`the core': understanding it, and retraining its dysfunction · clinical and research review...

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Journal of Bodywork & Movement Therapies (2013) xx, 1e19

Available online at www.sciencedirect.com

journal homepage: www.elsevier .com/jbmt

CLINICAL AND RESEARCH REVIEW

‘The core’: Understanding it, and retrainingits dysfunction

Josephine Key, MAPA, MMPAA, APAM*,1

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

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

KEYWORDSCore strength;Back pain;Pilates;Yoga;Injury prevention

* Tel.: þ61 0293261168; fax: þ61 02E-mail address: edgecliffphysio@pURL: http://www.edgecliffphy

keyapproach.com.au.1 Neuro-musculo-skeletal physiother

Please cite this article in press as: KeTherapies (2013), http://dx.doi.org/

1360-8592/$ - see front matter ª 201http://dx.doi.org/10.1016/j.jbmt.201

Summary “Core stability training” is popular in both the therapeutic and fitness industriesbut what is actually meant and understood by this concept? And does everyone need the sametraining approach?

This paper examines the landscape of ‘the core’ and its control from both a clinical andresearch perspective. It attempts a comprehensive review of its healthy functional role andhow this is commonly changed in people with spinal and pelvic girdle pain syndromes.

The common clinically observable and palpable patterns of functional and structural changeassociated with ‘problems with the core’ have been relatively little described.

This paper endeavors to do so, introducing a variant paradigm aimed at promoting the un-derstanding and management of these altered patterns of ‘core control’.

Clinically, two basic subgroups emerge. In light of these, the predictable difficulties thateach group finds in establishing the important fundamental elements of spino-pelvic ‘core con-trol’ and how to best retrain these, are highlighted.

The integratedmodelpresented is applicable forpractitioners re-educatingmovement inphys-iotherapy, rehabilitation, Pilates, Yoga or injury preventionwithin the fitness industry in general.ª 2013 Elsevier Ltd. All rights reserved.

93281695.acific.net.au.sio.com.au.http://www.

apist.

y, J., ‘The core’: Understanding i10.1016/j.jbmt.2013.03.012

3 Elsevier Ltd. All rights reserved3.03.012

Introduction

Despite a lot of research around the subject, there isapparent confusion in understanding what goes wrong with‘the core’ and how to properly retrain it. The notedresearcher, McGill (2009) opines: “There’s so much my-thology out there about the core. The idea has reachedtrainers and through them the public that the core meansonly the abs. There’s no science behind that”.

t, and retraining its dysfunction, Journal of Bodywork & Movement

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http://www.keyapproach.com.au

mailto:[email protected]




http://dx.doi.org/10.1016/j.jbmt.2013.03.012

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2 J. Key

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‘Core confusion’ and/or reductionism of ‘core’ as syn-onymous with the abdominals and by association, the ‘needto strengthen them’ utilizing ‘high load’ (strength/effort)training starts to permeate research design and outcomes(George et al., 2011; Escamilla et al., 2010). The misun-derstanding becomes further entrenched.

Most people with spino-pelvic pain syndromes generallyhave relatively low level function and cannot organize thebasic elements of ‘core control’. Subjecting them to indi-vidual muscle group and ‘high load’ training strategies islikely to further imprint perturbed motor patterns and inmany, symptom development or exacerbation.

Debate around ‘core stability’ has begun to surface(McNeill, 2010), questioning the concept and the real valueof ‘training the core’ (Allison and Morris, 2008; Allisonet al., 2008; Lederman, 2010).

A historical perspective on ‘core’

In spite of all the interest in ‘the core’ it is difficult to find asuccinct definition of it.

Long before ‘the core’ became fashionable, Ida Rolfconceptualized the myofascial system as ‘intrinsic’ and‘extrinsic’. The intrinsic are the ‘core’, inner ‘being’ mus-cles. The extrinsic are the ‘sleeve’ e the large/superficial‘doing’ muscles (Linn, 2004). She saw that inappropriatesubstitution by the ‘extrinsics’ for the ‘intrinsics’ e “livingin their extrinsics”, was a sign of somatic immaturity ordysfunction (Smith, 2008). These are useful concepts tokeep in mind.

The concept of ‘core stability’ probably emanated fromAustralian research into postural control in both healthyand chronic low back pain (CLBP) populations. They wereinterested in the role of the motor system e how the ner-vous system organizes the appropriate responses to supportthe spine, give us the postural control to counteract gravityand balance while at the same time, also co-coordinatingimportant functions such as breathing and continence. Theevidence suggests that when spinal pain is present, thestrategies used by the central nervous system may bealtered (Hodges, 1999, 2000, 2001). Much of their researchinvolved studying the feedforward anticipatory role playedby the intra-abdominal pressure (IAP) mechanism, animportant aspect of the antigravity postural control andspinal stabilization system. They studied the roles ofvarious muscles contributing to a synergy of musclesresponsible for generating intra-abdominal pressure (IAP) etransversus abdominis, the diaphragm, the pelvic floormuscles (PFM) and lumbar multifidus.

Hence it is appropriate to adopt the term ‘stabilizationsynergy’. This affords ‘intrinsic’ control from the inside ethe ‘core’ of our being.

These researchers found that in healthy populations theindividual elements of the ‘stabilization synergy’ sponta-neously co-activate in advance of limb movement: etransversus abdominis (Hodges and Richardson, 1996,1997); the diaphragm (Hodges et al., 1997a; Hodges andGandevia, 2000a,b); the pelvic floor (Hodges et al., 2007;Smith et al., 2007a); deep fibres of lumbar multifidus(Moseley et al., 2002). Yet, in CLBP and chronic pelvic gir-dle pain (CPGP), the pre-activation response of all these

Please cite this article in press as: Key, J., ‘The core’: Understanding iTherapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.03.012

muscles was variably delayed and/or diminished duringmovement (Hodges and Richardson, 1998, 1999a;Hungerford et al., 2003; O’Sullivan et al., 2002a).

However, their findings have been somewhat mis-interpreted, such that transversus abdominis has beensingled out as ‘the core muscle’ e transversus and ‘core’have become inextricably linked. This myth-conception ispropagated as the panacea for just about everything fromhelping back pain, enhancing performance, to improvingyour shape. Transversus abdominis dysfunction is only apart of the problem.

Joseph Pilates work has become linked with ‘the core’although he didn’t use the term. His interest was “physicalfitness and the complete coordination of body mind andspirit e good posture, flexibility and vitality” (Pilates andMiller, 1945). He worked with the physically elite e gym-nasts, dancers and circus performers, and many of his ex-ercises are ‘high load’ strengthening with a strong focus onactivating the abdominals (into lumbar flexion) and glutealswith the breath.

Many of the moves are difficult to perform properly andalso risk provoking lumbo-pelvic pain symptoms e.g. ‘TheRoll up’, ‘The Teaser’.

Later disciples of his method use the term ‘the power-house’ “. to describe the collective muscles of your ab-dominals, gluteals (buttock muscles) and lower backmusculature. We define the powerhouse as the centre ofstrength and control for the rest of your body. Pilatespractitioners also refer to this region as your ‘girdle ofstrength’ or your ‘core muscles’” (Ungaro, 2002).

