integrated core training manual_lowres.pdf

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IntegratedCore

Training

National Academy of Sports Medicine


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Integrated Core Training

Copyright 2008 National Academy of Sports Medicine

Printed in the United States of America

All rights reserved. Except for use in a review, the reproduction or utilization of this work in any form

or any electronic, mechanical or other means, now known or hereafter invented, including xerography,

photocopying and recording, and in any information-retrieval system is forbidden without the written

permission of the National Academy of Sports Medicine.

Distributed by:

National Academy of Sports Medicine

26632 Agoura RoadCalabasas, CA 91302

800.460.NASM

Facsimile: 818.878.9511

http: www.nasm.org

Author: Dr. Micheal Clark, DPT, MS, PES, CES


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IntroductionTo stay on the cutting edge of research, science, and practical application, the health and fitness professional

needs to follow a comprehensive, systematic, and integrated approach when training, reconditioning, or

rehabilitating a client. In order to develop a comprehensive integrated training program, the health and

fitness professional must fully understand the functional kinetic chain. An integrated training program

is a comprehensive approach that strives to improve all the components necessary to achieve optimum

performance (strength, balance, flexibility, endurance, and power). Since the core is where the human

bodys center of gravity is located and where all movement begins1,2,3,4this chapter focuses on the funda-

mental concepts of core stabilization, and how the health and fitness professional can design an effective

and dynamic core stabilization program.5,6,7,8,9,10,11

Section I: Core Stabilization Concepts

Section II: Functional Anatomy of the Core

Section III : Scientific Rationale for Core Stabilization Training

Section IV: Guidelines for Core Stabilization Training

Section V: Core Stabilization Training Program Design

Section VI: Summary

References

Traditionally, training has focused on isolated, absolute strength gains in isolated muscles, utilizing single

planes of motion. However, all functional activities are multi-planar and require acceleration, decelera-

tion, and dynamic stabilization.10,11,12Movement may appear to be single-plane dominant, but the other

planes need to be dynamically stabilized to allow for optimum neuromuscular efficiency.13Understanding

that functional movements require a highly complex, integrated system enables the health and fitness

professional to make a paradigm shift. The paradigm shift focuses on training the entire kinetic chain

utilizing all planes of movement, while establishing high levels of functional strength and neuromuscular

efficiency.3,14,15,16,17,18The paradigm shift also dictates that the health and fitness professional train force

reduction, force production, and dynamic stabilization during all kinetic chain activities.9,19


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A core stabilization training program (Figure 1) improves dynamic postural control, ensures appropriatemuscular balance and joint arthrokinematics around the lumbo-pelvic-hip complex (LPHC), and allows

for the expression of dynamic functional strength and improved neuromuscular efficiency throughout the

entire kinetic chain.9,10,13,14,15,17,18,19,20,21,22,23,24,25

Figure 1: Benefits of Core Training

1. Improve dynamic postural control

2. Ensure appropriate muscular balance and joint arthrokinematics

3. Allow for the expression of functional strength

4. Provide intrinsic stability to the LPHC, which allows for optimum

neuromuscular efficiency of the rest of the kinetic chain


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Section I:Core Stabilization Concepts

The core is defined as the LPHC.9,13There are twenty-nine muscles that attach to the LPHC.9,26,27,28An

efficient core allows for the maintenance of optimum length-tension relationships of functional agonists

and antagonists, which makes it possible for the body to maintain optimum force-couple relationships in

the LPHC. Maintaining optimum length-tension relationships and force-couple relationships allows for the

maintenance of optimum joint arthrokinematics in the LPHC during functional kinetic chain movements.18,25,29

This provides optimum neuromuscular efficiency in the entire kinetic chain, and allows for optimum accel-

eration, deceleration, and dynamic stabilization during integrated, dynamic movements.1,2,3,4,9,11,13,18,25,30

The core operates as an integrated functional unit, enabling the entire kinetic chain to work synergistically

to produce force, reduce force, and dynamically stabilize against abnormal force.13In an efficient state,

each structural component distributes weight, absorbs force, and transfers ground reaction forces.13This

integrated, interdependent system needs to be appropriately trained to enable it to function efficiently

during dynamic activities.

Many individuals have developed functional strength, power, neuromuscular control, and muscular endur-

ance in specific muscles that enable them to perform functional activities.9,11,13,31However, few people

develop the muscles required for spinal stabilization.30,31,32

The bodys stabilization system has to functionoptimally to effectively utilize the strength, power, neuromuscular control, and muscular endurance that

it has developed in its prime movers. If the extremity muscles are strong and the core is weak, there will

not be enough force created to produce efficient movements. A weak core is a fundamental problem

inherent to inefficient movement that leads to predictable patterns of injury.11,30,31,32

The core musculature is an integral component of the protective mechanism that relieves the spine of

deleterious forces that are inherent during functional activities.14A properly designed core stabilization

training program helps an individual gain strength, neuromuscular control, power, and muscle endurance of

the LPHC. This integrated approach facilitates balanced muscular functioning of the entire kinetic chain.13

Greater neuromuscular control and stabilization strength provides a more biomechanically efficient posi-tion for the entire kinetic chain, and thereby allows optimum neuromuscular efficiency throughout the

kinetic chain.


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Neuromuscular efficiency is established by the appropriate combination of postural alignment (static/dynamic) and stability strength, which enables the body to decelerate gravity, ground reaction forces, and

momentum.10,15,19If the neuromuscular system is not efficient, it will be unable to respond to the demands

placed on it during functional activities.13As the efficiency of the neuromuscular system decreases, the

ability of the kinetic chain to maintain appropriate forces and dynamic stabilization decreases significantly.

This decreased neuromuscular efficiency leads to compensation and substitution patterns (synergistic

dominance, altered reciprocal inhibition, arthrokinetic inhibition), as well as poor posture during functional

activities.18,20,25This increases mechanical stress on the contractile and non-contractile tissue and leads to

repetitive microtrauma, abnormal biomechanics, and injury.14,16,20,33


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Section II:Functional Anatomyof the Core

The traditional perception of muscles is that they work concentrically and predominantly in one plane of

motion. However, in order to more effectively understand motion and design efficient training, recondi-

tioning, and rehabilitation programs, it is imperative to view muscles functioning in all planes of motion

and in the full contraction spectrum (eccentrically, stabilization, and concentrically). The following section

will describe the isolated and integrated functions of the major muscles of the kinetic chain.

27,28

Lower Extremity Functional Anatomy

The lower extremity musculature functions synergistically to stabilize the entire kinetic chain during func-

tional movement patterns. The lower extremity also works synergistically to eccentrically decelerate and

concentrically accelerate the entire kinetic chain during functional movement patterns.27,34


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Hamstrings

The traditional view of the hamstring is that it assists with hip extension and knee flexion. The integrated

view is that it eccentrically decelerates knee extension, hip flexion, and internal rotation at heel strike,

eccentrically decelerates iliosacral anterior rotation during functional movements, and dynamically stabi-

lizes the LPHC during functional movement patterns.

Figure 2: Hamstrings


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Hip Abductors

These include the gluteus medius, gluteus minimus, and tensor fascia latae. The traditional view is that the

hip abductors abduct the femur. The integrated view is that the gluteus medius decelerates hip adduction

and hip internal rotation, and the gluteus minimus and tensor fascia latae decelerate hip adduction. The

tensor fascia latae also assists in decelerating hip extension and hip external rotation. The entire abductor

complex works synergistically as the primary frontal-plane stabilizing mechanism (lateral sub-system).

