniometer to
determine the angle.

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

36

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

37

Core Power Test

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

38

Backwards, overhead medicine ball

jump & throw
The client is instructed to hold a 4-kg

medicine ball between their legs as they

squat down.
Instructed to jump as high as possible
while simultaneously throwing the medicine
ball backward over their head.
The distance is measured from a starting
line to the point where the medicine ball
stops.
This is an assessment of total body power
production with an emphasis on the core.
5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

39

Lower Limb Functional Profiles

Isokinetic tests
Balance tests
Jump tests
Power tests
Sports specific functional tests

Kinetic chain assessment must assess all

areas of potential deficiency

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

40

Ultrasound imaging
Ultrasound imaging is also used as an

assessment technique.
The real-time ultrasound imaging is a means
of assessing muscle size and activity.
Most emphasis has been on the assessment
the transversus abdominis and multifidus
muscles.
These measures have been shown to be valid.

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

41

Core
Stabilization Training

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

42

Guidelines for Core Stabilization

Training Program
1. The program should be based on science.
2. The program should be systematic,

Progressive & functional.

3. The program should begin in the most
challenging environment the athlete can
control.
4. The program should be performed in a
proprioceptively enriched environment.

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

43

Program Variation
Plane of motion
Range of motion
Loading
(physioball, med. ball, body blade, weight vest,

tubing)

Body position
Amount of control & speed
Feedback
Duration and frequency (sets, reps, time

under tension)
5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

44

Exercise Selection.
Safe
Challenging
Stress multiple planes
Proprioceptively enriched
Activity specific/ sports specific

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

45

Exercise Progression
Slow to fast
Simple to complex
Stable to unstable
Low force to higher force
General to specific
Correct execution to increased intensity

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

46

Questions to Ask Yourself

Is
Is
Is
Is
Is
Is
Is
Is

it dynamic?
it multi-planar?
it multidimensional?
it proprioceptively enriched?
it systematic?
it progressive?
it activity-specific?
it based on functional anatomy &
science?

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

47

Abdominal Draw In
Maneuver
Aim
To use the correct

muscles in response to
command draw in your
abdominal without moving
spine or pelvis & hold for
10 sec while breathing
normally.
To activate Transversus
abdominis + lumbar
multifidus

Patient best position

The 4-point kneeling

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

48

Procedure
Ask the patient to take a relaxed breath in & out &

then draw the abdomen up towards the spine without

taking a breath.
The contraction must be performed in a slow and
controlled manner.
At the same time contracts the pelvic floor and
slightly anteriorly rotates the pelvis to activate the
multifidi.

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

49

Core Stabilization Training

Program
4 levels to core stabilization training

program
Level 1 = Stabilization
Level 2 = Stabilization & strength
Level 3 = Integrated stabilization

strength
Levcl4 = Explosive

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

50

Level I: Stabilization

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

51

Level II: Stabilization & Strength

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

52

Level II: Stabilization & Strength

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

53

Level III:
Integrated Stabilization Strength

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

54

Level IV: Explosive Stabilization

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

55

References
Prentice, W.E. (2004). Rehabilitation

Techniques for Sports Medicine & Athletic

Training, 4th ed.
Peter Brukner & Karim Khan with colleagues.
Clinical sports medicine, 3rd ed

5/18/15

Ratankhuman M.P.T. (Ortho & Sports)

56