Core Stability for Back and SI Core Stability for Back and SI - - PowerPoint PPT Presentation

Core Stability for Back and SI Pathologies Core Stability for Back and SI Pathologies

58th Eastern Athletic Trainers’ Association’s Annual Meeting and Clinical Symposium Philadelphia, Pa 2006 Michael Higgins PhD, ATC/PT,CSCS 58th Eastern Athletic Trainers’ Association’s Annual Meeting and Clinical Symposium Philadelphia, Pa 2006 Michael Higgins PhD, ATC/PT,CSCS

Stabilizing Systems Stabilizing Systems

• 3 Subsystems

– Passive

• Vertebrae
• Discs
• Ligaments

– Active

• 3 Subsystems

– Passive

• Vertebrae
• Discs
• Ligaments

– Active

• Muscle and tendons that apply force to the

spine

– Neural

• Muscle and tendons that apply force to the

spine

– Neural

Trunk Stabilizers Trunk Stabilizers

• Attach directly to the vertebrae
• Are all important
• Importance depends on activity
• Unisegmental
• Multisegmental
• Attach directly to the vertebrae
• Are all important
• Importance depends on activity
• Unisegmental
• Multisegmental

Target Muscles Target Muscles

• Unisegmental

– Force transducers – Provide feedback on spinal position – Work closely with neural system EXAMPLES: – Multifidus – Intertransversi muscles – Interspinalis muscles

• Unisegmental

– Force transducers – Provide feedback on spinal position – Work closely with neural system EXAMPLES: – Multifidus – Intertransversi muscles – Interspinalis muscles

Rotators and Intertransversari Rotators and Intertransversari

• Small cross-

sectional areas

• Contribution to

rotation is minimal

• Vertebral position

sensors

• Small cross-

sectional areas

• Contribution to

rotation is minimal

• Vertebral position

sensors

Longissumus, Iliocostalis and Multifidus group Longissumus, Iliocostalis and Multifidus group

• Divided into pars thoracic

and pars lumborum

• Pars thoracics have a

strong extensor moment with low compressive force

• Pars lumborum

generates posterior shear forces that support reaction anterior shear force of the upper vertebrae

• Divided into pars thoracic

and pars lumborum

• Pars thoracics have a

strong extensor moment with low compressive force

• Pars lumborum

generates posterior shear forces that support reaction anterior shear force of the upper vertebrae

Multifidus Multifidus

• Forces only affect

small areas of the spine

• Produce extension

torque

• Forces only affect

small areas of the spine

• Produce extension

torque

Target Muscles Target Muscles

• Multisegmental muscles

– Produce and control spinal motion Examples: – Transversus Abdominis – Rectus Abdominis – Lumbar Erector Spinae – Quadratus Lumborum – Obliques

• Multisegmental muscles

– Produce and control spinal motion Examples: – Transversus Abdominis – Rectus Abdominis – Lumbar Erector Spinae – Quadratus Lumborum – Obliques

Transversus Abdominis Transversus Abdominis

• Inner surfaces of

cartilage of lower six ribs to linea alba by aponeurosis

• Abdominal hollowing
• Draw abdomen up

and in

• Incorporate into the

exercise program

• Inner surfaces of

cartilage of lower six ribs to linea alba by aponeurosis

• Abdominal hollowing
• Draw abdomen up

and in

• Incorporate into the

exercise program

Rectus Abdominis Rectus Abdominis

• Pubic crest and

symphisis to 5th, 6th and 7th rib costal cartilage

• Major trunk flexor
• All sections of the

rectus are activated together

• No functional

separation appears to exist between upper and lower abs*

• Pubic crest and

symphisis to 5th, 6th and 7th rib costal cartilage

• Major trunk flexor
• All sections of the

rectus are activated together

• No functional

separation appears to exist between upper and lower abs* *Lehman, McGill, 2001

Erector Spinae Erector Spinae

• Superman exercises

– > 4000N of spinal compression

• Quadruped exercises

– Minimizes spine load

• Superman exercises

– > 4000N of spinal compression

• Quadruped exercises

– Minimizes spine load

Quadratus Lumborum Quadratus Lumborum

• Attach to TP of all

lumbar vertebrae, pelvis and rib cage

• Acts as a buttress

to lateral instability

• Appears to be

highly involved in spine stability

• Attach to TP of all

lumbar vertebrae, pelvis and rib cage

• Acts as a buttress

to lateral instability

• Appears to be

highly involved in spine stability

Internal/External Oblique

(Anterior view)