Figure 3: Hip Abductor Complex


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Gluteus Maximus

The traditional view is that the gluteus maximus produces hip extension and external rotation. The

integrated view is that it eccentrically decelerates hip flexion, hip adduction, and hip internal rotation

during stance phase, decelerates tibial internal rotation via the iliotibial band (ITB), assists in stabilizing

the sacroiliac joint (SIJ) via the sacrotuberous ligament and the lateral knee via the ITB.

Figure 4: Gluteus Maximus


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Iliopsoas

This consists of the iliacus, psoas major, and psoas minor. The traditional view is that the lliopsoas pro-

duces hip flexion. The integrated view is that it eccentrically decelerates femoral internal rotation at heel

strike, eccentrically decelerates hip extension, and assists in stabilizing the lumbar spine during functional

movements.

Figure 5: Iliopsoas


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Core Functional Anatomy

The core musculature functions synergistically to stabilize, eccentrically decelerate, and concentrically

accelerate the entire kinetic chain during functional movement patterns.

Erector Spinae

This muscle includes the iliocostalis, longissimus, and spinalis. The traditional view is that the erector spinae

extends the trunk. The integrated view is that it eccentrically decelerates flexion, rotation, and lateral

flexion of the lumbar spine, and dynamically stabilizes the lumbar spine during functional movements.

Figure 6: Erector Spinae


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Abdominal Complex

This includes the rectus abdominus, external oblique, internal oblique, and transverse abdominus (TVA).

The traditional view of the abdominal complex is that it flexes and rotates the trunk. The integrated view

is that the rectus abdominuseccentrically decelerates extension and rotation, dynamically stabilizes the

LPHC, and concentrically flexes the spine. The external obliqueeccentrically decelerates extension and

rotation, dynamically stabilizes the LPHC, and concentrically posteriorly rotates the pelvis, flexes the pelvis

and produces contralateral rotation. The internal oblique

eccentrically decelerates extension and rotation,

dynamically stabilizes the LPHC, and concentrically produces flexion and ipsilateral rotation. And finally,

the TVAworks primarily to dynamically stabilize the LPHC during functional movement patterns.

Figure 7: Addominal Complex


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Upper Extremity Functional AnatomyThe upper extremity musculature functions synergistically to stabilize, eccentrically decelerate and con-

centrically accelerate the entire kinetic chain during functional movement patterns.

Latissimus Dorsi

The traditional view of the latissimus dorsi is that it adducts, extends, and internally rotates the humerus.

The integrated view is that it eccentrically decelerates flexion, abduction, and external rotation of the

upper extremity, assists in dynamic stabilization of the LPHC through the thoracolumbar fascia (TLF)

mechanism, and functions as a bridge between the upper and lower extremity.

Figure 8: Latissimus Dorsi


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Current Concepts in Functional AnatomyIt has been proposed that there are two distinct yet interdependent muscular systems that enable our

bodies to maintain proper stabilization and ensure efficient distribution of forces for the production of

movement. Crisco and Panjabi12have suggested that muscles located more centrally to the spine provide

intersegmental stability (support from vertebrae to vertebrae) while the more lateral muscles support

the spine as a whole. Bergmark35has categorized these different systems with relation to the trunk into

local and global muscular systems.


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Joint Support System

The Inner Unit (Local Muscular System): The local musculature or inner unit consists of muscles that

are predominantly involved in joint support or stabilization.35,36Thus we have chosen to refer to the local

muscles as joint support systems. It is important to note, however, that joint support systems are not

confined to the spine and are evident in the peripheral joints as well.

Joint support systems consist of muscles that are not movement specific, but provide stability to allow

movement of a joint. They usually are located in proximity to the joint. They also have a broad spectrum

of attachments to the joints passive elements that make them ideal for increasing joint stiffness and thus

stability.36A common example of a peripheral joint support system is the rotator cuff for the glenohu-

meral joint that provides dynamic stabilization for the humeral head in relation to the glenoid fossa during

movement.37,38Other joint support systems include the posterior fibers of the gluteus medius and the

external rotators of the hip that perform pelvo-femoral stabilization,39and the vastus medialis obliquus

that provides patellar stabilization at the knee.40The joint support system of the core (LPHC) consists of

muscles that either originate or insert (or both) into the lumbar spine.4The major muscles include the

TVA, lumbar multifidus, internal oblique, diaphragm and the muscles of the pelvic floor.35,36,41This joint

support system has also been referred to as the inner unit. 41

Figure 9: Inner Unit


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The Outer Unit (Global Muscular Systems): The global muscles (outer unit) are predominantly respon-sible for movement and consist of more superficial musculature that attaches from the pelvis to the rib cage

and/or the lower extremities.35,36,41The major muscles include the rectus abdominis, external obliques,

erector spinae, hamstrings, gluteus maximus, latissimus dorsi, adductors, hamstrings, and quadriceps. The

outer unit muscles are predominantly larger and are associated with movement of the trunk and limbs and

equalize external loads placed upon the body. They also are important because they transfer and absorb

forces from the upper and lower extremities to the pelvis.36The outer unit musculature has been broken

down and described as force couplesworking in four sub-systems.42,43,44,45These sub-systems include the

deep longitudinal, posterior oblique, anterior oblique, and lateral sub-systems.This distinction allows for

an easier description and review of functionalanatomy. Its crucial for health and fitness professionals to

think of these sub-systems

operating as an integrated functional unit. Remember, the

central nervous

system is designed to optimize the selection of musclesynergies, not isolated muscles.46,47,48,49

Figure 10: Outer Unit


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The Deep Longitudinal Sub-System (DLS): The major contributors to the DLS are the erector spi-nae, TLF, sacrotuberous ligament, and biceps femoris. Some experts suggest that the DLS provides one

means of a reciprocal force transmission longitudinally from the trunk to the ground.42,45As illustrated in

Figure 11, the long head of the biceps femoris attaches to the sacrotuberous ligament at the ischium. The

sacrotuberous ligament in turn attaches from the ischium to the sacrum. The erector spinae attaches

from the sacrum and ilium up to the ribs and cervical spine. Activation of the biceps femoris increases

tension in the sacrotuberous ligament, which transmits force across the sacrum stabilizing the SIJ, and

allows force transference up through the erector spinae to the upper body.42,45

Figure 11: Deep Longitudinal Sub-System

This transference of force is apparent during the normal gait. Prior to heel strike, the biceps femoris

activates to eccentrically decelerate hip flexion and knee extension.50Just after heel strike, the biceps

femoris is further loaded through the lower leg via inferior movement of the fibula.51,52This tension from

the lower leg, up through the biceps femoris, into the sacrotuberous ligament and up the erector spinae

creates a force that assists in stabilizing the SIJ.42,45

Another force couple not mentioned in the DLS consists of the superficial erector spinae, the psoas and

the inner unit. While the erector spinae and psoas create lumbar extension and an anterior shear force

at L4S1, the inner unit provides inter-segmental stabilization and a posterior shear force (neutralizer)


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during functional movement.28,36,41

Dysfunction in any of these structures can lead to SIJ instability and lowback pain (LBP),45demonstrating the importance of training these structures as a functional unit.

The Posterior Oblique Sub-System (POS): The POS works synergistically with the DLS. As illustrated

in Figure 12, the gluteus maximus and latissimus dorsi attach to the TLF, which connects to the sacrum.