One starts to understand how the confusion begins tooccur e the shift in seeing ‘the girdle’ and the ‘abdominals’in becoming synonymous’ with ‘core’. Note also that thisnotion of the ‘powerhouse’ alludes to a more ‘extrinsic’locus of control.

The risk is that the ‘inner locus of control’ getsbypassed.

Examining the healthy ‘core’

‘Core’ structure

‘Core’ is often simply construed as the muscles that wraparound and ‘pull in the midriff’ e the transversus trap.‘Core’ is more complex.

The pelvis is the main centre of weight shift and ‘loadtransfer’ in the body. The body’s centre of gravity isanterior to the second sacral segment (S2) in the standinganatomical position (Neumann, 2002) hence our mechanical‘core’ is principally around the front of the sacrum. Yet, asthe diaphragm and anterolateral abdomen are critical in‘core support’ and movement control, structurally, ‘thecore’ reaches from the ischial tuberosities up to the midthorax where the diaphragm and transversus abdominisattach superiorly.

Energy expenditure is minimized when the head, thoraxandpelvis arealigned in relation to the lineofgravitye knownas the ‘neutral’ spinal posture. The rib cage, anterolateralabdominal wall (ALAW) and the pelvic ring form a frameworkof ‘hoop bracing’ to the spinal column and enclose an internalbody chamber capable of volume change through expansion


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andcontraction. Thediaphragmdivides this chamber into thethoracic and thoraco-abdominal-pelvic cavities e the latterbeing our ‘core’. A balanced postural and functional rela-tionship between the thorax and pelvis affords ‘ideal’ inter-nal dimensions of ‘the core’ promoting optimal functionbetween the thoracic and pelvic diaphragms.

‘Core’ functional mechanisms

In essence, healthy antigravity postural support and spino-pelvic movement control can be distilled as consisting ofthree inter-dependent functions:

1. The breathing mechanism e plays a fundamental rolein the generation of IAP

2. Postural control mechanisms of the axial column e aduality of:� Balanced yet adaptable co-activation between theaxial flexor and extensor muscle systems (Cholewickiet al., 1997) e helped by

� Appropriate levels of IAP for postural support3. Sound posturo-movement control of the proximal limb

girdles e particularly the pelvis as its control directlyinfluences trunk flexor/extensor activation patterns.Space constraints do not allow an in-depth explorationof this aspect, which has been addressed elsewhere(Key et al., 2008; Key, 2010a).

Coordinated activity between these 3 functional systemsis achieved by synergistic co-activation of many muscles, toprovide adaptable and complex patterns of control. The‘intrinsic system’ contribution is significant e those ofthe ‘abdominal canister’ (diaphragm, PFM, transversusabdominis) and also lumbar multifidus, the interspinalesand intertransversarii, psoas, medial fibres of quadratuslumborum and the internal oblique (Hodges, 2003). Clini-cally, the iliacus and deep hip rotators are also important.Excluding the intrinsic spinal extensors, these ‘deep’ mus-cles form a continuous inner myofascial sleeve surroundingthe thoraco-abdominal-pelvic cavity e collectively termedthe ‘Lower Pelvic Unit’ (LPU) (Key, 2010a,b) (Fig. 1).

Variable patterns of activity within this provide theadaptive underlying support in the modulation of thesebasic ‘mechanisms of core control’.

Figure 1 Schematic depiction of the myofascial elements ofthe Lower Pelvic Unit which contribute to ‘intrinsic’ mecha-nisms of spino-pelvic support and control.


Breathing and postural control in particular, are inex-tricably linked and are important elements common toboth mechanisms in the generation of appropriate levelsof IAP.

‘The core’ regulates internal pressure changesThe ability to appropriately pressurize the thoraco-abdomino-pelvic cavity and modulate its volumes andshape not only underlies breathing and postural control butalso a range of other functions e.g. functional expiratorypatterns e vocalisation, singing, laughing, sneezing; andacts of elimination e coughing, nose blowing, vomiting,defecation, birthing etc.; e while also maintaining conti-nence during impact activities like running and jumping.

Like a suction pump, the diaphragm plays a crucial rolein generating these internal pressure change mechanisms.IAP in variable measure is behind them all. The creation ofeach distinct function is achieved by differing timing onsetand proportional activity levels between the three principalelements e the thoracic and pelvic diaphragms and trans-versus abdominis.

Breathing and postural control: the root mechanisms of‘core control’Breathing is our most fundamental motor pattern. At birthwe have an abdominal breathing pattern e where dia-phragm descent creates a negative intra-thoracic pressuredrawing air into the lungs. To ‘get up’ against gravity weneed to develop postural control e the underlying platformsupporting all our movements. In the developmentalsequence, breathing becomes integrated into our evolvingpatterns of posturo-movement control. Breathing andpostural control are inextricably linked e each supports theother.

Consider the apparent ‘effortless’ yet protracted up-right posture adopted by the meditating Buddha e anendurance activity sustained by breathing (Ong, 2007). Thisco-dependency between posture and breathing isconsidered.

Breathing sub serves the postural control mechanism:

� Breathing transiently changes the volume and shape ofthe trunk creating slight postural disturbance whichwhen we are upright is counteracted by small angulardisplacements through the lower trunk and legs(Hodges et al., 2002). The sensori-motor activity fromthese adjustments constantly ‘refuels’ the posturalreflex mechanism.

� A healthy breathing pattern is principally one of lateralexpansion of the lower rib cage. This only occurs ifthere is sufficient generation of IAP acting through thezone of apposition between the diaphragm and lowerpole of the thorax ‘to push the ribs out’ (Urmey et al.,1988; De Troyer, 1997). This ‘respiratory generated IAP’simultaneously contributes towards the postural sup-port and stabilisation system.

Postural control supports the breathing mechanism:

� By providing a spatially appropriate and stable base ofsupport for the lower spinal column and pelvis and so,stability for the diaphragm’s crural attachments


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� In ‘healthy posturo-movement’, the thorax is aligned ina balanced relationship to the pelvis, affording spatialstability of the lower pole of the thorax and so for thediaphragm’s costal attachments enabling optimal con-ditions for its descent.

If the posture is ‘good’ so too is the breathing patternand conversely, if the breathing pattern is healthy, so is theposture (Cumpelik 2008). In dysfunction, altered postureand compromised breathing patterns always go togetherand are found almost universally in our clients.

Lewit (2008) speculates that in essence, healthybreathing and postural patterns depend upon balancedactivity levels and good coordination between the dia-phragm, and the ALAW e in particular transversusabdominis. This is further explored.

‘Core control’ and the intra-abdominalpressure mechanism

The spine like any column, risks buckling through non-axially applied loading stresses e particularly those in thesagittal plane. Yet the spine is but the ‘backbone of thetrunk’ and other mechanisms come into play to assist itssupport and control.

IAP has long been regarded as important for the stabi-lization and support of the back when exposed to liftingheavy loads. Early lifting studies mostly looked at maximaleffort with Valsalva’s manoeuvre with a closed glottis(Hemborg and Moritz, 1985; Hemborg et al., 1985a,b;Goldish et al., 1994). The focus then was on trunk musclestrength rather than ‘control’.

