The Importance of Developing a

Primary Core Stability Protocol

Angela M. Homan, SPTDuke University

Doctor of Physical Therapy Intern

SportsMedicine of Atlanta

Dr Robert E DuVallPT, DHSc, MMSc, ATC, OCS, SCS, FAAOMPT, DAC, MTC, PCC, CSCS

Shenandoah University, Associate Professor

Alabama State and Northeastern University, Clinical Assistant Professor

SportsMedicine of Atlanta, Inc.

Residency & APTA Fellowship Curricula Director

reduvall@bellsouth.net www.SportsMedicineofAtlanta.com

SportsMedicine of Atlanta, Inc.

NMR Research Shown Beneficial

to Reduce Pain and Disability "In America alone, the treatment cost of back pain is

estimated to be $86 billion per year or 9% of the country's

total health expenditure. The search for new ways to

manage this old problem is critical in order to improve the

health and quality of life of individuals who struggle with

this condition.“

According to researchers not only do patients feel less pain,

but patients performing these types of exercises are able to

be more physically active and experience positive effects

over a longer period of time than those who receive other

treatments.

Macedo, Luciana G. Maher, Christopher G. Latimer, Jane. McAuley, James H. Motor Control Exercise for

Persistent, Nonspecific Low Back Pain: A Systematic Review. PTJ 2009;89(1).9-95.

Primary Core

Transverse Abdominis (TrA)

Multifidus

Transverse Abdominis Anatomy

Origin: inner surface of cartilages of lower 6

ribs, interdigitation with diaphragm,

thoracolumbar fascia, anterior ¾ of internal lip

of iliac crest, and lateral 1/3 of inguinal ligament

Insertion: linea alba (broad aponeurosis), pubic

crest, and pecten pubis

Nerve Innervation: T7-T12, L1

(iliohypogastric and ilioinguinal)Kendall et al.

Actions of TrA

Flattens abdominal wall and compress the

abdominal viscera

Decrease infrasternal angle of ribs in expiration

(upper portion of TrA)

No Action in lateral trunk flexion, except to

compress the viscera and to stabilize linea alba

(= better action of anterolateral trunk muscles)Kendall et. al.

Weakness in TrA (observations)

Standing position: Permits bulging of

anterior abdominal wall (= increases

lordosis)

Supine position: during flexion a lateral

bulge tends to occur

Prone position: hyperextension of

trunk with lateral bulge tends to occurKendall et al.

Multifidus Anatomy

Origin: Sacral region: posterior surface of sacrum, medial surface of posterior iliac spine & postero-sacroiliac ligaments. Lumbar, thoracic, & cervical regions: transverse processes of L5-C4

Insertion: Spanning two to four vertebrae, inserting onto spinous process of one of vertebra above from last lumbar to axis (second cervical vertebra

Nerve Innervation: SpinalKendall et al.

Actions of Multifidis

Extends vertebral column and rotation toward

opposite side.Kendall et al.

Functions of TrA & Deep Multifidus

Deep Multifidus and TrA provide intersegmental

spinal stability

Deep fibers of Multifidus control intervertebral

motion

Superficial fibers of Multifidus control spine

orientationMoseley GL, Hodges PW, Gandevia SC. Deep and superficial fibers of the lumbar multifidus muscle are differentially active during voluntary arm movements. Spine.

2002;27:E29–E36.

TrA Muscle Activation Patterns

TrA may be controlled independently of the motor command for limb movement in contrast to the other abdominal muscles. Hodges PW, Richardson CA. Transversus abdominis and the superficial abdominal muscles are controlled independently in a postural task.

Neuroscience Letters. 1999;265:91-94.

Feedforward TrA activation pattern with Lower extremity movement Hodges P, Richardson C. Contraction of the abdominal muscles associated with movement of the lower limb. Physical Therapy. 1997;77:132-144.

Feedforward activation TrA activation pattern with upper extremity movement Hodges P, Richardson C. Feedforward contraction of transversus abdominis is not influencedby the direction of arm movement. Experimental Brain

Research. 1997;114:362-370.

Preparatory trunk movement precedes upper extremity movement Hodges P, Cresswell AG, Daggfeldt K, Thorstensson A. Preparatory trunk motionaccompanies rapid upper limb

movement. Experimental Brain Research. 1999;124:69-79. Hodges P, Cresswell AG, Daggfeldt K, Thorstensson A. Three dimensional preparatory trunk motion precedes

asymmetrical upper limb movement. Gait and Posture. 2000;11:92-101.