The fiber arrangements of these muscles run perpendicular to the SIJ. Thus, when the contralateral glu-

teus maximus and latissimus dorsi contract, they create a stabilizing force for the SIJ. 45Just prior to heel

strike, the latissimus dorsi and the contralateral gluteus maximus are eccentrically loaded. At heel strike,

each muscle accelerates (concentric action) its respective limb and creates tension in the TLF. This ten-

sion assists in the stability of the SIJ. In addition, the POS transfers forces that are summated from the

transverse plane orientation of these muscles to propulsion in the sagittal plane when we walk or run.The POS is also of prime importance for other rotational activities such as swinging a golf club, swinging

a baseball bat, and/or throwing a ball.42,44,45Dysfunction of any structure in the POS can lead to SIJ insta-

bility and LBP. The weakening of the gluteus maximus and/or latissimus dorsi may also lead to increased

tension in the hamstring and therefore cause reoccurring hamstring strains.41,45,53

Figure 12: Posterior Oblique Sub-System Image

The Anterior Oblique Sub-System (AOS): The AOS also functions in a transverse plane orientation

very similarly to the POS only from the anterior portion (front) of the body. Its prime contributors are

the oblique muscles (internal and external) adductor complex, and hip external rotators. Viewing elec-

tromyography (EMG) data on the obliques, adductors, and hip external rotators, it is apparent that they


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function to aid in the stability and rotation of the pelvis, as well as contributing to leg swing.27,50

The AOSis also implicated in the stabilization of the SIJ.54As illustrated in Figure 13, when we walk, our pelvis must

rotate in the transverse plane in order to create a swinging motion for the legs. 42 This rotation comes in

part from the POS posteriorly and the AOS anteriorly. One only needs to look at the fiber arrangements

of the muscles involved (latissimus dorsi, gluteus maximus, internal and external obliques, adductors, and

hip rotators) to realize this point. The AOS is also necessary for functional activities involving the trunk,

upper and lower extremities. The obliques, in concert with the adductor complex, not only produce

rotational and flexion movements, but also are instrumental in stabilizing the LPHC.44,54

Figure 13: Anterior Oblique Sub-System Image

The Lateral Sub-System (LS) : The LS is comprised of the gluteus medius, tensor fascia latae, adductor

complex, and quadratus lumborum. The LS has been implicated in frontal plane stability.28,53This system

is responsible for pelvo-femoral stability. Figure 14illustrates how, during single-leg functional movements

such as in gait, lunges, or stair climbing, the ipsilateral gluteus medius, tensor fascia latae, and adductors

combine with the contralateral quadratus lumborum to control the pelvis and femur in the frontal plane.28,53

Dysfunction in the LS is evident by increased pronation (flexion, internal rotation and adduction) of the

knee, hip and/or feet during walking, squats, lunges or climbing stairs. Accessory frontal plane movementduring gait is characterized by decreased strength and neuromuscular control in the LS.55,56Keep in mind

that for reasons of explanation, these four sub-systems have been oversimplified and that the human

body simultaneously utilizes all four of these sub-systems during activity. Each sub-system individually and

interdependently contributes to the production of efficient movement by accelerating, decelerating, and

dynamically stabilizing the kinetic chain during motion.


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Figure 14: Lateral Sub-System

All of these muscles play an integral role in the kinetic chain because they provide dynamic stabilization

and optimum neuromuscular control of the entire LPHC. When isolated, these muscles do not effectively

achieve stabilization of the LPHC. It is the synergistic, interdependent functioning of the entire LPHC that

enhances the stability and neuromuscular control throughout the entire kinetic chain.

Stabilization Mechanisms

The LPHC is stabilized during integrated multi-planar movement by two primary systems, the tho-

racolumbar stabilization mechanism and the intra-abdominal pressure stabilization mechanism (IAP)

(Figure 15).1,2,3,4,30,31,32,57,58,59,60,61

Figure 15: Stabilization Mechanisms

m Thoracolumbar Stabilization

m Intra-abdominal Pressure


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Thoracolumbar Stabilization MechanismThe TLF is a fascial network of non-contractile tissue that plays an essential role in the functional stability

of the lumbar spine. The TLF is divided into three layers, the posterior, anterior, and middle. Although the

TLF is non-contractile, it can be engaged dynamically because of the contractile tissue that attaches to it .

The muscles that attach to the TLF include deep erector spinae, multifidus, TA, internal oblique, gluteus

maximus, latissimus dorsi, and quadratus lumborum. The TA and the internal oblique are particularly

important for stabilization. They attach to the middle layer of the TLF via the lateral raphe. Contraction

of the TA and the internal oblique creates a traction and tension force on the TLF, which enhances the

regional inter-segmental stability in the LPHC. This preferential contraction decreases translational and

rotational stress at the lumbosacral junction.30,31,32,60,62,63,64

Figure 16: Thoracolumbar Stabilization Mechanism


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Intra-abdominal Pressure MechanismThe second stabilization mechanism is the IAP.1,2,4,7,65Increased IAP decreases compressive forces in the

LPHC. As the abdominal muscles contract against the viscera, they push superiorly into the diaphragm

and inferiorly into the pelvic floor. This results in elevation of the diaphragm and contraction of pelvic

floor musculature. This will assist in providing intrinsic stabilization to the LPHC.

Figure 17: Intra-abdominal Pressure Mechanism

Postural Considerations

The core maintains postural alignment and dynamic postural equilibrium during functional activities.

Optimum alignment of each body part is a cornerstone of an integrated training and rehabilitation pro-

gram. Optimum posture and alignment allow for optimum neuromuscular efficiency because the normal

length-tension relationship, force-couple relationship, and arthrokinematics are maintained during func-

tional movement patterns.9,11,14,16,17,18,19,20,25,66,67,68,69A comprehensive core stabilization program prevents

the development of serial distortion patterns and provides optimum dynamic postural control during

functional movements.9,11,14,23,24


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Neuromuscular ConsiderationsA strong and stable core can improve optimum neuromuscular efficiency by improving dynamic postural

control.18,25,30,32,63,70,71Several authors have demonstrated kinetic chain imbalances in individuals with

altered neuromuscular control.14,15,16,17,18,21,22,23,24,30,31,32,33,60,62,63,67,68,72,73,74,75,76 Research has demonstrated

that people with LBP have an abnormal neuromotor response of the trunk stabilizers accompanying limb

movement.31,32,76Additionally, individuals with LBP had significantly greater postural sway and decreased

limits of stability. Research also demonstrates that approximately 75 to 90% of all individuals suffer from

recurrent episodes of back pain. Furthermore, it has been demonstrated that individuals have decreased

dynamic postural stability in the proximal stabilizers of the LPHC following lower extremity ligamentous

injuries.14,72,73,74

It has also been demonstrated that joint and ligamentous injury can lead to decreasedmuscle activity.20,29,77,78Joint and ligament injury can lead to joint effusion, which in turn leads to muscle

inhibition.77This alters neuromuscular control in other segments of the kinetic chain secondary to altered

proprioception and kinesthesia.72,73Therefore, when an individual has pain and swelling, all of the muscles

that cross that joint can be inhibited.