Later studies showed that low levels of IAP were also animportant part of the dynamic antigravity postural controland support mechanism during daily ‘functional activities’e moving a limb (Cresswell et al., 1992, 1994; Hodges andGandevia, 2000a,b; Kolar et al., 2010); lifting andlowering (Cresswell and Thorstensson, 1994).

IAP is generated when the diaphragm descends creatinga simultaneous reflex co-activation of the transversusabdominis and the pelvic floor muscles. This positive intra-abdominal pressure is an automatic, anticipatory or ‘pre-movement’ stabilizing response which acts like an inflatedballoon providing internal ‘pneumatic support’ for theanterior spine and pelvis and tensioning of the thor-acolumbar fascia (Bartelink, 1957; Tesh et al., 1987;Cresswell et al., 1992; Hodges et al., 2001b). It is importantthat the activity levels and timing onsets between thediaphragm and transversus with the PFM are well balanced.Problems arise when any element is overactive or under-active thus disturbing the balanced pattern of coordinationand leading to ‘system blow outs’ and loss of optimal con-trol e postural, breathing, continence etc..

In healthy function, the amount of IAP generated is at alevel appropriate to the task e to enable postural supportand regular breathing patterns during functional activ-ities (Grillner et al., 1978; Hodges and Gandevia, 2000b;Kolar et al., 2010). Hence IAP increases in proportion to thereactive forces created by limb movement (Hodges andGandevia, 2000b; Beales et al., 2010b) and more so withincreasing respiratory demand (Beales et al., 2010a). It varies


phasicallywitheach stepwhenwalking (Grillner et al., 1978).A ‘heavy lift’ requires strongmuscle splinting of thebodywalland high levels of IAP as in Valsalva’s manoeuvre (McGill andSharratt, 1990) where breathing is temporarily sacrificed.

It isn’t possible to generate IAP without associated trunkmuscle co-activation and conversely trunk muscle co-activation is normally associated with IAP generation eeach increases proportionally to the other and the higherthe forces, the stiffer the spine (Cholewicki et al., 2002). Indysfunction, this proportionality is lost - increased anddominant ‘outer myo-fascial squeeze’ suffocates the ‘coreresponse’.

Spinal stiffness also changes throughout the breathingcycle due to fluctuating IAP and trunk muscle activity(Shirley et al., 2003). Holding the breath at the end ofinspiration during loading generates higher levels of IAP andspinal stiffness (Hagins et al., 2004, 2006). However aregular breathing pattern under loading conditions resultsin ‘more optimal’ IAP levels reducing the risk of unduespinal compression (Beales et al., 2010b).

IAP also expands the lower rib cage three dimensionallye in particular laterally. Thus it ‘opens the centre’ body,helping to maintain the optimal spatial alignment betweenthe thorax and pelvis and helping preserve the body’s lon-gitudinal integrity. Through it we can change the volumesof the body cavities e contributing also to changes in bodyshape in posturo-movement.

Importantly in healthy control, IAP is not a ‘rigid hold-ing’! Instead, it affords a buoyancy and resilience to axialantigravity control. This promotes adaptable, flexibleintersegmental control, and three-dimensional posturalweight shifts and adjustments throughout the whole spinee necessary for optimal control and balance.

Significantly, IAP provides internal stability to supportin particular, the actions of psoas (Kolar, 2007), and thelarge superficial ‘extrinsic’ trunk muscles involved in moredynamic postural control e providing internal countersupport against the ‘yanking’ and ‘squeezing’ effects oftheir activity. This is important during functional loadtransfer between the pelvis and trunk as in the supineActive Straight Leg Raise (ASLR) test (Beales et al., 2009a).

Microgravity studies are illuminating. Weightlessness ofthe abdominal contents dramatically removes tension in theabdominal wall allowing the sternumand ribs tomove upwardchanging the rib cage shape andmotion. When the resistanceprovided by the abdominal fulcrum decreases, the di-aphragm’s ability togenerate IAP in thezoneofappositionandexpand the lower rib cage is compromisede and the scalenesand parasternal intercostals show increased tonic activity(Paiva et al., 1993). Conversely, in hyper gravity states, IAPincreased and the lateral rib cage invariably expanded andassumed a more caudal position. These researchersconcluded that “IAP thus appears to be a major determinantof the configuration of the related lower rib cage”.

So, when ‘up’ against gravity, low levels of IAP are al-ways present but vary in magnitude to accommodate therespiratory cycle and the fluctuating demands of axialpostural control (Cresswell and Thorstensson, 1994; Hodgesand Richardson, 1997).

To achieve this, the diaphragm, transversus abdominisand the pelvic floor muscles need to be able to both co-activate in patterns of low grade, sustained yet varying



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levels of tonic activity for postural uprightness and at thesame time be able to generate superimposed phasic ac-tivity to meet the prevailing demands of respiration andpostural reflex adjustments and movements of the trunkand limbs (Hodges and Gandevia, 2000a,b; Kolar et al.,2010; Beales et al., 2010b).

This is most important to appreciate.Like the fairy story character Goldilocks’ porridge, the

amount of IAP needs to be not too high; not too low e but‘just right’. This is not only dependent upon balanced ac-tivity within the deep ‘intrinsic’ system but is also reliantupon balanced activity levels between the ‘deep’ and su-perficial ‘extrinsic’ myofascial systems.

It is clinically apparent that in general, patient pop-ulations have difficulty achieving and modulating this bal-ance where the amount of IAP is either deficient orexcessive. Either way the quality of breathing and posturalcontrol suffers.

The principal elements contributing to ‘corecontrol’

The diaphragm: the forgotten element in ‘corecontrol’?

Long acknowledged as ‘the’ principal muscle of respiration,we now know that the diaphragm is also important inpostural control (Allison et al., 1998; Hodges et al., 2001b,2003; Kolar et al., 2009, 2010) through its contribution tothe generation of IAP (Hodges et al., 1997a; Hodges andGandevia, 2000a,b).

The crural and costal parts of the diaphragm simulta-neously co-activate with transversus and the PFM to createIAP as part of the feedforward postural responses prior tolimb movement (Hodges et al., 1997a; Kolar et al., 2010).

The diaphragm is non-uniformly recruited respondingdifferently to postural and respiratory demands. Theincreased descent in response to limb load postural challengeis greater than during tidal breathing alone and is moremarked during lower extremity challenges e.g. supine resis-ted hip flexion. The contraction occurs mostly at the domeapex and the crural (posterior) sections (Kolar et al., 2010).

While diaphragmatic activity is largely reflexive, itspostural function can be activated voluntarily independentof respiration. Subjects were able to increase the degree ofdiaphragm descent while breath holding beyond that seenin tidal breathing e with varying individual response pat-terns (Kolar et al., 2009).

As the crura are attached between T12 to L2-3 the dia-phragm directly affects upper lumbar stiffness (Richardsonet al., 2004). Experimental stimulation of the diaphragmwithout concurrent activity of the abdominal or backextensor muscles creates an extensor torque in the spine(Hodges et al., 2001b).

When respiratory demand is substantially increased(during hypercapnoea; taxing exercise; or respiratory dis-ease) respiration wins over postural control. The diaphragm(and transversus and the PFM) show diminished tonic activityand postural IAP may be degraded (Hodges et al., 2001a).