Core Dysfunction: Anatomy

Transverse Abdominis:

Isometric Knee extension/flexion

tasks identified subjects with LBP had

smaller increase in TrA thickness and

less EMG activity Ferreira PH, Ferreira, Hodges PW. Changes in recruitment of the abdominal muscles in people with low back pain

ultrasound measurement of muscle activity. Spine. 2004;29:2560-2566.

Core Dysfunction: Anatomy

Multifidus:

Atrophy of multifidus has been used as a rationale for spine stabilizing exercises.

Barker et al, found selective ipsilateral atrophy of multifidus in patients with unilateral LBP (low back pain)

MRI analysis of the CSA of Multifidus At level of pain: 21.7 % decrease

Above level of pain: 15.8% decrease

Below level of pain: 16.8% decrease

Decreased CSA at level of pain was positively correlating with duration of pain.

Barker KL, Shamley DR, Jackson D. Changes in the cross-sectional area of multifidus and psoas in patients with unilateral back pain. The relationship to pain and disability. Spine. 2004;29:E515-E519.

Core Dysfunction: Activation

Patterns

Subjects with chronic LBP do not pre-activate TrA prior to rapid upper and lower limb tasks.

Barr KP, Griggs M, Cadby T: Lumbar stabilization: Core concepts and current literature, part 1. Am J Phys Med Rehabil. 2005;84:473-480.

Hodges P, Richardson C. Inefficient muscular stabilisation of the lumbar spine associated with low back pain: a motor controlevaluation of transversus abdominus. Spine. 1996;21:2640-2650.

Onset of internal obliques, multifidus, & gluteus maximus was delayed on the symptomatic side (>20ms)= no feed-forward activation in subjects with sacroiliac joint pain

Hungerford B, Gilleard W, Hodges P, Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine. 2003;28:1593-1600.

TrA Muscle Activation

Three different techniques used in clinical practice:

Drawing-in Maneuver

Abdominal Bracing

Posterior Pelvic Tilt

Drawing-in Maneuver is more selective in coactivating the TrA and multifidus than the other 2 techniques.

Hodges, PW, Richardson, GA, and Jull, G: Evaluation of the relationship between laboratory and clinical tests of transversus abdominis function. Physiother Re Internat 1(1):30, 1996.

Richardson, C, Jull, G, et al: Techniques for activae lumbar stabilisation for spinal protection: A pilot study. Austral J Physiother 38:105, 1992.

Drawing-In Manuever

Recommended for stabilization training

Functions to ↑ intra-abdominal pressure by inwardly displacing the abdominal wall.

Increases CSA (cross sectional area) of TrA on MRI (TrA contracts bilaterally to form a musculofascial band that appears to tighten like a corset and most likely improves stability of lumbopelvic region. Hides J, Wilson S, Stanton W, et al. An MRI investigation into the function of the transversus abdominis muscle during

“drawing-In” of the abdominal wall. Spine. 2006;31:E175-E178

Drawling-in Maneuver:

Patient starts in hook-lying position and assumes a neutral spine position & attempts to maintain it while drawing in and hollowing the abdominal muscles.

Kendal, F, McCreary, E, and Provance, PG: Muscles: Testing and Function, ed 4. Williams & Wilkins, Baltimore, 1993.

Subtle posterior pelvic tilt & flattening of lumbar spine.

No flaring of lower ribs, bulging out of abdominal wall or ↑ pressure through feet.

Instructions: draw the “belly button” up and in toward the spine while exhaling

Feedback Techniques

If patient is having difficulty activating the Transverse Abdominis, the following has been used to assist with learning:

Pressure transducer for clinical testing and visual feedback (Pressure Bio-Feedback Chatanooga Pacific)

Biofeedback with surface electrodesHagins, M, et al: Effects of practice on the ability to perform lumbar stabilization exercises. J Orthop Sports Phys Ther 29(9):546, 1999.

Jull, GA, and Richardson, CA: Rehabilitation of Active Stabilization of the Lumbar Spine. In Twomy, LT and Taylor (eds): Physical Therapy of the Lumbar Spine, ed 2. Churchill Livingstone, New Yourk, 1994.

Richardson, C, Jull, G, et al: Techniques for active lumbar stabilization for spinal protection: A pilot study. Austral JPhysiother 38:105, 1992.

Richardson C, and Jull, G: An historical perspective on the development of clinical techniques to evaluate and treat the active stabilizing system of the lumbar spine. Austral J Physiother Monograph 1:5, 1995.

Visual Feedback- hook-lying

Place small inflatable bladder with pressure sensor

(similar to BP cuff) under lumbar spine and inflate it to

40-mm Hg.

Correct Activation: 10-mm Hg increase in pressure

Large increase occurs if activating rectus abdominis

and/or increased lumbar flexion (posterior pelvic tilt).