Research has also demonstrated that muscles can be inhibited from an arthrokinetic reflex.14,22,29,78This

is referred to as arthrogenic muscle inhibition. Arthrokinetic reflexes are reflexes that are mediated by

joint receptor activity. If an individual has abnormal arthrokinematics, the muscles that move the joint

will be inhibited. For example, if an individual has a sacral torsion, the multifidus and the gluteus medius

can be inhibited.79

This leads to abnormal movement in the kinetic chain. The tensor fascia latae becomesynergistically dominant and become the primary frontal plane stabilizer. 28This often leads to tightness in

the iliotibial band, which decreases frontal and transverse plane control at the knee. Furthermore, if the

multifidus is inhibited,79the erector spinae and the psoas become facilitated. This will further inhibit the

inner unit stabilization mechanism (internal oblique and TVA) and the gluteus maximus,31,32which also

decreases frontal and transverse plane stability at the knee. As previously mentioned, an efficient core

improves neuromuscular efficiency of the entire kinetic chain because it dynamically stabilizes the LPHC

and therefore improves pelvo-femoral biomechanics. This is yet another reason that training programs

should include a comprehensive core stabilization-training program to prevent injury as well as the chain

reactions that are initiated secondary to injury in the kinetic chain.


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Section III:Scientific Rationale forCore Stabilization Training

Most individuals train their core stabilizers inadequately compared to other muscle groups.13Although

adequate strength, power, muscle endurance, and neuromuscular control are important for lumbo-pel-

vic-hip stabilization, it is detrimental to perform exercises incorrectly or that are too advanced. Several

authors have found decreased firing of the TVA, internal oblique, multifidus, and deep erector spinae in

individuals with chronic LBP.

30,31,32,60,76,80

Research has shown decreased stabilization endurance in individu-als with chronic LBP.1,2,5,81The core stabilizers are primarily type I slow-twitch muscle fibers.1,2,3,4These

muscles respond best to time under tension. Time under tension is a method of contraction that lasts

for 620 seconds and emphasizes hyper-contractions at end ranges of motion. This method improves

intramuscular coordination, which improves static and dynamic stabilization. To get the appropriate train-

ing stimulus, you must prescribe the appropriate speed of movement for all aspects of exercises.7,8Core

strength endurance must be trained appropriately to allow an individual to maintain dynamic postural

control for prolonged periods of time.65

Performing core training with inhibition of these key stabilizers leads to the development of muscle imbal-

ances and inefficient neuromuscular control in the kinetic chain. Research demonstrates that abdominaltraining without proper pelvic stabilization increases intradiscal pressure and compressive forces in the

lumbar spine.5,30,31,32,60,65,82,83In fact, maintaining the cervical spine in a neutral position during core training

will improve posture, muscle balance, and stabilization. If, for instance, the head protracts during move-

ment, the sternocleidomastoid is preferentially recruited. This increases the compressive forces at the

C0C1 vertebral junction. This can also lead to pelvic instability and muscle imbalances secondary to the

pelvo-occular reflex. This reflex is important to maintain the eyes level.16,22 If the sternocleidomastoid

muscle is hyperactive and extends the upper cervical spine, then the pelvis will rotate anteriorly to realign

the eyes. This can lead to muscle imbalances and decreased pelvic stabilization.16,22

Additional research demonstrates that hyperextension training without proper pelvic stabilization can

increase intradiscal pressure to dangerous levels, cause buckling of the ligamentum flavum, and lead to

narrowing of the intervertebral foramen.5,65,83Moreover, the traditional curl-up increases intradiscal pres-

sure and increases compressive forces at L2L3.5,65,82,83

Increasingly, research has uncovered decreased cross sectional area of the multifidi in subjects with LBP.79

Researchers found that there was not spontaneous recovery of the multifidi following resolution of


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symptoms.79

Hence the need for adequate reconditioning of local, intrinsic core musculature. This needcan be addressed through implementing a training regimen that focuses on first creating core stabilization

(increasing the endurance capacity of local core muscles) by retraining the local muscles with a drawing-in

maneuver. Additional research demonstrates increased EMG activity and increased pelvic stabilization when

an abdominal drawing-in maneuver was performed prior to initiating core training.5,6,8,60,61,62,63,65,70,84,85In

fact, recent research by Hides et al. has shown that the technique of drawing-in significantly increased in

the thickness of the TVA as well as decreased cross-sectional area, theorized to bilaterally contract and

form a corset which will most likely increase the stability of the lumbar spine.86A study by Richardson

et al. published in 2002 uncovered decreased joint laxity of the SIJ when a drawing-in maneuver (activat-

ing the TVA with co-contraction of the multifidi) was performed.87This further supports the notion of

increased core stability when the local core musculature is successfully engaged.

The NASM Stance on Core Training Based on the Research

It seems that much of the debate surrounding core training centers on theories of motor learning and

muscle capacity, not on whether a core training program can help decrease LBP. In fact, many researchers

agree on the integration of some aspect of core training to alleviate LBP in patients. A review of current

core concepts and literature addressing the core revealed a shift in thought about the exercise and appli-

cations of a lumbar stability program (LSP). A review published in theAmerican Journal of Physical Medicine

and Rehabilitationprovided some insight into the highly debated and increasingly interesting research of

LSPs. Despite every view, the review found a universal acceptance that exercise may be a vital part of

treatment of nonspecific LBP.88The question most researchers are currently fixated on is what program

implementation will work best.89

There are various approaches to training the core. The rationale behind core training seems to fall into

two main categories: the muscle capacity model, which states that exercises are performed because the

demands of trunk control require a restoration of strength and endurance; and the control model, which

states that exercises are performed to gain control and coordination of the trunk musculature.90

The first rationale of muscle capacity is based on the Euler model of spinal stability. Eulers model equates

the forces acting on a flexible column in order to control buckling forces. This model proposes that themusculature that surrounds the spine acts as guy wires to help support and stabilize the spine (i.e., stability

is dependent on muscles acting to limit trunk motion). As Eulers theory suggests, devoid of musculature

to stiffen the spine, compressive forces of as little as 90 Newtons (20.23 lbs) could cause the lumbar spine

to buckle. This mode of thought asserts that these muscles keep the spine in a mechanically stable equi-

librium (i.e., neutral spine). These muscles are proposed to control and restrict movement and maintain


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a stable lumbo-pelvic position (bracing). However, this is a very static analysis of the spine, and theorieshave not been tested on a dynamic model. This exercise strategy would require a stable or stiff spine,

with force and load being applied through movement of the extremities.

In the control model of core stability, theorists claim that lumbo-pelvic function and health are dependent

on the accurate interplay of the trunk musculature.90In other words, the nervous system must be able

to determine how much stability the spine needs to meet the internal or external demands and recruit

the proper muscles to handle those needs. Feed-forward control dictates that the nervous system can

plan muscle-activation strategies in advance to prepare the spine to handle forces and loads resulting from

movement of an extremity. If the forces are unexpected, the nervous system must be able to respond

accurately and recruit the correct muscles to protect the spine from deleterious forces. Therefore, theo-rists claim that control of the lumbar spine and pelvis are dependent not only on muscle capacity, but also

on the sensory system that communicates spinal stability, which allows the nervous system to respond

accurately by choosing and implementing the correct muscle strategy.

Studies have shown that people with LBP have changes in motor control. Research has found in LBP suf-

ferers a delayed activity of the TVA and lumbar multifidi with quick movements of the extremities. 90,91

Independent of force direction, the local musculature has been shown to be active and activated prior to

movement in healthy participants. Hodges noted in his research that the TVA, when properly activated,

creates tension in the TLF, contributing to spinal stiffness, and compresses the SIJ, increasing stability.91The

lumbar multifidus, in conjunction with the TVA, can help control movement and translation of vertebraeby generating an intervertebral compressive force. The global system was found to have little ability to

control the movement of the spine, yet it contributes spinal orientation and helps counter forces. Based

on these findings, exercise recommendations or program considerations can vary, depending on whether

the individual focus is on control or muscle capacity.

