core stability methods

[NARSTR]

I am becoming increasingly alarmed by the number of PTs who are teaching core stability by the use of lumbar flexion incorporated into facilitation of transversus abs.
My understanding from Hydes and Hodge et al is that correct contraction of these intrinsics does not involve pelvic tilting and it is quite incorrect to teach this way.
Anyone agree?????

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[Bazza]

I tend to agree with you on this. TrA works with the pelvic floor muscles to stabilise but the spine should be in neutral not slight flexion

[gc]

My understanding is that TA, multifidus, VMO and any other dynamic stabilisers are ideally used thru all (or most) ROMs. As such they should be taught to be activated thru all the functional range. As many patients have difficulty activating these mm. it is often easier to teach in one part of range and then progress to the more difficult parts. A problem is when they have been taught a certain way(eg supine and they retrovert the pelvis by use of rectus abdominus) and the accessory movements are not eliminated. In fact elimination of superfluose movements is paramount in isolating and optimising use of the stabilisers. I understand your concern and I guess the problem arises from a combination of expediency{(some patients just don't get it do they) and are therefore taught a "modified version" of TA activation which we can argue isn't} and confusion on the physio/PTs part. I have done a course with Hodges albeit a few years ago and believe what I am suggesting is correct. Also retroversion of the pelvis is initiated by rectus abdominus and iliopsoas and not by TA or multifidus so it would seem illogical to suggest that pelvic tilt is anything to do with training of these stabilisers. Janda would also agree with this as well but that's another story...........

[gc]

Ooops. Iliopsoas is not a retroverter(posterior tilter) of the pelvis. I meant to say hamstrings and rectus abdominus.

[alinguyen]

Sometimes, patients simply don't get it, so a modified position is required. I try four point kneeling or sidelying or on a fitball or a pilates reformer. The main idea, as GC said is to eliminate accessory movements. Keeping the pelvis neutral is really theoretical and not very practical at times especially if the patient has lordotic features and the patient needs to be able to contract the TA in standing. Ideally you can 'isolate' the TA with the pelvis neutral and perhaps lumbar flexion can achieve that with a lordotic patient. However, 'isolating' the TA is only the beginning of stability training.

Like with all stabilising muscles as 'gc' said, the patient eventually needs to be taken throughout range, flexion, extension, rotation, with varying loads placed on that muscle, such as with difficult postures, weight training and slow to brisk walking.

[alophysio]

Hi all,

Keeping the pelvis neutral is certainly not theoretical. From my experience, getting the whole spine in neutral will facilitate the activation of TrAb. THe reason why people may find it hard to get TrAb in supine is simply because they are too extended through the thoracolumbar junction.This puts the TrAb in a disadvantageous position leading to substitution strategies.

The other reason why i think people fail is because they haven;'t addressed the reason why TrAb is inhibited. Dealing with the dysfunctions in the spine and pelvis will improve their activation levels.

The TrAb doesn't actually generate the force and torque required to "stabilise" the whole spine against large loads - what it does do is provide the segmental positioning and allows the strong global muscles to then do their job - effective load transfer.

I have observed many people teaching their patients 'core stability' - i think we know a lot more in theory than practice. I had to pay more attention to seeing segmental motion rather than blocky movements.

Pilates trained people like the flat back position but i much rather we didn't do that. Get the sequencing right - "core" then globals then movement. Skip the first step, you will almost certainly have joint compression problems. Also remember that some people can actually be functional and sequence correctly but not be able do the specific motor task of "isolation of TrAb". Look for 'beautiful movement'...

But that is just my opinion...

[Yarok]

hi guys

what perfect (simple&effective) would you suggest, then?

thanks

[alophysio]

Hi Yaro, I am not sure i understand the question...

Hi GC, you mention that TA and multifidus (LM) are not initiators of posterior pelvic tilt.... it really depends on what your definition of intitiation is.

TA and LM WILL activate BEFORE the RA and Hams actually generate the torques to posteriorly rotate the pelvis. TA and LM won't actually move the pelvis but they are shown to activate BEFORE *movement* intitiation.

If you think of inititation as 1.thought/intention, 2. preparatory movements 3. actual movement, then TA and LM are part of the initiation sequence of movement...

[gc]

Hi alophysio

Seems a bit redundant to reply after so long but seeing how I've come our of hibernation then here goes:

Yep, I guess it does depend on definition and maybe initiator was a poor choice of words and maybe prime movers or force couple or something like that would have been more apposite. I agree with you regarding 'thought/intention', and 'preparatory movements' as being part of the movement although I find it interesting to ask where does it end in terms of what is involved in the whole movement? Do we hold our breathe, make conscious or unconscious associations with "unrelated" events -cognitive or unconscious, squint, or use a host of other parasitic movements as part of the movement, or preparatory to the movement. I'll keep wondering.