No change in pressure = no activation of TrA

Visual Feedback- hook-lying

Biofeedback with surface electrodes

Electrodes placed over rectus abdominis &

external obliques (near attachment on the 8th

rib).

Correct activation: minimal to No activation of

these muscles

Can be used in conjunction with inflatable cuff.

Abdominal Bracing

Occurs by setting the abdominals and actively

flaring out laterally around the waist

Technique has been taught years

It has been shown to activate the oblique

abdominal musclesRichardson, C, Jull, G, et al: Techniques for active lumbar stabilization for spinal protection: A pilot study. Austral JPhysiother 38:105,1992.

Posterior Pelvic Tilt

Activates Rectus Abdominis: it is NOT a core

spinal stabilization muscle

Only useful for teaching awareness of the

movement of the pelvis and lumbar spine.

Activated when patient explores lumbar ROM

with pelvic tilts to find neutral spine position.Richardson, C, Jull, G, et al: Techniques for active lumbar stabilization for spinal protection: A pilot study. Austral JPhysiother 38:105,1992

Lower Abdominal Progression

Levels developed by Shirley A. Sahrmann

Purposes:

To improve the performance of abdominal muscles

(external obliques, rectus abdominis, transverse

abdominis)

To learn to prevent lumbar spine motions associated with

leg motion

Starting Position -Sahrmann

Supine with hips and knees flexed and feet on

the floor. Contract abdominal muscles by

flattening the abdomen and reducing the

arch in the lumbar spine. Patient is instructed to

place fingers on abdominal muscles and “pull

the navel in toward the spine.”

Level 0.3 (E1)-Sahrmann

Lift one foot with alternate foot on floor

Method:

Flex one hip while keeping knee flexed.

Return the LE to starting position and repeat with

opposite LE.

Level 0.4 (E2)- Sahrmann

Hold one knee to chest & lift the alternate foot

Method:

Flex one hip and use hands to hold knee to chest.

While maintaining contraction of abdominal muscles, flex the

other hip. Hold for a count of 3 and return the LE to starting

position.

Perform with opposite extremity.

Repeat 5-6 times

Level 0.5- Sahrmann LIGHTLY hold one knee toward the chest and lift

the alternate foot

Methods:

Flex one hip and use one hand to hold knee to chest, but hold it less firmly than level E2 (0.4).

While maintaining contraction of abdominal muscles, flex other hip.

Hold for a count of 3 and return the LE to starting position

Perform with the opposite extremity.

Repeat 5-6 times

Level 1A- Sahrmann Flex the hip to > 90˚and lift the alternate foot

Methods:

Contract the abdominal muscles; flex one hip to > 90 degrees by lifting the foot from the table.

Contract the abdominal muscles and flex the other hip by lifting the foot off the table.

Maintain the contraction of

abdominal muscles and lower

the legs, one at a time, to

starting position.

Repeat by starting the

sequence with opposite leg.

Level 1B- Sahrmann

Flex the hip to 90˚ and lift the other foot.

Methods:

Contract abdominal muscles and flex one hip to 90 degrees.

Contract abdominal muscles and lift other leg to same

position. Maintain contraction of abdominal muscles, lower

the legs one at a time to starting position.

Repeat by starting the sequence

with the opposite LE.

Repeat, alternating legs, correctly

10 times to progress to Level 2.

Level 2-Sahrmann Flex one hip to 90˚ and lift & slide the other foot to extend

the hip and knee.

Methods: Contract abdominal muscles and flex hip to 90 degrees, lifting foot off

the table.

Maintain contraction of abdominal muscles; lift other leg up to same position.

Maintain one leg at 90 degrees, place other heel on table and slowly slide heel along table until hip and knee are extended.

Return leg to starting position by sliding hell along table.

Repeat extension motion with other LE and return it to starting position.

Repeat, alternating legs, correctly 10 times to progress to Level 3.

Level 3-Sahrmann Flex one hip to 90 degrees, and lift the foot and extend the

leg without touching the support surface.

Methods: Flex hip to 90 degrees, lifting foot from the table.

Maintain contraction of abdominal muscles and lift other leg up to same position.

Maintain one hip at 90 degrees, extend the other hip and knee while holding the foot off the table until hip and knee are resting in an extended position on the table.

Return leg to the hip and knee flexed position.

Maintain contraction of abdominal muscles, extend and lower the other leg and return it to the 90 degree position.

Repeat, alternating legs, correctly 10 times to progress to Level 4.

Level 4-Sahrmann Slide both feet along the supporting surface into

extension and return to flexion

Methods:

Begin in supine position with both legs in extension.