Both strategies should be implemented in a core training program, as research has shown the need for both

retraining motor control of local and global musculature as well as retraining the strength and endurance

of these muscles. Research has upheld the hypothesis that proper function of both the local and global

musculature is needed to maintain efficacy of the spine. For retraining control of core stability, retraining

recruitment strategies of the Central Nervous System would be appropriate. In these cases, the intrinsicmusculature is not functioning appropriately and is often inhibited by the superficial musculature that has

become synergistically dominant or hyperactive.

A core program that incorporates skilled activation of the deep muscles and then progressive integration

of the intrinsic musculature with the superficial musculature is necessary. Once the coordinated activation


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is accomplished, training in varying environments, at differing speeds, forces, and intensities, is needed toshift an individual into activities of daily living. The muscle capacity model of core stability exercise tends

to overlap the control model. The muscle capacity model is more aggressive in utilizing superficial trunk

musculature right away, claiming the need for coordination of both groups of muscles to work together

synergistically. In essence, this is a correct observation; however, devoid of proper initial training of the

intrinsic musculature, continual dominance of the superficial muscles could result.

In the end, both theories aim to re-establish the trunk muscles ability to meet the higher demands or

forces placed on them for spinal stability, and the theories, used together, can be a significant approach

to core stability training.

NASM is continually stressing the integration of both theories of motor relearning and increased capacity

of core muscles. The core stabilization training guidelines require activation and skilled learning of proper

intrinsic muscle recruitment before integration of the superficial musculature.

One starts with what is termed core stabilization training, where the neutral spine is located and retraining

of the inner unit is accomplished. This creates increased lumbo-pelvic-hip stability through the co-contrac-

tion of the TVA and the lumbar multifidi, as well as the TLF that is dynamically engaged through muscle

insertions such as the TVA, deep erector spinae, internal obliques, and lumbar multifidi. This retraining

also increases neuromuscular efficiency, leading to increased muscle capacity as the superficial muscles

are introduced later in training. Performing exercises without proper firing of the inner unit musculature

can lead to muscle imbalances and inefficient neuromuscular control of the entire kinetic chain. This, in

turn, can lead to or propagate already existing injuries, such as LBP.

As mentioned earlier, research has found that lack of proper stabilization leads to increased intradiscal

pressure and compressive forces in the lumbar spine. Once skilled activation is accomplished, movement

of the extremities is added while the client maintains a neutral spine, retraining muscle capacity as the

extremities pose substantial force requirements on the spine. These exercises should be done without

noticeable compensation before integration of superficial muscles into the exercises.

The next level of core training integrates and coordinates activation of the deep musculature with the

superficial muscles of the core. The core strength level of training in NASMs model is intended toenhance neuromuscular efficiency, create a multi-dimensional progression and teach control of eccentric,

isometric, and concentric phases of core activity. Specificity, speed and neural demand are also increased

in this phase. This coincides with both the motor control theory and the muscle capacity theory of core

training. In the NASM core training continuum, both theories are utilized as progressions of one another

and not as differing approaches.


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Lastly, in the core power stage of training, core stabilization and strength are integrated into the specificactivity, as are speed and neural demand. The speed and forces utilized in this phase are comparable to

those encountered in a clients return to his or her environment. This phase places a high demand on the

coordinated activity of the core musculature as a whole. Each level of core training treats both theories of

core training as valid, and integrates each approach into a systematic progression to restore and increase

function of the core, while avoiding injury.


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Section IV:Guidelines for CoreStabilization Training

Focusing on assessing the local musculature and incorporating exercises that teach proper muscle activa-

tion of the TVA and multifidi in patients lacking proper activation may help clinicians begin the process of

rehabilitation. An important key to success in a core training program is the understanding of flexibility

and muscle imbalances. Activation of local stabilization musculature is important; however, activation of

these muscles alone may not bridge the gap into functional living. Integration of core stabilization andstrength training is important in keeping clients functioning properly. Teaching proper activation patterns

and increasing the endurance capabilities of both local and global musculature may transition a client safely

from training into everyday movements and activities.

Prior to performing a comprehensive core stabilization program, each individual must undergo a compre-

hensive kinetic chain assessment. All muscle imbalances and arthrokinematic deficits need to be corrected

prior to initiating an aggressive core training program. A team approach is the best way to thoroughly

assess each client. Find a competent health care professional in your community with whom you can

establish a referral basis for comprehensive evaluations.

As outlined in Figure 18, a comprehensive core stabilization training program should adhere to specific

guidelines. It should be systematic, progressive, and functional. The program should emphasize the entire

muscle contraction spectrum, focusing on force production (concentric contractions), force reduction

(eccentric contractions), and dynamic stabilization (isometric contractions). The core stabilization program

should begin in the most challenging environment the individual can control.


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Figure 18: Core Training Guidelines and Program Variables

CORE STABILIZATION TRAINING GUIDELINES

1. Progressive

2. Systematic

3. Activity Specific

4. Integrated

5. Proprioceptively Challenging

6. Based on Current Science

PROGRAM VARIABLES

1. Plane of motion

2. Range of motion

3. Loading parameters (physioball, ball,

Bodyblades, power sports trainer,

weight vest, dumbbell, tubing, etc.)

4. Body position

5. Amount of control

6. Speed of execution

7. Amount of feedback

8. Duration (sets, reps, tempo, time

under tension)

9. Frequency

As outlined in Figures 19 and 20, a progressive continuum of function that adheres to multi-modal loading

parameters should be followed to systematically train the individual. The program should be manipulated

regularly by changing any of the following variables: plane of motion, range of motion, loading parameters

(physioball, ball, bodyblades, power sports trainer, weight vest, dumbbell, tubing, etc.), body position,

amount of control, speed of execution, amount of feedback, duration (sets, reps, tempo, time under ten-

sion), and frequency.5,6,7,8,9,10,11,13,15,17,18,19,60,61,62,63,71,74,80,83,84,85,92,93,94,95,96,97,98,99,100


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Figure 19: Functional Continuum

CORE STABILIZATION TRAINING; FUNCTIONAL CONTINUUM

1. Multi-planar (3 planes of motion)

2. Multi-dimensional

3. Utilize the entire muscle contraction spectrum

4. Utilize the entire contraction velocity spectrum

5. Manipulate all acute training variables (sets, reps, intensity, rest intervals,

frequency, duration)

Figure 20: Multi-Modal Loading Parameters

1. Stability Ball

2. Cable (Free motion)

3. Tubing

4. Medicine Ball

5. Power Balls

6. Bodyblades

7. Dumbbells

8. Weight Vests

When designing a core stabilization training program, the health and fitness professional should create

a proprioceptively enriched environment and select the appropriate exercises to elicit a maximal train-

ing response. As outlined in Figure 21, the exercises must be safe, be challenging, stress multiple planes,

incorporate a multi-sensory environment, be derived from fundamental movement skills, and be activity

specific.


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Figure 21: Exercise Selection Criteria

1. Safe

2. Challenging

3. Progressive

4. Systematic (Integrated Functional Continuum)

5. Proprioceptively Enriched

6. Activity Specific

The health and fitness professional should follow a progressive and integrated functional continuum like

the one illustrated in Figure 22 to allow optimum adaptations.9,10,11,84

Figure 22: Integrated Functional Continuum

In addition, the health and fitness professional should follow an exercise progression continuum similar

to the one outlined in Figure 23.