With added significant spinal loading and ventilatorychallenge the trunk becomes stabilized by the large axial


muscles and the diaphragm goes into respiratory modeEntrainment of the abdominals to the breathing cycle maybe apparent (McGill et al., 1995).

The abdominal muscles: more than just flexors

‘The abdominals’, a group of myofascial layers forming theanterolateral abdominal wall (ALAW) do not work alone butin complex synergies of control which contribute to bothbreathing and three dimensional posturo-movementcontrol.

It is important that training the ALAW is done in a waythat is both safe for the spine and promotes functionalcapacity.

Postural perturbation (Hodges and Richardson, 1997,1999a) and respiratory studies (Hodges et al., 1997b) sug-gest that there is independent control between the deeplyplaced transversus and the more superficial abdominals ethe obliques and rectus abdominis. Transversus activates inadvance of the superficial abdominals (Hodges andRichardson, 1999b) and is more tonically yet adaptivelyinvolved in the generation and modulation of IAP for thefluctuating demands of respiration and postural control(Eriksson et al., 2011).

More task dependent, the obliques and rectus work morephasically to control the imposed torques and the spatialrelationship between the thorax, pelvis and the axial spinein posturo-movement (Bergmark, 1989; Hodges, 2003;Saunders et al., 2004; McCook et al., 2009). Their activity islow grade for most ordinary activities of daily living and it isonly during ‘high load’ activities where they strongly splintthe body wall e stiffening the body and limiting breathing.

Importantly, transversus activity does not occur inisolation but as part of the coordinated pre-movement’‘stabilizing synergy’ creating IAP. Some researchersconcluded that it is transversus activity which is mostconsistently related to changes in IAP (Cresswell et al.,1992; Cresswell and Thorstensson, 1994) while othersthought it was the diaphragm (Hemborg et al., 1985b).

However, this differential function between the deepand superficial abdominals is generally overlooked bytrainers. Instead of specific activation and building controland endurance in the deep ‘stabilizing synergy’ to support‘uprightness’, much of the ‘core training’ offered simplybecomes ‘strengthening the abs’ as a group e principallythe superficial abdominals e invariably in supine intorepeated cycles of spinal flexion: crunches, curls, sit-upsetc with predictable adverse consequences on the discsand spinal health and wellbeing.

Abdominal activation patterns change depending uponwhether the prime purpose is to control pelvis motion orthorax motion: the obliques are most active particularly theinternal oblique, and more so when the pelvis initiates themovement (Vera-Garcia et al., 2011). During a supine ASLR,the lower internal obliques are generally more active(particularly ipsilaterally) than the external obliques(Beales et al., 2009a).

Regional variations in the morphology and recruitmentof transversus and internal oblique have also been shown.The greatest tonic postural activity occurs in the lowersection; the least in the upper sections while the middle


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was most associated with respiratory activity. Activation ofthe lower and middle sections was independent of theupper region (Urquhart et al., 2005).

Clinically, differing activity levels between the ‘upper’and ‘lower’ abdominals have been long reported with‘upper’ strong and ‘lower’ weak the most common, fol-lowed by both ‘upper’ and ‘lower’ weak (Kendall et al.,1993).

Significantly, the abdominal muscles particularly trans-versus, are important when antigravity for efficient dia-phragm activity: on inspiration they provide both stabilityof the lower rib cage to support diaphragmatic descent andcounter support for the abdominal contents e and so thegeneration of IAP. Transversus is more eccentrically activeon inspiration and concentrically active on exhalation(Hodges and Gandevia, 2000b). As respiratory demand in-creases the whole abdominal group becomes increasinglyinvolved in active exhalation to assist diaphragm ascent inreadiness for the next diaphragm descent and inhalation.However individual strategies vary and some may showgreater activity synchronised to inspiration (Beales et al.,2010a). During hypoxic hypercapnic breathing studies,transversus activity occurs well before activity in the otherabdominals (De Troyer et al., 1990).

The ‘Abdominal Drawing in Maneuver’ (ADIM) or‘Abdominal Hollowing’ is a suggested strategy to activatethe ‘deep muscle corset’ which aims to preferentially re-cruit the lower transversus while minimally contracting theobliques. Subjects are asked ‘to pull in the lower abdomen’keeping a ‘neutral spine’ (Richardson et al., 2004). Thequality of the response is important and substitution pat-terns avoided. The lower internal oblique is also consid-ered part of the ‘deep corset’ by some and the ability toisolate it from the upper rectus and external oblique in theADIM has been demonstrated (O’Sullivan et al., 1997b).Correct performance of the ADIM also recruits the dia-phragm (Allison et al., 1998) and PFM (Sapsford andHodges, 2001). Positive treatment effects have beendemonstrated utilizing the ADIM combined with co-activation of lumbar multifidus in a CLBP subgroup(O’Sullivan et al., 1997a).

However, achieving the correct action can be difficultfor many ‘healthy’ subjects (Beith et al., 2001). Ishida et al.(2012) demonstrated that a maximum voluntary exhalationrecruits transversus and internal oblique e followed byexternal oblique, significantly more than during the ADIM.

‘Bracing’ the whole ALAW has been shown to be moreeffective in increasing lumbar stiffness or ‘stability’ thanthe ADIM (Grenier and McGill, 2007). However, it’s alsoimportant to keep in mind that this can create ‘too muchstability’, rigidity and stiffness for healthy spinal control.While the obliques and rectus help to anchor the thoraxcaudally their excessive activity also constricts the inferiorthorax interfering with diaphragm descent. Conversely,transversus activity through IAP increases the transversediameter of the lower rib cage.

Underactive or overactive abdominals compromise thediaphragm’s functionWhen the ALAW is underactive, the abdomen protrudes, the‘neutral’ spino-pelvic posture is lost and so also control ofthe functional relationship between the thorax and pelvis,


affording little stability for the diaphragm and the rest ofthe ‘stabilizing synergy’ in the creation of optimal IAP.

Conversely, when the superficial abdominals are ‘toostrong’, the ‘neutral’ spino-pelvic ‘posture is also lost, theinferior thoracic opening is constricted, inhibiting dia-phragm descent and so, disturbing the associated reflexfunction between the diaphragm, transversus and pelvicfloor e again IAP generation is compromised.

Balanced activity between all muscles in the abdominalgroup ensures an ‘ideal’ thoraco-pelvic alignment and astable, ‘open centre’ for the generation of optimum IAPand postural control. To achieve this, transversus (and thediaphragm) via the ‘stabilization synergy’ needs to havethe capacity to match the activity of the more superficialrectus and the obliques. This is important to appreciate.

Abdominal postscript: an ‘hour glass figure’ is a beautymyth and non-functional! Just observe the torso of a singer,an elite track and field athlete or a professional dancer ethe thorax is balanced over the pelvis, the ‘centre is open’with balanced activity in the ALAW (Fig. 2.) and theextensor system (Fig. 3.). The waist is subtle.

The pelvic floor: the seat of breathing and posturalcontrol

The PFM must contract during tasks that elevate IAP to bothcontribute to pressure increase and to maintain continence(Sapsford and Hodges, 2001). Avoiding bladder neckdepression requires the PFM activity to be high relative tothe IAP increase (Junginger et al., 2010). Increasingly, thereis an evident association between CLBP, continence andbreathing disorders (Smith et al., 2006; Eliasson et al.,2008; Smith et al., 2009). If you don’t breathe well andposture well, you are more likely to get CLBP and developincontinence.