Contract abdominal muscles and slide heels along table,

flexing both hips and knees while bringing them toward the

chest.

Once hips and knees are flexed, pause

and reinforce abdominal contraction.

Slide both legs back into extension.

Repeat correctly 10 times to

progress to Level 5

Level 5-Sahrmann

Lift both feet off the supporting surface, flex the hips to 90 degrees, extend the knees, and lower both extremities to supporting surface.

Methods: Begin with LE extended position.

Contract abdominal muscles

while simultaneously flex hips

and knees, lifting both feet

off the table to bring the hips

to 90 degrees.

Reinforce the contraction of

abdominal muscles, extend the

knees and lower LEs to table.

Primary Core Protocols

Transverse Abdominis (Levels I-V)

Multifidus (Levels I-III)

http://lowerabexercises.blogspot.com/

The TrA Level Progression

These proposed levels were designed from the research and are clinically applied to strengthen the Transverse Abdominis in isolation.

Purpose:

To have a common terminology among practicing clinicians in the same physical therapy setting.

To improve the performance of TrA muscle.

To prevent lumbar spine motion (neutral spine) during functional activity.

Starting Position: TrA Level I

Method:

Supine with hips & knees flexed and feet on the

floor.

Patient is instructed keep a Neutral lumbar spine

using the „Drawing-in Maneuver‟ and place two

fingers on transverse abdominus and one hand on

superficial abdominal muscles.

Next, patient is asked to “pull the navel in toward

the spine” without tightening superficial abdominal

muscles and only the TrA.

TrA Level I

Level I will be the starting position for all levels

I-V.

TrA Level II

Lift one foot to 90

degrees with alternate

foot on table

Method:

Contract TrA and flex one

hip to 90 degrees while

keeping knee flexed.

Return the LE to starting

position and repeat with

opposite LE.

TrA Level III

Flex the hip to 90˚ and lift the other foot.

Methods:

Contract TrA and flex one hip to 90 degrees.

Lift other leg to same position. While maintaining contraction

of TrA, lower the legs one at a time to starting position.

Repeat by starting the sequence

with the opposite LE.

Repeat, alternating legs, correctly

10 times to progress to Level 4.

TrA Level III

TrA Level IV

Flex one hip to 90 degrees, and lift the other foot. Extend the one leg without touching the support surface.

Methods:

Flex hip to 90 degrees, lifting foot from the table.

Maintain contraction of TrA and lift other leg up to same position.

Maintain one hip at 90 degrees, extend the other hip and knee while holding the foot off the table.

Return leg to the hip and knee flexed position.

Maintain contraction of abdominal muscles, extend other leg and return it to the 90 degree position.

Repeat, alternating legs, correctly 10 times to progress to Level 5.

TrA Level IV

TrA Level V

Flex the hips to 90 degrees and extend the knees without touching the support surface.

Methods:

Flex hip to 90 degrees, lifting foot from the table.

Maintain contraction of TrA and lift other leg up to same position.

Extend both hips and knees while holding the feet off the table.

Return legs to the hip and knee flexed position.

Repeat correctly 10 times.

TrA Level V

Multifidus Level Progression (I-III)

These proposed levels were designed from the research and are clinically applied to strengthen the Multifidus in isolation.

Purpose:

To have a common terminology among practicing clinicians in the same physical therapy setting.

To improve the performance of Multifidus muscle.

To prevent lumbar spine motion (neutral spine) during functional activity.

Multifidus Level Ia

Start position: Quadriped

Neutral lumbar spine

Have patient lift one lower extremity (LE) ( knee) ~ 1 inch from table

Hold position ~ 5 seconds

Alternate with the other LE.

Multifidus Level Ib

Start position: Quadriped

Neutral lumbar spine

Have patient lift one LE

(knee) and the

contralateral upper

extremity (UE) (hand) ~ 1

inch from table

Hold ~ 5 seconds

Alternate with the other

LE and contralateral UE

Multifidus Level II

Starting position: Prone

Maintain neutral lumbar spine (i.e. placement of

pillow)

Lift one UE and contralateral LE from the table

Alternate with other UE and contralateral LE.

Multifidus Level III

Starting position:

standing on stool facing

wall

Extend one UE and

contralateral LE

Alternate with other UE

and contralateral LE

Clinical Biomechanics:

Intervention Skill Sets

NMR (97112)

Longus Colli Isolation

Text References

Kendall, FP et al. Muscles Testing and Function

with Posture and Pain. Fifth edition, 2005.

Sahrmann, SA. Diagnosis and the Treatment of

Movement Impairment Syndromes. 2002.

Kisner, C & Colby LA. Therapeutic Exercise:

Foundations and Techniques. Fourth edition,

2002.