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Figure 23: Exercise Progression Continuum

m Slow to Fast

m Simple to Complex

m Known to Unknown

m Stable to Unstable

These concepts are critical for a proper exercise progression: slow to fast, simple to complex,known to unknown, low force to high force, static to dynamic, correct execution to increased reps/

sets/intensity.7,8,9,10,11,84

The goal of core training is to develop optimal levels of functional strength and dynamic stabilization. 5,13

Neural adaptations become the focus of the program instead of striving for absolute strength gains.9,14,15,30,62

Increasing proprioceptive demand by utilizing a multi-sensory, multi-modal environment becomes more

important than increasing the external resistance. Quality of movement is stressed over quantity. The

focus of the program must be on function.9,10,11


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Section V:Core StabilizationTraining Program

The following is an example of an integrated core training program. As mentioned earlier, the individual

begins at the highest level at which he or she is able to maintain stability and optimum neuromuscular

control. He/she is progressed through the program when he/she achieves mastery of the exercises in the

previous level.1,2,5,6,7,8,9,10,11,13,14,15,17,19,30,34,60,62,65,71,74,83,92,93,94,99,100,101,102,103,104,105

Figure 24: OPTModel


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Core StabilizationIn core stabilization (phase 1 of the OPTmodel), exercises involve little motion through the spine and

pelvis. These exercises are designed to improve the functional capacity of the stabilization system.

Marching Prone Iso-Abs Side Iso Abs

Iso Abs w/Hip Extension Floor Bridge 1 Floor Bridge 2

Floor Cobra 1 Floor Cobra 2 Arm/Opposite Leg Raise


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Core StrengthIn core strength training (phases 2, 3, and 4 of the OPTmodel), the exercises involve more dynamic

eccentric and concentric movements of the spine through a full range of motion. The specificity, speed, and

neural demand are also progressed in this level. These exercises are designed to improve dynamic stabiliza-

tion, concentric strength, eccentric strength, and neuromuscular efficiency of the entire kinetic chain.

Ball Crunch 1 Ball Crunch 2 Ball Crunch Ball Crunch

w/Rotation 1 w/Rotation 2

Back Extension 1 Back Extension 2 Reverse Crunch 1

Reverse Crunch 2 Knee Ups 1 Knee Ups 2


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Cable Lift 1 Cable Lift 2 Cable Chop 1 Cable Chop 2

Core Power

In core power training (phase 5 of the OPTmodel), exercises are designed to improve the rate of force

production of the core musculature. These forms of exercise prepare an individual to dynamically stabilize

and generate force at more functionally applicable speeds.

Ball MB Pullover Throw 1 Ball MB Pullover Throw 2 Woodchop Throw 1 Woodchop Throw 2


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MB Scoop Toss 1 MB Scoop Toss 2 Rotational Chest Rotational Chest

Pass 1 Pass 2

Integrated Core Training Program Design

OPTLevel Phase Example Core Exercises Sets/Reps Rest

Stabilization

Strength

Power

1

2, 3, 4

5

14 Core Stabilization

2Leg Floor Bridge

Prone Iso-Abs

Prone Cobra

*04 Core Strength

Back Extensions

Ball Crunches

Cable PNF

Knee-ups

**02 Core Power

Medicine Ball Rotational Chest Pass

Ball Medicine Ball Pullover

13 x 1220

23 x 810

24 x 510

0 90 s

0 60 s

0 60 s

Table 1 Integrated Core Training Program Design

*For the goal of muscle hypertrophy and maximal strength, it may be optional (although recommended) for individuals.

**Because core exercises are performed in the dynamic warm-up portion of this program and core power exercises are included

in the resistance training portion of the program, separate core training may not be necessary in this phase of training.


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Section VI:Summary

This type of training should be included in all integrated training programs. A core training program enables

an individual to gain optimum neuromuscular control of the LPHC and to achieve optimum performance.

To choose the proper exercises when designing a program, follow the progression of the OPTmodel.

In the stabilization level, choose one to four core stabilization exercises. In the strength level, select from

zero to four core strength exercises. In the power level, pick from zero to two core power exercises.


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References

1 Gracovetsky S, Farfan H: The Optimum Spine. Spine11:543573. 1986.

2 Gracovetsky S, Farfan H, Heuller C: The Abdominal Mechanism. Spine10:317324. 1985.

3 Panjabi MM: The Stabilizing System of the Spine. Part I: Function, Dysfunction, Adaptation, and

Enhancement.J. Spinal Disord.5:383389. 1992.

4 Panjabi MM, Tech D, White AA: Basic Biomechanics of the Spine. Neurosurgery7:7693. 1980.

5

Beim G, Giraldo JL, Pincivero DM, Borror MJ, FU FH: Abdominal Strengthening Exercises: AComparative EMG Study.J. Sport Rehabil.6:1120. 1997.

6 Bittenham D, Brittenham G: Stronger Abs and Back.Champaign, IL: Human Kinetics. 1997.

7 Chek P: Scientific Back Training. Correspondence Course.La Jolla, CA: Paul Chek Seminars. 1994.

8 Chek P: Scientific Abdominal Training. Correspondence Course.La Jolla, CA: Paul Chek Seminars. 1992.

9 Dominguez RH: TotalBody Training. East Dundee, IL: Moving Force Systems. 1982.

10Gambetta V: Building the Complete Athlete; Course Manual. Chicago, IL. 1996.

11 Jesse J: Hidden Causes of Injury, Prevention, and Correction for Running Athletes. Pasadena, CA: The

Athletic Press. 1977.

12 Crisco J, Panjabi MM: The Intersegmental and Multisegmental Muscles of the Lumbar Spine. Spine

16:793799. 1991.

13Aaron G: The Use of Stabilization Training in the Rehabilitation of the Athlete. Sports Physical Therapy

Home Study Course.1996.

14Bullock-Saxton JE:Muscles and Joint : Inter-Relationships with Pain and Movement Dysfunction.Course

Manual, November 1997.

15 Janda V, Vavrova M: Sensory Motor Stimulation Video.Brisbane, Australia: Body Control Systems. 1990.

16 Lewit K:Manipulative Therapy in the Rehabilitation of the Locomotor System. London: Butterworths. 1985.

17 Liebenson CL: Rehabilitation of the Spine.Baltimore: Williams and Wilkins. 1996.


42/48

42


18

Sahrmann S: Diagnosis and Treatment of Muscle Imbalances and Musculoskeletal Pain Syndrome.Continuing Education Course.St. Louis. 1997.

19 Blievernicht J: Balance; Course Manual.Chicago, IL. 1996.

20 Edgerton VR, Wolf S, Roy RR: Theoretical Basis for Patterning EMG Amplitudes to Assess Muscle

Dysfunction.Med. Sci. Sports Exerc.28(6):744751. 1996.

21 Janda V: Muscle Weakness and Inhibition in Back Pain Syndromes. In: Grieve GP:Modern Manual

Therapy of the Vertebral Column.New York: Churchill Livingstone. 1986.

22 Lewit K: Muscular and Articular Factors in Movement Restriction.Manual Medicine1:8385. 1985.

23 Liebenson CL: Active Muscle Relaxation Techniques. Part I. Basic Principles and Methods.

J. Manipulative Physiol. Ther.12(6):446454. 1989.

24 Liebension CL: Active Muscle Relaxation Techniques. Part II. Clinical Application.J. Manipulative

Physiol. Ther.13(2). 1989.