As far as I know, the wisdom is that TA and MF are s'posed to be activated prior to the global mm being activated otherwise there is undue strain on the spine, (or whatever it is that is stressed by the instability (?brain)) which is implicit in what you are saying. With dysfunctional stabilisation the timing is awry, so the TA and MF are activated too late and as you say, getting the sequencing/timing right is the important thing. Hodges used to teach that getting the core activated in isolation is the first step in the sequence of 'core, global mm, then functional movement'.That's the theory as I understand it and seems like we all agree some version of that.

As for supine being difficult to get TA contraction due to thoraco lumbar extension then you may well be right but I guess there would be a host of other reasons as well. The point for me is that it doesn't really matter what position we train the patient in as long as we have isolation as a starting point to progress from. In my experience it varies from patient to patient (which I think is what alinguyen was saying) so it is a matter of being flexible in how it is taught. Part of that flexibility means recognising some patients just ain't gonna get it and making the best of it.

Now what was the original posting about??

On another tangent, I think Peter O'Sullivan from WA has done some interesting stuff of late on core stability and related it to the effect on sacral movement and the role of the pelvic floor mm, connection to SIJ dysfunction, and how they all inter-relate. Not sure about the details/accuracy of that. I remember some time ago hearing from a colleague (now that sounds really reliable doesn't it) that Paul Hodges was conceiving of core stabilisation as just tapping into a pathway (what sort??) rather than being a biomechanical mechanism but I can't remember the details. Then there was someone else talking about the role of iliopsoas as being part of the stabilising mechanism and so on and on and on ... Interesting that when Beryl Kennedy was around teaching dynamic abdominal bracing (DAB) (anyone remember her and DAB?) that it allegedly produced great results as well. It utilised activation of external obliques as the mechanism to "stabilise" for those of you who were too young to know about it. Holy Sheet - that's probably most of you!!!! Anyway, why was that? It certainly didn't isolate TA or MF? Maybe it activated pelvic floor or tapped into "The Pathway". Interesting. Perhaps another lesson in 'The more we know the more we don't!' Then there's the old stand-by of 'it is the belief of the therapist that is all important'.

Aaah! dinner calls

[alophysio]

Hi gc [long post warning!!! It is way too early but i am avoiding writing a letter at the moment!]

No problems on when you reply! People have replied months and even years later on this forum!

I think you are right - we do agree on the theory etc. My assistant read this thread and told me i was too particular but i guess i like to make sure my thoughts are expressed in a particular way.

In my personal experience, i used to be more flexible in the way i positioned the L/S but i have found it better to get lumbopelvic-hip neutral and use pillows or props to help support the T/S and C/S and gradually get down to neutral up higher.

The reason why L/S neutral is important to me is because i have found it easier to activate the TA, LM and pelvic floor (PF).

In looking for compensations, you are right in saying there are many reasons for what we see. However, thoracolumbar extension in the presence of lumbar decreased lordosis and decreased hip flexion is something i see a lot of - perhaps it is simply because the people i see are office workers etc.

Another consideration is that Pilates was originally taught to ballet dancers - these girls tend to be lordodic (has anyone seen a ballet dancer who had excessive kyphosis problems??) so teaching them flat back may actually have been inspired because they would need to learn to control their spines in flexion as well as their usual extension (which is why they may have developed problems and sought out rehab with Joseph Pilates...)

As for Peter O'Sullivan, he doesn't believe in isolation of TA and then LM or PF but rather a functional co-contraction of TA and LM. I think this is because of his 1997 published study on stabilisation of spondylolithesis patients.

As for the Hodges tapping into a "pathway", from what i can gather, it is a motor learning strategy that imposes a "break" in the patient's usual motor control strategy.

By enforcing an isolation of TA in a bilateral co-contraction, you are bringing patients right back to a very basic "push" type strategy - Pushing being simultaneous angular rotation like shot putting. I guess it is considered easier to push something accurately rather than throw with sequential angular rotations. Think of how a novice throws and then develops their baseball throw etc...

Garry Allison did some research that suggeted that in "normals", the TA activated UNILATERALLY - he did this by measuring TA bilaterally and doing the Hodges series of unilateral rapid, unexpected arm raises.

THe whole biomechanical argument is that TA and Deep Fibres of LM don't generate enough torque to actually change things. Nor do they do so in enough time. It is like teaching "proprioception" exercises to ankle sprain patients - the time taken for joint receptors to actually cause a change in ankle positioning is about 100ms or more yet an accident event will take 70ms so by the time you realise you are going too far, it is too late - the balance exercises hopefully just keep you in the right position at the right strength.

There are other people looking at the role of iliopsoas in stability. I think there is some older (20 years old?) that showd that Iliopsoas is really iliacus generating an anterior tilting of the pelvis and psoas generating the posterior tilting to balance that out - and that iliopsoas is not really a strong hip flexor... I will try to find it sometime...