The PFM are tonically active as part of the ‘stabilizationsynergy’ and demonstrate respiratory modulation eshowing more activity on exhalation (Hodges et al., 2007).

Upright unsupported sitting postures recruit greater PFMactivity than slumped supported postures (Sapsford et al.,2006, 2008). Resting PFM activity is also higher in standingand is affected by the lumbo-pelvic posture being highest ina hypo-lordotic posture (Capson et al., 2011) e not neces-sarily a good thing as continence disorders have been linkedto increased PFM and external oblique activity (Smithet al., 2007a,b). Over-training the PFM and abdominalscan be deleterious!

Voluntary activation of the PFM normally creates a co-contraction in the abdominal muscles (Sapsford et al.,2001) e here, transversus activation was greatest withthe spine in extension; external oblique when the spine wasflexed. Similarly, voluntary lower abdominal activation re-sults in a reflex activation of the PFM which occurred inadvance of IAP (Sapsford and Hodges, 2001).

The PFM also contribute to intrapelvic myomechanics(Bendova et al., 2007). Bear in mind that their (over) ac-tivity counternutates the sacrum and coccyx which placesthe sacroiliac joint in its less stable position. The ability toeccentrically lengthen the PFM is important in ‘funda-mental patterns of pelvic control’ (Key, 2010a) which sup-port healthy axial control mechanisms.


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


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‘Core control’: It’s about coordination ratherthan strength

As research has demonstrated, the ‘core response’ is aboutmuscle co-activation and coordination. Reliant upon inputfrom the sensory system, it is the accurate interplay ofmany muscles working in synergies to produce complexpatterns of control and movement rather than the strengthof individual muscles (Hodges, 2003). No muscle worksalone. Activating single muscles is impossible e trying to,creates dysfunctional spines (McGill, 2004). Retraining‘core control’ involves relearning basic motor skills.

Functional control requires the ability to coordinate thepostural and respiratory functions of the trunk muscles. Toachieve this, a well-coordinated IAP mechanism contributesmuch towards our ability to operate well in a gravity-basedenvironment.

Figure 3 Balanced activity in the extensor system in a pro-fessional dancer.


This suggests a definition of ‘core control’: “The abilityto generate optimal IAP to support both breathing and theprovision of three dimensional postural and movementcontrol of the torso e particularly control of the pelvis onthe legs”.

Real ‘core control’ comes from inside. Most people tryto train it from the outside.

What goes wrong with ‘the core’?

Dysfunction of ‘the core’ involves subtle to overt shifts inthe pattern of motor activity. There is both dys-coordination in the deep system and imbalance between‘inside’ and ‘outside’ control e too little, too late deepsystem control necessitates substitution strategies byvarious superficial muscles (Hodges, 2003) which showdistinct patterns of tonic and/or phasic overactivity. Theiroveractivity involves both timing (too early) and degree ofactivity (too much) e further interfering with the mecha-nisms of deep system control. This augmented muscle ac-tivity is being increasingly reported (Hodges et al., 2009;Van der Hulst et al., 2010; Jones et al., 2012). This createsgreater trunk stiffness e and so, and contrary to popularbelief CLBP subjects actually move their spines less (Moket al., 2007) and move with excess muscle tension andeffort e and breath holding.

Importantly, the deep system ‘stabilization synergy’ isnot coordinated. The principal problem is more one of poorcoordination and endurance than reduced strength.

CLBP and related research now provides ample evidenceshowing delayed and/or reduced activity of the individualdeep system elements which contribute to IAP and controletransversus abdominis (Hodges and Richardson, 1997, 1998,1999a,b; Ferreira et al., 2004; Hides et al., 2010); lumbarmultifidus (Hides et al., 1994, 2008; MacDonald et al., 2009)transversus and lumbar multifidus (Hides et al., 2011b); PFMe delayed yet increased activity in incontinent women(Smith et al., 2007a; Madill et al., 2010).


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Similarly, altered postural function of the diaphragm hasbeen shown. In a CPGP cohort, an ASLR on the painful sideresulted in increased bilateral oblique muscle ‘bracing’ ofthe abdominal and chest wall associated with diaphragm‘splinting’ and reduced excursion while PFM descent wasincreased (O’Sullivan et al., 2002a; Beales et al., 2009b).This was associated with an increased baseline shift in IAP,increased minute ventilation and a high variability of respi-ratory patterns including accessory breathing patterns andtransient breath holding. Significantly, in the O’Sullivanstudy, over half the sacroiliac pain cohort showed zero dia-phragmatic motion! It is important to note that with this‘inversion function’ of the diaphragm, the automatic reflexrelationship between it, transversus and the PFM is lost,hence the non-optimal IAP generated by superficial abdom-inal splinting was associated with increased PFM descent.

Another CLBP study found a higher resting position of thediaphragm and in response to postural tasks in supine(resisted bilateral arm or hip flexion) there was significantlyless diaphragmatic excursion (Kolar et al., 2012).

Howcanweseewhatgoeswrongwith the ‘core’?

Altered neuromotor control results in common observableeffects e in essence:

� Altered sagittal spatial pelvic position (and intrapelviccontrol) and related.

� Altered spinal alignment� Deficient ‘intrinsic’ control e including the ‘stabilizingsynergy’ and

� A compensatory over-reliance on ‘extrinsic’ control indistinct patterns of myofascial ‘holding’ or ‘cinching’ecreating regional segmental ‘hyper-stability’ while inother regions, spinal segmental control is inadequate.

Figure 4 Schematic depiction of ‘healthy alignment’ (centre) andabdomino-pelvic cavity in the crossed syndromes: Posterior PelviSyndrome (APXS) (right).


The body shape and its functions change resulting indisturbed regulation of internal pressure change mecha-nisms because of compromised diaphragmatic function.The IAP generated provides suboptimal support forbreathing and postural control (Fig. 4).

The necessary compensatory control strategies actuallystiffen and bother the spine and pelvis in differing ways.

Two subgroups are apparent e thearchitecture of ‘the core’ and its control aredifferently compromised

Based upon the altered postural alignment and changedregional myofascial activation patterns, two main sub-groups are clinically apparent which have been described asthe Pelvic Crossed Syndromes (Key et al., 2008; Key,2010a,b).

Simply looking at the client as he sits or stands in front ofyou tells you his problems. In particular, observing the ar-chitecture of the lower pole of the thorax and the ALAWinforms as to the activity level and balance between thediaphragm and transversus abdominis.

Imbalance in the ALAW is common yet differs betweengroups. In general there is underactivity of the deeptransversus associated with either increased or decreasedsuperficial activity in the obliques and rectus. Theincreased activity is more apparent in the ‘upper’ ALAWwhile the ‘lower’ ALAW is generally deficient.

The posterior pelvic crossed syndrome (PPXS)

This subgroup is more axial extensor dominant. This isnon-uniform, principally occurring in the extensor systemover the thoracolumbar junction between the dorsal hinge

the apparent altered body shape including that of the thoraco-c Crossed Syndrome (PPXS) (left) and Anterior Pelvic Crossed


Figure 6 Typical appearance of underactivity in the wholeALAW in a PPXS picture.