Internal/External Oblique

(Anterior view)

• Anterior and lateral

fibers

• IO has upper and

lower anterior fibers

• Lower anterior fibers

support and compress lower abdominal viscera with TA

• Anterior and lateral

fibers

• IO has upper and

lower anterior fibers

• Lower anterior fibers

support and compress lower abdominal viscera with TA

Internal/External Oblique

(Posterior view)

Internal/External Oblique

(Posterior view)

• Obliques are

regionally activated

• Increase activity when

spine is axially compressed*

• Obliques are

regionally activated

• Increase activity when

spine is axially compressed*

*Juker, McGill and Kropf, 1998

Internal/External Oblique Internal/External Oblique

• Assists with active

expiration^

• Creates “hoop

stresses” and stiffness with TA to assist with spine stability

• Assists with active

expiration^

• Creates “hoop

stresses” and stiffness with TA to assist with spine stability

^Henke, et. al., 1988

Internal/External Oblique

(hoop stress)

Internal/External Oblique

(hoop stress)

Training Training

Goals of Training Goals of Training

• Produce high levels of muscle

activation

• Low level of spinal loading
• Consider strength, endurance and

neuromuscular factors

• Produce high levels of muscle

activation

• Low level of spinal loading
• Consider strength, endurance and

neuromuscular factors

Stabilization Myths Stabilization Myths

• Sit ups

– Replicates potential injury mechanism – Cause increase compression of lumbar spine and discs – Do not press low back against floor

• Leg raises

– Increase psoas activiation and spine compression

• Sit ups

– Replicates potential injury mechanism – Cause increase compression of lumbar spine and discs – Do not press low back against floor

• Leg raises

– Increase psoas activiation and spine compression

Stabilization Myths Stabilization Myths

• Strength

– Poor association with low back health

• Range of Motion

– Increased ROM may lead to greater risk of back injury – Must have enough stability for all motions

• Endurance

– Most important in preventing back dysfunction

• Strength

– Poor association with low back health

• Range of Motion

– Increased ROM may lead to greater risk of back injury – Must have enough stability for all motions

• Endurance

– Most important in preventing back dysfunction Biering-Sorensen. Spine 9:106-119, 1984

Strength vs. Endurance Strength vs. Endurance

• Many traditional weight training

approaches for other joints are not applicable for the back.

• Motor control important for spine

stability

– Motor control errors resulting in improper muscle forces increase with fatigue

• Many traditional weight training

approaches for other joints are not applicable for the back.

• Motor control important for spine

stability

– Motor control errors resulting in improper muscle forces increase with fatigue

Advanced Exercise Advanced Exercise

EXTENSION EXTENSION

Hyper vs. Reverse Curl Hyper vs. Reverse Curl

• Hypers tend to focus on larger erector muscles
• Reverse curl activate the smaller muscle groups

that attached segmentally

• Hypers tend to focus on larger erector muscles
• Reverse curl activate the smaller muscle groups

that attached segmentally

Hypers vs Reverse Curl Hypers vs Reverse Curl

• Focus on where the axis of movement

is occurring (ie; hips or lumbar spine)

• Focus on where the axis of movement

is occurring (ie; hips or lumbar spine)