I have heard from older therapists who remember your "DAB" - while this may help a lot of people, particularly those who used an internal oblique strategy, it CERTAINLY WON"T help everyone. I would say that those who teach obliques as a strategy are simply assuming that the TA and LM will activate properly - and so in patients who don't have a problem in automatic activation, his would be fine BUT in those who do not automatically activate properly, then this DAB method, like McGill's co-contraction brace using the erector spinae and obliques WILL NOT help their problems (theoretically).

I would estimate that 99% of personal trainers, gym instructors, Pilates instructors and even a lot of physios teach obliques as the stabilisation strategy because their patients can "FEEL" it working. A 30% contraction of LM or TA or PF will not feel very strong at all - which is the whole "does it do anything biomechanically" point...

As for Yaro's question... i think you meant "what simple and effective [exercise] do we use?"

I use 5-6 simple exercises taught in a specific way...

1. Cat Stretch
2. Bridge Roll-up
3. Single-Leg Bridge (SLB)
4. Modified 100s
5. Modified Clams
6. 4-point "Swimming"

The focus of the first two exercises are on segmental motion control, dissociation of the pelvis and hips, T/S and pelvis/L/S and control of the shoulders. SLB is for glut strength while maintaining neutral L/S. Mod 100s is for control of IAP using TA/LM/PF co-contractions before leg movement. Mod Clams is for Glut Med. 4-pt-Swimming is for LM, using muscles like gluts with contralateral lats, control of hip position using glut med, scap stability, etc etc.

Sorry about the long post. It would be interesting to hear thoughts on the above. I now have to write that report i have been avoiding!

[linbin]

hi
the lumbopelvic movements are done to make the patient aware of the neutral zone.core spinal exercises are done in the neutral zone initially.isolation ex of transveerse abs and multifidus is done.then progresses to cocontraction of both and superimposing limb movements.progress to various functional positions.oblique strengthening is done i feel is based on the fact that transverse abdominis and obliques merge to thoracodorsal fascia to form tje "corset".so obliques also contribute to spinal stability. another point is that isolating a muscle action is difficult practically.

[alophysio]

Hi linbin,

I would have to disagree. I have taught many people to isolate the obliques from TrAb - that is why it is such a small contraction.

This can be using real-time ultrasound however it is not essential.

It is the whole "dog-and-poodle" argument - a Poodle is always a dog but a dog is not always a Poodle. In other words (assuming the other components of the inner unit muscles - diaphragm, multifidus and pelvic floor - are intact) TrAb isolated activity before movement initiation will usually result in "core stability" (Poodle is always a dog) but oblique activity without isolation of the TrAb does not always result in "core stability" (Dog is not always a Poodle).

Sometimes teaching a person obliques gets lucky and the person will automatically assume the correct activation sequences but other times they won't and will just get worse.

Lastly, i don't think we do these exercises to make the patient aware of the "neutral zone". Perhaps you meant neutral joint position. The neutral zone is the loose packed position before non-contractile structures like joint capsules and ligaments start to tension up. We do the core stability exercises to protect the joint in all positions through its ROM.

Cheers!

BTW, Merry Christmas to you all!

[Canuck Physio]

I realised recently that during weight training there is much benefit to be gained from have a strong 'core'.

Previously, I would perform squats or other exercises without thoughtful emphasis on keeping the core tight. More recently, I have attempted to resolve this during exercise movements.

I believe so far that it has been beneficial in allowing me to incorporate heavy exercises back into my program (back injury recently).

I definitely feel that the evidence around this topic is lacking, but, there is benefit to be gained from strengthening the core.

[alophysio]

Hi canuck_physio,

What is your idea of what the "core" actually is??

[Canuck Physio]

Hi canuck_physio,

What is your idea of what the "core" actually is??

I complete a combination of exercises targeting the rec abs, and include exercises that allow me to isolate the TrA. Creating INtra-abdominal pressure during heavy lifts. Avoiding the use of the belt. (When I mentioned the evidence was lacking, I meant in reference to back injuries in relation to outcome measures - which is difficult to measure).
Back_Strong_Figure5.jpg

[physiofixme]

Hi all

I've joined this forum late and can't believe I've missed it because I LOVE the whole topic of core strength and pelvic stability. I'm also a fan of Peter O'Sullivan's work. His studies focus on when the transverse abs are switched on and when they aren't. He found that too much lumbar flexion (or extension for that matter) inhibits TrAb activity.................so going back to original question about introducing lumbar flexion while teaching core stability he would say that in lumbar flexion the transverse abdominal activity is inhibited.

Also an important point is that supine positions are really just for isolating activity and teaching the technique.......then ultimately getting people to do core strength exercises in an upright position and still be able to isolate TrAb and multifidis while performing a squat, upright lift etc as these are the more functional positions....this is when people need to be able to use their core. Good core muscle activity in supine is all very well but no good if a patient can't transfer this to an upright position.

I'd also wonder about introducing too much lumbar flexion in to core strength exercises in someone recovering from back injury???