25 Sahrmann S: Posture and Muscle Imbalance: Faulty Lumbo-Pelvic Alignment and Associated

Musculolskeletal Pain Syndromes: Orthop. Div. Rev. Can. Phys. Ther.12:1320. 1992.

26Basmajian J:Muscles Alive.Baltimore: Williams and Wilkins. 1974.

27Basmajian J:Muscles Alive ; Their Functions Revealed by EMG.5th edition. Baltimore: Williams and

Wilkins. 1985.

28 Porterfield JA, DeRosa C:Mechanical Low Back Pain; Perspectives in Functional Anatomy.Philadelphia:

WB Saunders. 1991.

29 Warmerdam ALA:Arthrokinetic Therapy; Manual Therapy to Improve Muscle and Joint Functioning.

Continuing Education Course.Marshfield, WI. 1996.

30 Hodges PW, Richardson CA: Contraction of the Abdominal Muscles Associated with Movement of

the Lower Limb. Phys. Ther.77:13214. 1997.

31 Hodges PW, Richardson CA: Inefficient Muscular Stabilization of the Lumbar Spine Associated with

Low Back Pain. Spine21(22):26402650. 1996.


43/48

43


32

Hodges PW, Richardson CA: Neuromotor Dysfunction of the Trunk Musculature in Low Back PainPatients. In: Proceedings of the International Congress of the World Confederation of Physical Therapists,

Washington, DC. 1995.

33 Lewit K: Myofascial Pain; Relief by Post-Isometric Relaxation.Arch. Phys. Med. Rehabil.65:452. 1984.

34 Greenman PE: Principles of Manual Medicine.Baltimore: Williams and Wilkins. 1991.

35 Bergmark A: Stabilityof the Lumbar Spine. A Study in Mechanical Engineering. Acta. Ortho. Scand.

1989;230(suppl):204.

36 Richardson C, Jull G, Hodges P, Hides J: Therapeutic Exercise for Spinal Segmental Stabilization in Low

Back Pain. London: Churchill Livingstone. 1999.

37 Culham LC, Peat M: Functional Anatomy of the Shoulder Complex.J. Ortho. Sports Phys. Ther.

18:34250. 1993.

38 Dempster WT: Mechanismsof Shoulder Movement.Arch.Phy. Med. Rehab.46:4967. 1965.

39 Gottschalk F, Kourosh S, Leveau B: The Functional Anatomy of TensorFascia Latae and Gluteus

Medius and Minimus.J. Anat.166:17989. 1989.

40 Lieb FJ, Perry J: Quadriceps Function.J. Bone Joint Surg.50A:153548. 1971.

41 Lee D: The Pelvic Girdle. London: Churchill Livingstone. 1999.

42 Gracovetsky SA : Chapter 20. In Vleeming A, Mooney V, Dorman T, Snijders C, Stoeckart R editors.

Movement, Stability and Low Back Pain.London: Churchill Livingstone. 1997.

43 Mooney V: Chapter 2. Sacroiliac Joint Dysfunction.In Vleeming A, Mooney V, Dorman T, Snijders C,

Stoeckart R editors.Movement, Stabili ty and Low Back Pain.London: Churchill Livingstone. 1997.

44 Mooney V, Pozos R, Vleeming A, Gulick J, Swenski D: Chapter 7. Coupled Motion of Contralateral

Latissimus Dorsi and Gluteus Maximus: Its Role in Sacroiliac Stabilization.In Vleeming A, Mooney V,

Dorman T, Snijders C, Stoeckart R editors.Movement, Stabili ty and Low Back Pain. London: Churchill

Livingstone. 1997.

45 Vleeming A, Snijders CJ, Stoeckart R, Mens JMA: Chapter 3. The Role of the Sacroiliac Joints in

Coupling Between Spine, Pelvis, Legs and Arms. In Vleeming A, Mooney V, Dorman T, Snijders C,

Stoeckart R editors. Movement, Stability and Low Back Pain.London: Churchill Livingstone. 1997.


44/48

44


46

Kelso JAS: Dyanmic Patterns. The Self-Organization of Brain and Behavior. Cambridge, MA: The MITPress. 1995.

47 Newton RA: Neural Systems Underlying Motor Control.In Montgomery PC, Connoly BH editors.

Motor Control and Physical Therapy: Theoretical Framework and Practical Applications.Hixson, TN:

Chatanooga Group, Inc. 1991.

48Rose DJ:A Multi Level Approach to the Study of Motor Control and Learning. Needham Heights, MA:

Allyn and Bacon. 1997.

49 Tuller B, Turvey MT, Fitch HL: The Berstein Perspective: II . The Concept of Muscle Linkage or

Coordinative Structure.In Kelso JAS editor. Human Motor Behavior, an Introduction.Hillsdale, NJ:Lawrence Erlbaum. 1982.

50 Inman VT, Ralston HJ, Todd F: Human Walking. Baltimore: Williams and Wilkins. 1981.

51 Innes KA: Chapter 9. The Effect of Gait on Extremity Evaluation.In Hammer WI editor. Functional

Soft Tissue Examination and Treatment by Manual Methods.2nd edition. Gaithersburg, MD: Aspen

Publishers, Inc. 1999.

52 Weinert CR, MacMaster JH, Ferguson RJ: Dynamic Function of the Human Fibula. Amer. J. Anat.

138:14550. 1973.

53 Lee D: Chapter 18. Instability of the Sacroiliac Joint and the Consequences for Gait.In Vleeming

A, Mooney V, Dorman T, Snijders C, Stoeckart R editors.Movement, Stabili ty and Low Back Pain.

London:Churchill Livingstone. 1997.

54 Snijders CJ, Vleeming A, Stoeckart R, Mens JMA, Kleinrensink GJ: Chapter 6. Biomechanics of

the Interface Between Spine and Pelvis in Different Postures.In Vleeming A, Mooney V, Dorman

T, Snijders C, Stoeckart R editors:Movement, Stabil ity and Low Back Pain.London: Churchill

Livingstone. 1997.

55 Gross J, Feto J, Rosen E:Musculoskeletal Examination. Malden, MA: Blackwell Sciences, Inc. 1996.

56 Loudon J, Bell S, Johnston J: The Clinical Orthopedic Assessment Guide. Champaign, IL: Human

Kinetics. 1998.

57 Cresswell AG, Grundstrom H, Thorstensson A: Observations on Intra-Abdominal Pressure and

Patterns of Abdominal Intra-Muscular Activity in Man.Acta. Physiol. Scand. 144:409418. 1992.


45/48

45


58

Cresswell AG, Oddson L, Thorstensson A: The Influence of Sudden Perturbations on Trunk MuscleActivity and Intra-Abdominal Pressure While Standing. Exp. Brain Res. 98:336341. 1994.

59 Fairbank JCT, OBrien JP: The Abdominal Cavity and the Thoracolumbar Fascia as Stabilizers of the

Lumbar Spine in Patients with Low Back Pain. In: London: Engineering Aspects of the Spine. 1980.

60 Hodges PW, Richardson CA, Jull G: Evaluation of the Relationship Between Laboratory and Clinical

Tests of Transverse Abdominus Function. Physiother. Res. Int.1:3040. 1996.

61 Tesh KM, Shaw Dunn J, Evans JH: The Abdominal Muscles and Vertebral Stability. Spine12:501508.

1987.

