Download How to Train the Core “Properly”

Introduction
How to Train the Core “Properly”
By Cindy Kester, PT Atrium Sports
Medicine and Physical Therapy
Assisted by David Gabriel, SPT
University of Cincinnati
Objectives:
• 1. To be able to identify structures within the current
definitions of “the core”
• 2. To be able to understand the difference between the
inner core, the outer core, and the different strategies
to assess, recruit, and progress in rehabilitation and
fitness
• 3. To analyze the various controversies and
philosophies on core training
• 4. To apply this understanding for more mindful fitness
and rehabilitation programs
• 5. To introduce Rehabilitative Ultrasound Imaging
(RUSI) as an adjunct for Treatment
The Core of 2014
(FMS Leo Shveyd CSCS)
Current Definitions of the Core:
• Diane Lee:
– Cylindrical core
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Respiratory diaphragm
Pelvic Floor
Transversus Abdominis
Multifidus
As the definition of core has evolved, So too has
our understanding of its function and how to
improve it.
…Leo Shveyd
Paul Hodges:
Grandfather of TrA Isolation
Anatomy Review:
• Respiratory Diaphragm
Stewart McGill:
“Step-Dad of bracing”
“Everything between the shoulders and hips”
“The Value of Blowing up a Balloon”
... A relative “new-comer” on the core
scene.
…Clinically significant for patients with chronic
low back pain as having smaller diaphragm
excursions and higher diaphragm positions
JOSPT 2012
Richardson describes coordination of
TrA and the diaphragm
• Inspiration diaphragm contracts concentrically
whereas TrA contracts eccentrically
• Function in reverse during exhalation
-- Zone of Apposition
-- Controlled by
abdominals and
directs
diaphragmatic
tension
Respiratory Diaphragm has a role in
motor strategy of abdominal wall
Pelvic Floor
Contribute to the mechanical stabilization of
the spine- superior stabilizing structure of
“abdominal canister”
Increases intra-abdominal pressure
Works synergistically with pelvic floor and
abdominal muscles to increase spinal stiffness
and stability
Contribution to stabilizing effect of
Torso
• Anticipate impending load and contract
synergistically with the cylinder core
Dispute with women’s health
advocates and the “brace everything
advocates”
Problems with dysfunctional pelvic
floor
• Primarily urinary stress incontinence
• LBP, pelvic pain, inability to stabilize and
maintain optimal posture and adjustments
Multifidus
Deeper fibers are more influential than
superficial
Strong relationship between multifidus
and TrA
• You need to get TrA firing first before working
on multifidus
Dynamic Changes to Elasticity, CSA,
and fat infiltration
• Segmental decrease in cross-sectional area (CSA)
mostly L4-5, L5-S1 levels- does not spontaneously
recover
• Decrease in CSA of multifidus ipsilateral to painful
symptoms
• Alterations in motor control seen in chronic LBP
• Muscle atrophy quantified with MRI and CT
• Repositioning accuracy found to be significantly
lower
Transversus Abdominis
Multifidus elasticity important in study of muscle
contractile function in response to motor control for
spinal stability in chronic LBP patients
Assessed muscle contractile function at L4 level in prone,
upright and 25 & 45 degrees stooped position. Also
measured CSA and fat area
Findings in back pain group:
Decreased in stiffness in upright and 25& 45 stooped
position
CSA improved from prone to upright position, but
decreased in 25& 45 degree stooped position
Smaller CSA in all postures and + fat infiltration
Assessment
Due to horizontal fiber orientation contraction
of TrA results in an increase in tension in the
thoracolumbar fascia.
It has limited ability to produce trunk motion
Respiratory Diaphragm
• Clinical options
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–
–
–
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Observation
Postural cues
History
Tape measure
Incentive spirometry
Multifidus
Pelvic Floor
• Interview questions
• Postural assessment
• Is there need for women’s health/PT referral?
Transverse Abdominis
• Current best practice based upon study
– Spine Journal 2013
– https://www.youtube.com/watch?v=RevIf3Dumc
M
FMS
Screening
The Controversies…
TrA Isolation
Vs
Bracing
Hodges
Vs
McGill
Core Training
Vs
Core Strengthening
Brain Recognizing Movement Patterns
vs
Isolation training
Core Runs on Reflex Base -Grey Cook
Vs
Cognitive Base -Diane Lee
Where do I Begin?
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•
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•
•
Timing
Co-activation
Core compensations
Mobility then Stability
Impact of pain and debility
LAB 1
Core Breathing:
by Tom Ockler
Blowing up a balloon
Training Pelvic Floor
• Recruitment Training
• Coordinating PF contraction with TrA and
deep fibers of multifidus
Training Lumbosacral Multifidus
• Recruitment Training
• Strength Training
Rehabilitative Ultrasound Imaging
Training Transversus Abdominis
• Recruitment Training
• Strength Training
Why Use RUSI?
How does it work
Help further assess patient’s muscle function
Educational tool that allow therapist to
explain and physically demonstrate to a
patient the subtleties of their specific motor
control
Invaluable biofeedback tool with motor
learning and motor skill acquisition
• Reverse piezoelectric effect (conversion of
electrical signals into US waves)
• Reflections of the sound waves are captured
and used to generate images- conventional
grayscale US
• Reflective properties and architecture of
tissues, bone, muscle, fascia, fluid, fat, and gas
– Hyperechoic- appear white
– Hypoechoic- appear dark or black
“Muscle control = Pain control”
LAB: RUSI
Merit of RUSI for patient education
• Draw awareness and allow patient view
behavior of muscle
• Provide level of awareness and understanding
of their problem
• Get patient to buy in and take responsibility.
Help with level of motivation
Special Thanks
Anne Plattenburg, PT Miami Valley Wright
Health
Eva Huey, PT Miami Valley Wright Health
Andy Konczal from SonoSite