Physioball Use Physioball Use

• Liable surfaces have been found to cause more

activity in the core musculature while increasing spinal loading*

*Vera-Garcia, Grenier, and McGill. 2000

• Liable surfaces have been found to cause more

activity in the core musculature while increasing spinal loading*

*Vera-Garcia, Grenier, and McGill. 2000

Cable Extensions Cable Extensions

• Pull thrus

– Maintain neutral spine – Start with no or very light weight – Progress to stepping in different directions

• Pull thrus

– Maintain neutral spine – Start with no or very light weight – Progress to stepping in different directions

Lat Pull Downs Lat Pull Downs

• Will enhance spine

stabilization by increasing the demand of the spinal extensor muscles and the Latissimus Dorsi

• May want to do

standing (basketball)

• Will enhance spine

stabilization by increasing the demand of the spinal extensor muscles and the Latissimus Dorsi

• May want to do

standing (basketball)

Bridges Bridges

• Great for glute

activation

• Single leg
• Progress to liable

surfaces

• Great for glute

activation

• Single leg
• Progress to liable

surfaces

Romanian Deadlift (RDL) Romanian Deadlift (RDL)

• Head up/chest up
• Bend from hips
• Glute and hamstring
• Head up/chest up
• Bend from hips
• Glute and hamstring

Wrong Right

Band or Cable Extension Band or Cable Extension

• Maintain neutral spine/abdominal brace
• Pull thru hips
• Breathe normally
• Maintain neutral spine/abdominal brace
• Pull thru hips
• Breathe normally

ABDOMINAL ABDOMINAL

Abdominal Exercises Abdominal Exercises

• Curl -ups
• Increase reps as endurance increase 7-8 sec hold
• Must maintain normal breathing, neutral spine and

abdominal brace

• Progress to liable surfaces
• Curl -ups
• Increase reps as endurance increase 7-8 sec hold
• Must maintain normal breathing, neutral spine and

abdominal brace

• Progress to liable surfaces

Abdominal Exercises Abdominal Exercises

• Planks
• Increase reps as endurance increase 7-8 sec hold
• Must maintain normal breathing, neutral spine and

abdominal brace

• Planks
• Increase reps as endurance increase 7-8 sec hold
• Must maintain normal breathing, neutral spine and

abdominal brace

Abdominal Exercises Abdominal Exercises

• Keep a neutral position
• End in plank position (hold)
• Progress from knees to feet
• Keep a neutral position
• End in plank position (hold)
• Progress from knees to feet

Abdominal Exercises Abdominal Exercises

• Liable surface planks
• Push ups off balls
• Must maintain normal breathing, neutral spine

and abdominal brace

• Liable surface planks
• Push ups off balls
• Must maintain normal breathing, neutral spine

and abdominal brace

Abdominal Exercises Abdominal Exercises

• Liable surface planks
• Push ups off balls
• Must maintain normal breathing, neutral spine

and abdominal brace

• Liable surface planks
• Push ups off balls
• Must maintain normal breathing, neutral spine

and abdominal brace

Abdominal Exercises Abdominal Exercises

• Overhead pulls
• Good for total

body integration

• Must maintain

normal breathing, neutral spine and abdominal brace

• Overhead pulls
• Good for total

body integration

• Must maintain

normal breathing, neutral spine and abdominal brace

Standing Press Standing Press

• Can add lunge with

pressing motion

• Must maintain

abdominal brace

• Good for co-

activation of lumbar stabilizers

• Can add lunge with

pressing motion

• Must maintain

abdominal brace

• Good for co-

activation of lumbar stabilizers

Multi-Segmental Exercise Multi-Segmental Exercise

Overhead Squat Overhead Squat

• Neutral spine a must
• Incorporates thoracic

and lumbar extensors

• Increases demand by

using weights in the hands

• Neutral spine a must
• Incorporates thoracic

and lumbar extensors

• Increases demand by

using weights in the hands

Overhead Squat Overhead Squat

Squat Squat

• Add bands or

chains to help increase balance and proprioceptive feedback

• Add bands or

chains to help increase balance and proprioceptive feedback

High Row with Squat High Row with Squat

• Maintain neutral spine/abdominal brace
• Can add more rotation
• Co-activation of lumbar stabilizers
• Maintain neutral spine/abdominal brace
• Can add more rotation
• Co-activation of lumbar stabilizers