62 OSullivan PE, Twomey L, Allison G: Evaluation of Specific Stabilizing Exercises in the Treatment

of Chronic Low Back Pain with Radiological Diagnosis of Spondylolisthesis.Gold Coast, Queensland:

Manipulative Physiotherapists Association of Australia. 1995.

63 Richardson CA, Jull G, Toppenberg R, Comerford M: Techniques for Active Lumbar Stabilization for

Spinal Protection.Aust. J . Physiother.38:105112. 1992.

64 Wilke HJ, Wolf S, Claes LE: Stability Increase of the Lumbar Spine with Different Muscle Groups: A

Biomechanical in Vitro Study. Spine20:192198. 1995.

65 Ashmen KJ, Swanik CB, Lephart SM: Strength and Flexibility Characteristics of Athletes with

Chronic Low Back Pain.J. Sport Rehabil.5:275286. 1996.

66Chaitow L:Muscle Energy Techniques.New York: Churchill Livingstone. 1997.

67 Janda V: Physical Therapy of the Cervical and Thoracic Spine.In Grant R (ed). New York: Churchill

Livingstone. 1988.

68 Janda V: Muscles, Central Nervous System Regulation and Back Problems. In Korr IM (ed):

Neurobiologic Mechanisms in Manipulative Therapy.New York: Plenum Press. 1978.

69 Jull G, Richardson CA, Hamilton C, Hodges PW, NG J: Towards the Validation of a Clinical Test for the

Deep Abdominal Muscles in Back Pain Patients.Gold Coast, Queensland: Manipulative PhysiotherapistsAssociation of Australia. 1995.

70 Hall T, David A, Geere J, Salvenson K: Relative Recruitment of the Abdominal Muscles during Three

Levels of Exertion during Abdominal Hollowing.Gold Coast, Queensland: Manipulative Physiotherapists

Association of Australia. 1995.


46/48

46


71

Jull G, Richardson CA, Comerford M: Strategies for the Initial Activation of Dynamic LumbarStabilization.New South Wales: Proceedings of Manipulative Physiotherapists Association of

Australia. 1991.

72 Beckman SM, Buchanan TS: Ankle Inversion and Hypermobility: Effect on Hip and Ankle Muscle

Electromyography Onset Latency.Arch. Phys. Med. Rehabil.76(12):11381143. 1995.

73 Bullock-Saxton JE : Local Sensation Changes and Altered Hip Muscle Function Following Severe

Ankle Sprain. Phys. Ther.74(1):1723. 1994.

74 Bullock-Saxton JE, Janda V, Bullock M: Reflex Activation of Gluteal Muscles in Walking; An Approach

to Restoration of Muscle Function for Patients with Low Back Pain. Spine18(6):704708. 1993.75 Janda V:Muscle Function Testing.London: Butterworths. 1983. 61.

76 OSullivan PE, Twomey L, Allison G, Sinclair J, Miller K, Knox J: Altered Patterns of Abdominal

Muscle Activation in Patients with Chronic Low Back Pain. Aust. J . Physiother.43(2):9198. 1997.

77 DeAndre JR, Grant C, Dixon ASJ: Joint Distension and Reflex Muscle Inhibition in the Knee.J. Bone

Joint Surg. (Am)47:313322. 1965.

78 Stokes M, Young A: The Vontribution of Reflex Inhibition to Arthrogenous Muscle Weakness.

Clin. Sci.67:714. 1984.

79 Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH: Evidence of Lumbar Multifidus Wasting

Ipsilateral to Symptoms in Subjects with Acute/Subacute Low Back Pain. Spine19:165177. 1994.

80 Richardson CA, Jull G: Muscle Control Pain Control. What Exercises Would You Prescribe?

Man. Ther.1:210. 1995.

81 Calliet R: Low Back Pain Syndrome.Oxford: Blackwell. 1962.

82 Nachemson A: The Load on the Lumbar Discs in Different Positions of the Body. Clin. Orthop.

Rel. Res.45:107122. 1966.

83 Norris CM: Abdominal Muscle Training in Sports. Br. J. Sports Med.27(1):1927. 1993.

84 Gustavsen R, Streeck R: Training Therapy; Prophylaxis and Rehabilitation.New York: Thieme Medical

Publishers. 1993.


47/48

47


85

Miller MI, Medeiros JM: Recruitment of the Internal Oblique and Transverse Abdominus Muscles onthe Eccentric Phase of the Curl-Up. Phys. Ther.67(8):12131217. 1987.

86 Hides J, Wilson S, et al.: An MRI Investigation Into the Function of the Transverse Abdominis Muscle

During Drawing-In of the Abdominal Wall. Spine31(6): E175E178. 2006.

87 Richardson CA, Snijders C, Hides JA, et al.: The Relation Between the Transversus Abdominis

Muscles, Sacroiliac Joint Mechanics, and Low Back Pain. Spine27(4):399405. 2002.

88 Barr KP, Griggs M, Cadby T: Lumbar Stabilization: A Review Of Core Concepts and Current

Literature, Part 2.Am. J. Phys . Med. Rehabil.86:7280. 2007.

89 Cleland J, Schulte C, Durall C: The Role of Therapeutic Exercise In Treating Instability-Related

Lumbar Spine Pain: A Systematic Review.J Back and Musculoskeletal Rehab 16:105115. 2002.

90 Hodges P: Core Stability Exercises in Chronic Low Back Pain. Orthop. Clin. North Am. 34(2): 24554.

2003.

91 Hodges PW, Richardson CA: Delayed Postural Contraction of Transverses Abdominis Associated

with Movement of the Lower Limb in People with Low Back Pain.J. Spinal Disord.11:4656. 1998b.

92Chek P: Swiss Ball Training. Correspondence Course.La Jolla, CA: Paul Chek Seminars; CA. 1996.

93

Creager C: Therapeutic Exercise Using Foam Rollers.Berthoud, CO: Executive Physical Therapy. 1996.94 Gambetta V: The Complete Guide to Medicine Ball Training.Sarasota, FL: Optimum Sports Training. 1991.

95 Kennedy B: An Australian Program for Management of Back Problems. Physiotherapy66:108111. 1980.

96 Mayer TG, Gatchel RJ: Functional Restoration for Spinal Disorders. The Sports Medicine Approach.

Philadelphia: Lea and Febiger. 1988.

97 Mayer-Posner J: Swiss Ball Applications for Orthopedic and Sports Medicine.Denver, CO: Ball Dynamics

International. 1995.

98

Robinson R: The New Back School Prescription: Stabilization Training. Part I. Occup. Med.7:1731. 1992.99 Saal JA: The New Back School Prescription: Stabilization Training Part II. Occup. Med.7:3342. 1992.

100Saal JA: Nonoperative Treatment of Herniated Disc: An Outcome Study. Spine14:431437. 1989.


48/48

48


101

Aaron G: Clinical Guideline Manual for Spine. Healthsouth Corporation. 1996.102Chek P: Dynamic Medicine Ball Training. Correspondence Course.La Jolla, CA: Paul Chek Seminars. 1996.

103Freeman MAR: Coordination Exercises in the Treatment of Functional Instability of the Foot.

Phys. Ther.44:393395. 1964.

104Gambetta V: Following a Functional Path. Training and Conditioning. 5(2) :2530. 1995.

105Gambetta V: Everything in Balance. Training and Conditioning. 1(2):1521. 1996.

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