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and the mid lumbar spine. Termed a ‘Central PosteriorCinch’ (Key, 2010a), this automatic reflex hyperactivity is atonic, bilateral, posterior ‘bracing’ response (Fig. 5) char-acteristically co-associated with observable underactivityof the entire anterolateral abdominal wall (Fig. 6).

The quality of breathing and postural control patternssuffers in a typical manner.

Thoraco-pelvic alignment alters e the pelvis moves backand the thorax moves forward assuming a more obliquerelationship to each other. Importantly the whole thoraxalso moves up because of the poor inferior stabilisationafforded from the abdominals. The infra-sternal angle isincreased being generally greater than 90� while thepostero-inferior thorax is hyper-stabilized and ‘drawn in’limiting postero-lateral costo-vertebral movement. Theperson principally relies upon habitual ‘Central PosteriorCinch’ (CPC) behaviour for antigravity postures and move-ment control (Dankaerts et al., 2006a,b). The resultingmore anterior and elevated position of the thorax in-terferes with the functional relationship between thethoracic and pelvic diaphragms disturbing Lower Pelvic Unit‘stabilization synergies’.

As a result the person lifts the thorax on inspirationthrough a synergy of pectoral ‘lift’ and ‘CPC’ adopting anupper chest breathing pattern. Active exhalation is difficultas abdominal activation is inadequate to bring the thoraxdown and back into the more ‘expiratory’ caudal, or‘neutral’ position, as well as generate the necessary IAP.The expiratory phase is shortened. Breathing pattern dis-orders are common. In general, the person cannot achieveposterior basal expansion and a lateral widening of thelower rib cage and he cannot generate appropriate IAPwhen antigravity e let alone during movement where

Figure 5 Typical appearance of a ‘Central posterior Cinch’activity in a PPXS picture.


breath holding is common. The important co-activation andcoordination, between transversus and the diaphragm ismissing e the abdominal underactivity is paramount. He isforced to rely upon ‘CPC’ behaviour which is co-associatedwith overactivity in the psoas and probably the crural dia-phragm, further disturbing patterns of control.

Retraining the PPXS client

In rehabilitation, this group certainly need to generatemore activity in the ALAW! However, ‘sit-ups’, ‘crunches’‘curls’ etc are not the answer! These create large flexionloading stresses on the spine (McGill, 2002) and do notrestore the function actually needed. Multiple, deleterioussegmental effects ensue from over-flexing spinal tissues(Solomonow, 2012).

The best way to initially activate the ALAW in particulartransversus is through improving active exhalation (Ishidaet al., 2012; Ishida and Watanabe, 2013) to bring the tho-rax caudally on a stable pelvis. Initially the client may needassistance with this (Figs, 7 and 8). He then has to learn tomaintain this more ‘neutral’ position through ALAW acti-vation while also breathing down not up! (Fig. 9) And thenfurther, to be able to maintain the above while generatingsustained LPU activity and IAP with a regular basalbreathing pattern e in particular a more extended exha-lation (Fig. 10). The IAP is monitored low down at thelateral iliac fossa (Fig. 11) where a sustained firming shouldbe felt. This pressure can only be developed if all elementsof the ‘stabilization synergy’ are co-activated.

Applicable to both subgroups albeit with differingemphasis, this is ‘The Fundamental Pattern of Control’which simultaneously trains both the postural and respira-tory aspects of the ‘stabilization synergy’. It is easiest to


Figure 7 In supine supported hip flexion, the ‘inspiratory’more cephalad position of the thorax is apparent. Note thereduced abdominal tone and wide infra-sternal angle.

Figure 9 The practitioner helps to maintain the caudalthorax while asking the patient to ‘breathe down to my lowerhand’. Encouraging an active and longer exhalation helpsactivate the ALAW and facilitate a firming in the ‘Lower PelvicUnit’ giving him ‘the sense of’ the required action which healso monitors with his (R) hand.

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first establish with the hips in supported flexion, gravityeliminated. When the correct pattern is mastered it isincreasingly sustained to build endurance and capacity inthe ‘stabilization synergy’. This is further progressed intounsupported hip flexion (Fig. 12), progressing to variouslimb load challenges and sustained antigravity control insitting and standing.

Postero-lateral expansion of the lower rib cage can onlybe achieved by ALAW activation with an appropriatepattern of IAP hence we simply work for this. This is pro-gressed from recumbent (to ‘re-groove’ the posturalresponse) to upright. ‘Opening the centre’ is achieved by‘pushing the ribs wide and back’ without lifting the thoraxwhile continuing a regular basal breathing pattern(Fig. 13). Developing capacity in the ‘stabilizing synergy’helps overcome the tendency to ‘Central Cinch Pattern’

Figure 8 The thorax is passively brought into the caudal‘expiratory position’ to help give the client the sense of the‘neutral’ thoraco-pelvic position. Holding it so helps him inhibitlifting the thorax on inspiration and also facilitates betterdiaphragmatic and ALAW activity so that he can experience the‘feel of it’.


behaviour when antigravity. Once this is mastered, appro-priate limb load challenge can be judiciously applied pro-vided that control of the ‘fundamental pattern’ affordingthoraco-lumbo-pelvic stabilization, IAP and a regular dia-phragmatic breathing pattern are maintained. If lost, weneed to go back and reestablish better ‘fundamental con-trol’, reduce the challenge such that it can be properlysustained.

Abdominal ‘bracing’ strategies in a ‘neutral’ thoraco-pelvic position are more appropriate for this group but needto be carefully applied while ensuring correct andadequate pre-activation of the ‘stabilizing synergy’.

Figure 10 He is now managing to control the thorax positionand generate sustained IAP while continuing to regularly‘breathe down not up’. He needs to keep focusing upon alonger exhalation and holding the lower ribs down and back incontact with the support surface. Sustaining the action forincreasing periods of time builds capacity and endurance in the‘stabilizing synergy’.


Figure 11 Sustained Lower Pelvic Unit ‘switch on’ is moni-tored low down in the ‘lateral valley’ of the iliac fossa e notcentrally over rectus abdominis.

Figure 13 The client is being asked to ‘push out sidewaysand back into my hands’. She can only do this by adequateactivation of the ‘stabilization synergy’. Note the ‘CentralPosterior Cinch’ hyperactivity which will lessen as she improvesinternal control.


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Otherwise, overdeveloping abdominal ‘bracing’ riskscompromising diaphragm descent and creates hyper-stability and spinal compression (Reeves et al., 2006)limiting movement through the spine and degradingposturo-movement control and balance (Grὔneberg et al.,2004).

‘Planks’, ‘side bridge’ ‘stir the pot’ etc. are way toomuch for many and encourage superficial ‘lock down’ e inparticular reinforced ‘Central Cinch Pattern’ behaviour,‘pectoral armouring’, and further deep system inhibition.

Attempting ‘abdominal hollowing’ invariably results in a‘suck in’ and lift of the thorax and/or a posterior pelvic tiltwith lumbosacral flexion. This just further imprints patternsof non-optimal control.

Figure 12 When the correct pattern is mastered it is furtherprogressed to no support for the legs. Care must be exercisedin not over challenging the client beyond his abilities. Notethat the subject’s lower ribs have lifted slightly of the supportsurface hence ‘going back’ and spending longer time devel-oping and sustaining a better pattern of control in the ‘legssupported position’ is indicated.