Lunges with Resistance Lunges with Resistance

• Make sure that proper form is used
• Abdominal bracing is required
• Make sure that proper form is used
• Abdominal bracing is required

Standing Row Standing Row

• Abdominal brace
• Progress from bilateral to unilateral stance
• Abdominal brace
• Progress from bilateral to unilateral stance

Rotation Exercises Rotation Exercises

• Needed for advanced training in athletes
• Tradeoff of high compressive stresses
• Needed for advanced training in athletes
• Tradeoff of high compressive stresses

Band or Cable Extension/Rotation Band or Cable Extension/Rotation

• Maintain neutral spine/abdominal brace
• Pull thru hips
• Breathe normally
• Maintain neutral spine/abdominal brace
• Pull thru hips
• Breathe normally

Weighted Lunge Weighted Lunge

• Good for grooving

motor patterns for rotators to stabilize the spine during higher level activities

• Good for grooving

motor patterns for rotators to stabilize the spine during higher level activities

Star Pattern Exercises Star Pattern Exercises

• Place a + sign on the floor
• Stand in center of + or in one of the

four quadrants

• Perform lunges; back, side, diagonal

into desired quadrants

• What is performed on one side

should be repeated on the opposite side

• Place a + sign on the floor
• Stand in center of + or in one of the

four quadrants

• Perform lunges; back, side, diagonal

into desired quadrants

• What is performed on one side

should be repeated on the opposite side

Star Pattern Exercises Star Pattern Exercises

• Resistance may be added to

activities (pulleys or dumbbells)

• Promotes stability throughout an

activity

• Abdominal brace should be held

throughout exercise

• Resistance may be added to

activities (pulleys or dumbbells)

• Promotes stability throughout an

activity

• Abdominal brace should be held

throughout exercise

Star Pattern Exercises Star Pattern Exercises

Hip with Trunk Rotation Hip with Trunk Rotation

• Start slow to groove pattern progressing

to rapid movements

• Maintain abdominal brace
• Start slow to groove pattern progressing

to rapid movements

• Maintain abdominal brace

Cable Exercises Cable Exercises

• Cable rotation

– Maintain neutral spine – Start with no or very light weight – Progress to stepping in different directions – Single or double handed

• Cable rotation

– Maintain neutral spine – Start with no or very light weight – Progress to stepping in different directions – Single or double handed

Chopping Wood Chopping Wood

• Keep spine neutral
• Maintain

abdominal brace

• Progress from

slow to fast movement

• Flexion/rotation

movement

• Keep spine neutral
• Maintain

abdominal brace

• Progress from

slow to fast movement

• Flexion/rotation

movement

Reverse Chops Reverse Chops

• Keep spine neutral
• Maintain

abdominal brace

• Progress from

slow to fast movement

• Extension/rotation

movement

• May add hold at

the end

• Keep spine neutral
• Maintain

abdominal brace

• Progress from

slow to fast movement

• Extension/rotation

movement

• May add hold at

the end

Hip Thrust Hip Thrust

• Maintain neutral spine/abdominal brace
• Pull thru hips
• Breathe normally
• Maintain neutral spine/abdominal brace
• Pull thru hips
• Breathe normally

To Use or Not Use a Belt To Use or Not Use a Belt

• Belt wearers have

altered motor patterns

• For healthy backs

belts not necessary

• May be good for
• ne time heavy

lifts

• Athlete dependent
• Belt wearers have

altered motor patterns

• For healthy backs

belts not necessary

• May be good for
• ne time heavy

lifts

• Athlete dependent

Example Program Example Program

Basketball Conditioning (In-season) Basketball Conditioning (In-season)