Anterior pelvic crossed syndrome (APXS)

This subgroup is more axial flexor dominant withoveractivity of the upper anterolateral abdominal wallbetween the umbilicus and the xiphoid. Termed a ‘CentralAnterior Cinch’ (Key, 2010a), this automatic reflex hyper-activity is a bilateral, tonic anterolateral ‘bracing’ responsewhich is co-associated with underactivity in the lowerALAW and relative underactivity in the axial extensor sys-tem. A crease and/or a hollow are generally apparent abovethe umbilicus (Fig. 14). However, transient ‘Central Poste-rior Cinch’ (CPC) behaviour occurs when the postural systemis challenged e and more so in pain states. This combinedwith the Central Anterior Cinch (CAC) behaviour, hyper-stabilises and ‘draws in’ the whole lower pole of the tho-rax (Fig. 15). Regional joint function is suffocated.

The quality of breathing and postural control patternssuffers in a typical manner.

Thoraco-pelvic alignment again shows an oblique rela-tionship e the pelvis moves forward and the thorax back,assuming a more ‘expiratory’ position further constrictingthe lower pole of the thorax. The infra-sternal angle isusually less than 90�.

Static antigravity strategies invariably involve axialcollapse and ‘slumping’ relying upon passive end range


Figure 14 Typical appearance of ‘Central Anterior Cinch’activity in an APXS picture.

Figure 15 Combined anterior and posterior Central CinchPattern behaviour constricts the lower pole of the thorax. Thesubject is a 19-year-old ‘gym junkie’ who presented with aright femoral nerve irritation.

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loading of the spinal joints and posterior myofascial tissuesinto flexion (Dankaerts et al., 2006a,b). This postural mal-alignment and the associated ‘Central Cinch Pattern’behaviour interfere with the diaphragm’s ability to descend.Without diaphragmatic descent, the reflex relationship be-tween it and the PFM and transversus is lost (O’Sullivanet al., 2002a). Without this co-activation, the ability togenerate IAP is compromised and so suboptimal breathingand postural control ensues. Kolar suggests (2008) that whenthis ‘inversion function’ of the diaphragm occurs (it goes upinstead of down) and IAP is deficient, the central tendonnecessarily becomes the compensatory ‘place of stability’,further pulling in the lower pole of the thorax.

Posturo-movement challenges result in increased ‘CAC’behaviour, transient ‘CPC’ behaviour and breath holding.Restricted chest wall expansion during exercise has beenshown to increase diaphragmatic fatigue, reducing itsendurance (Hussain et al., 1985; Hussain and Pardy, 1985).

The person further compensates with an upper chestbreathing pattern as they find it difficult to relax the upperALAWand‘push’ thediaphragmdownandso, lateralexpansionof the lower rib cage and ‘opening the centre’ again suffers.

Breathing pattern disorders and poor energy levels arecommon.

While the thoracic diaphragm is relatively underactive,the pelvic diaphragm and related myofascial tissues overthe posterior inferior pelvis are characteristically tight eyet may show timing delays (Smith et al., 2007a,b) furtherdisturbing control. This is part of an ‘inferior tether’pattern of dysfunction in the pelvis (Key, 2010a).

Pelvic girdle pain syndromes are a common feature inthis subgroup.

Retraining the APXS client

In rehabilitation, it is important to understand and recog-nise the real needs of this subgroup. Their real difficulty isthe diaphragm e too little too late. Obtaining balanced andcoordinated activity between the ALAW and diaphragm canbe tricky. The ‘CAC’ reflex hyperactivity means thatattempting the ADIM predictably results in early ‘upper’ALAW over-activation (Lee et al., 2008) often involving a‘suck in’ and thorax lift and breath holding, further aug-menting the CAC response (Fig. 16) e and difficulty acti-vating the ‘lower’ ALAW (Hides et al., 2011a). Similarly,because the ‘upper’ ALAW is already overactive, abdominal‘bracing’ strategies are inappropriate.

The increased external oblique activity common in thisgroup is often associated with increased PFM activity (Smithet al., 2007b). Like squeezing a tube of toothpaste in thecentre, this Central Cinch Pattern behaviour constricts thewaist, creating undue pressure on both diaphragms.

Instead, we need to ‘down train’ the ‘Central Cinchpattern’ activity e in particular the CAC behaviour; andreally encourage better diaphragm activity towardsachieving good co-activation and balanced activity withinthe whole ‘stabilization synergy’. Establishing this alsohelps to relax the upper ALAW and gain better lateralexpansion of the lower pole of the thorax (Fig. 17). Withthis, it’s helpful to think of IAP as a balloon: e if yousqueeze the bottom (co-active PFM and lower transversus


Figure 16 Asking for “draw the lower abdomen up and in”results augmented CAC behaviour and breath holding. Note theasymmetry of the lower pole of the thorax.


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in response to diaphragm descent) e the top expands(pushing the ribs out), ‘opening the centre’.

Cueing the PFM to help re activate the lower transversusisn’t necessarily helpful as this can still result in augmentedCAC behaviour. Getting better ‘push down’ of the dia-phragm and re-establishing the ‘stabilising synergy’ helpsnormalize PFM function.

Discussion

Improper coordination between the abdominal wall and thediaphragm results in compromised breathing and ‘internalsupport’ and spinal stability mechanisms.

Figure 17 ‘Letting go’ the upper ALAW, establishing betterdiaphragm descent and its co-activation within the ‘stabilizingsynergy’ now enables ‘opening the centre’.


Each person has an individual presentation yet there arecommon subgroup patterns.

In the PPXS group the ALAW deficit is paramount causingthem to rely on CPC behaviour and related overactivity ofpsoas.

In the APXS group, reduced diaphragm activity necessi-tates reliance upon CAC behaviour and ‘locking’ thepostero-inferior pelvis.

The dysbalance may be subtle or marked where morecompromised function occurs.

The crux of the problem

‘Core problems’ are apparent in our clients as acommon difficulty in simply ‘sitting up’ and breathingproperly!: e achieving antigravity ‘neutral’ thoraco-pelvicpostural alignment with a regular diaphragmatic breathingpattern (O’Sullivan et al., 2002a; Beales et al., 2009a;Roussel et al., 2009). This is basic to all their otherproblems in achieving healthy spino-pelvic movementcontrol. These include diminished triplanar weight shift androtation through the spine and pelvis and so, reducedvariability of postural strategies (Moseley and Hodges,2006), impaired postural compensations (Grimstone andHodges, 2003) and reduced postural adjustments throughthe pelvis/hip affecting balance (Mok et al., 2004, 2011;Smith et al., 2008).

The Pelvic Crossed Syndromes are an expression ofdeficient deep system control.

In addition, a ‘Key Sign’ over the lower postero-lateralthorax is further indicative of an incapacity of the deep‘stabilizing synergy’ to match the degree of superficial(over) activity seen in the ‘Central Cinch Patterns’ e whereinternal counter support, ‘opening the centre’ and it’sthree dimensional control is wanting (Fig. 18 e and alsoFigs. 5, 15 and 22). It is usually more marked on thesymptomatic side.