• Conditioning exercise
• Curl up x 7
• Conditioning exercise
• Side-front-side plank x 2
• Conditioning exercise
• “Bird Dog” x 3 each side
• Repeat
• Conditioning exercise
• Curl up x 7
• Conditioning exercise
• Side-front-side plank x 2
• Conditioning exercise
• “Bird Dog” x 3 each side
• Repeat

Weight Room Exercises Weight Room Exercises

• May incorporate

– Lat pull down – Overhead squat (proper form a must) – Squat with bands or chains – Cleans (proper form a must) – Reverse curl up – Medicine ball lifts – Cable exercises – Rotation exercises – One legged leg press (helps keep spine in neutral position)

• May incorporate

– Lat pull down – Overhead squat (proper form a must) – Squat with bands or chains – Cleans (proper form a must) – Reverse curl up – Medicine ball lifts – Cable exercises – Rotation exercises – One legged leg press (helps keep spine in neutral position)

REMEMBER REMEMBER

• Most benefit when performed daily
• “No Pain No Gain” axiom not applicable
• Cardiovascular health important
• Do not emphasize strength gain at the

expense of endurance

• Avoid FROM spinal exercise close to rising

in the morning

• Most benefit when performed daily
• “No Pain No Gain” axiom not applicable
• Cardiovascular health important
• Do not emphasize strength gain at the

expense of endurance

• Avoid FROM spinal exercise close to rising

in the morning

REMEMBER REMEMBER

• Breath normally

– Helps maintain abdominal activation for spinal stability – Exception for maximal lifts

• Groove motion and muscular activation

patterns to prepare spine for athletic performance

• Stay away from repetitive positions of high

disc pressures

• Attain flexible hips and knees
• Breath normally

– Helps maintain abdominal activation for spinal stability – Exception for maximal lifts

• Groove motion and muscular activation

patterns to prepare spine for athletic performance

• Stay away from repetitive positions of high

disc pressures

• Attain flexible hips and knees

REFERENCES REFERENCES

• McGill SM. Exercise and Sport Science Reviews. 2001.
• McGill SM. Ultimate Back Fitness and Performance. 2004
• Axler CT, McGill, SM. Medicine and Science in Sport and
• Exercise. 1997.
• McGill SM. Low Back Disorders. 2002.
• Vera-Garcia FJ, Grenier SG, McGill SM. Physical Therapy. 2000
• Callaghan JP, Gunning JL, McGill SM. Physical Therapy. 1998.
• McGill SM. Physical Therapy. 1998.
• Cholewicki J, Panjabi MM, Khachatryan A. Spine. 1997.
• Henke KE, Sharratt MT, Pegelow D, Dempsey JA. Journal of

Applied Physiology. 1988.

• Lehman G, McGill SM. Physical Therapy. 2001.
• Biering-Sorensen F. Spine. 1984.
• Juker D, McGill SM, Kropf P. Journal of Applied Biomechanics.

1998.

• Juker D, McGill SM, Kropf P. Medicine and Science in Sports and
• Exercise. 1998
• McGill SM. Exercise and Sport Science Reviews. 2001.
• McGill SM. Ultimate Back Fitness and Performance. 2004
• Axler CT, McGill, SM. Medicine and Science in Sport and
• Exercise. 1997.
• McGill SM. Low Back Disorders. 2002.
• Vera-Garcia FJ, Grenier SG, McGill SM. Physical Therapy. 2000
• Callaghan JP, Gunning JL, McGill SM. Physical Therapy. 1998.
• McGill SM. Physical Therapy. 1998.
• Cholewicki J, Panjabi MM, Khachatryan A. Spine. 1997.
• Henke KE, Sharratt MT, Pegelow D, Dempsey JA. Journal of

Applied Physiology. 1988.

• Lehman G, McGill SM. Physical Therapy. 2001.
• Biering-Sorensen F. Spine. 1984.
• Juker D, McGill SM, Kropf P. Journal of Applied Biomechanics.

1998.

• Juker D, McGill SM, Kropf P. Medicine and Science in Sports and
• Exercise. 1998

THANK YOU THANK YOU