Correct breathing patterns are ‘the’ basic building blockof ‘core control’. Retraining faulty breathing is multifac-eted (Chaitow et al., 2002; McLaughlin, 2009) and may

Figure 18 A ‘Key Sign’ might be construed as a ‘roll of fat’but is indicative of inadequate and ‘empty’ intrinsic controland compensatory extrinsic hyperactivity.


Figure 19 The ability to ‘fill out’ sideways and back underthe subjects hands and sustain ‘opening the centre’ with aregular basal breathing pattern when antigravity requires ca-pacity and endurance in the ‘stabilizing synergy’ and helpsremedy a ‘Key Sign’.

Figure 21 Habitual ‘slumping’ switches off the deep systemand feels ‘normal’ over time.

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require quite some work in order to reestablish healthypatterns. Once mastered, it is important that they thenbecome incorporated through the ‘stabilizing synergy’ intosustained antigravity postures (Fig. 19) and functionalpatterns of posturo-movement control. In this regard, Kolar(2007) offers an excellent protocol.

Skilled assessment will delineate if any one element ethe diaphragm, PFM, multifidus or transversus requiresparticular individual attention in order to achieve co-activation of the whole ‘stabilization synergy’. This re-quires practitioner intuition, skill, patience and a pre-paredness to ‘play around’ to achieve the correct response.

Retraining the coordination between the diaphragm,transversus and PFM has demonstrated improvements in

Figure 20 The practitioner is providing tactile feedback tohelp the client inhibit lifting the chest on inspiration; while atthe same time directing his awareness to bringing the lowerribs down and back; and then expanding them sideways andback while also sustaining Lower Pelvic Unit engagement and aregular basal breathing pattern.


postural control (O’Sullivan and Beales, 2007) and conti-nence (Hung et al., 2010).

The desirable Fundamental Pattern of Control is alwaysone of correct thoraco-pelvic relationship with regulardiaphragmatic breathing, IAP generation and ‘opening thecentre’ and the ability to maintain this while integratingappropriate incremental limb load challenge. In general,the PPXS group need to master ‘opening the centre’ side-ways and backwards; the APXS sidewayse- and possibly

Figure 22 ‘Sitting up straight’ involves Central PosteriorCinching and throwing the lower ribs forward because ofreduced intrinsic control. This strategy will be short lived. Notethe inability to achieve a lumbosacral lordosis and the ‘KeySign’.


Figure 23 Activating the ‘stabilizing synergy’ helps achievea ‘neutral’ thoraco-pelvic alignment and removes the ‘KeySign’.


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forward. Otherwise, without adequate ‘control of thecentre’, proximal limb girdle activity predictably results infurther ‘Central Cinch Pattern’ behaviour.

Overly focusing upon ‘the abdominals’ e particularlywith cues to ‘tummy tuck’ or ‘tail tuck’ degrades control ofthe lumbosacral ‘neutral’ and disturbs diaphragmatic andPFM kinematics e particularly so in the APXS group. Thediaphragm has to come first (Kolar, 2008) with co-activationof transversus and the PFM.

Commonly, breathing instruction is delivered as anafterthought and so does not involve the correct pattern oflateral basal expansion. This is not possible if appropriateIAP is not generated and/or the chest lifts on inspiration.

Focusing on the PFM alone risks compromising spino-pelvic postural control e yet activating the PFM (with thelower transversus) and diaphragm improves postural control(O’Sullivan and Beales, 2007).

The correct pattern of IAP and stable control can only beachieved if all elements in the ‘stabilizing synergy’ areequally co-active.

Current approaches to ‘stability retraining’ seem to viebetween either ‘abdominal hollowing’ or ‘bracing’ strate-gies. Re-establishing the ‘stabilizing synergy’ as describedincorporates aspects of both approaches towards achievingbetter functional control. It is important to ensure that theprincipal activity is in the Lower Pelvic Unit, with postero-lateral costal expansion while the pelvis and thorax positionare appropriately controlled (Fig. 20). Undesirable compen-sations such as upper chest breathing; breath holding; push-ingwith the feet; clenching thebuttocks; posteriorpelvic tilt,increased ‘Central Anterior Cinch’ behaviour; ‘ballooning thebelly’; abdominal ‘suck in’ and lifting the thorax need to beanticipated. Appreciating the typical features of the PelvicCrossed Syndromes helps predict the likely strategies toovercome.

Remember that increasing the force or load increasessuperficial myofascial activity. If the client is ‘over-chal-lenged’ beyond his ‘deep system’ ability he will havecompensate with Central Cinch Patterns e the reverse ofwhat we want! Clients need to ‘work smarter’, not ‘harder’.High load ‘bracing’ strategies aimed at ‘not letting it move’risk developing ‘corsets of concrete’ which compress thespine and stiffen the body wall, limiting inner movement.

Thus, it is important that the deep ‘stabilizing synergy’ isfirst established and has the capacity to match the activitylevel of the superficial muscles to allow stable yet adaptablepatterns of spino-pelvic control. This is important.

Sitting and ‘the core’

Most people these days habitually sit in lumbo-pelvicflexion (O’Sullivan et al., 2010) eswitching off their deepsystem! e particularly the APXS group (Fig. 21). Normally,adopting ‘neutral’ thoraco-pelvic postures in sitting andstanding automatically facilitates better deep system ac-tivity without activating the large superficial muscles(O’Sullivan et al., 2002b, 2006; Claus et al., 2009a; Reeveand Dilley, 2009; Pinto et al., 2011). However, there isnon-uniform agreement between physiotherapists as towhat constitutes a ‘neutral spinal posture’ (O’Sullivanet al., 2012) Also bear in mind that most people are stiff


with poor intrapelvic control and so, have difficultyassuming a lumbosacral ‘neutral’ lordotic posture (Clauset al., 2009b) e even the young. This, coupled with inad-equate IAP generation means that attempts by the subjectto improve his posture and ‘sit up’ will usually result inincreased ‘CPC’ behaviour (marked in the PPXS group) andpossibly ‘CAC’ strategies (in the APXS group) which maywell exacerbate symptoms (Fig. 22). Conversely, estab-lishing and improving the capacity of the ‘stabilising syn-ergy’ helps to regain a neutral thoraco-pelvic position andreduce this superficial global muscle hyperactivity andtension when antigravity (Fig. 23).

Conclusion

‘Retraining the core’ should redress the client’s actualfunctional deficits and promote functional capacity.

Understanding healthy ‘core control’ is a prerequisite toseeing it’s dysfunction.

‘Core dysfunction’ is both a reflection of inadequate‘intrinsic’ neuro-myofascial system control and the related,necessary compensatory ‘extrinsic’ motor behaviour.

Two basic subgroups are clinically apparent, each dis-playing common features and distinct difficulties with ‘corecontrol’. Posture and movement control of the spine are


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compromised, contributing to both the cause and perpet-uation of many spino-pelvic pain syndromes.

It is important that the practitioner can appreciate andrecognise these subgroup patterns as each dictates adifferent emphasis in therapeutic movement retraining.

Re-establishing the ‘stabilizing synergy’ helps restorefundamental control and has been described for eachgroup.

Acknowledgement

The author would like to thank her senior colleagues atEdgecliff Physiotherapy Sports and Spinal Centre for theirsupport and valuable contributions to this paper and inparticular Andrea Clift co-principal.

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