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Core and More Sheryl Poremba, PT, CCM Rehab Connections

No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections. 08/2015 1

Core and More

Sheryl Poremba, PT, CCM Licensed Physical Therapist

Certified Case Manager

What do you call it?

Lumbar stabilization (17)

Trunk stability Core strength

Lumbopelvic stabilization (1)

Powerhouse Core control

Trunk strength (6)

Core stabilization Abdominal bracing

Do we need to lessen our use of “core” (35) to differentiate skilled therapeutic intervention from fitness?



Key muscles of postural control and stability

• Abdominals, emphasis on

transversus abdominis • Trunk extensors,

emphasis on lumbar multifidus

• Latissimus dorsi • Trapezius (lower) • Serratus anterior • Adductors and gluteals • Hip rotators (deep) • Hip abductors

Examination: Palpation of muscle recruitment

Palpation of muscle recruitment (Demo then lab) Transversus abdominis in supine / hooklying • Tighten belt or brace for punch,

forced exhale thru pursed lips • Polite cough, sniff, and/or clear

throat (also facilitation techniques)

• Palpable contraction graded 0-3 • May also assess using pressure

biofeedback • If not palpable, facilitate with

ipsilateral arm press or hip flexion



Examination: Palpation of muscle recruitment

Palpation of muscle recruitment (Demo then lab)

Multifidus in prone

• May need pillow under stomach

• Heel squeeze and/or bent elbow lift

• Palpable contraction graded 0-3, assess symmetry and timing

• To test unilaterally, initiate elbow lift or hip extension

Examination: Functional tests specific to core stabilization

Substitutions, such as but not limited to: Elevation of rib cage Holding breath Valsalva, bearing down Posterior pelvic tilt Flexing or extending lumbar spine during exercises Rectus abdominis dominance, check for diastasis Trunk extension / extensor bias

Limiting factors including, but not limited to: Impaired ROM including muscle length

• Hamstrings, hip flexors, abductors, hip rotators

Impaired posture due to structural deformity

• Scoliosis, kyphosis, anterior pelvic tilt

Positioning restrictions

• Colostomy, pregnancy

Medical restrictions

• Hernias, recent surgery

Body proportions may be a consideration also




Lumbopelvic stabilization, prone

• Knee flexion, hip rotation, hip extension

• Test each lower extremity individually

• Consider limited muscle length of psoas and/or rectus femoris

• Test without cues for abdominal bracing, repeat with cues if needed

• Able vs. unable to stabilize lumbar spine


Abdominal bracing, supine 90-90

• Test without cues for abdominal bracing, repeat with cues if needed

• Arms crossed over chest

• Palpate lumbar spine or monitor with Stabilizer/BP cuff

1 Able to perform abdominal bracing in hooklying

2 Able to lift one leg to 90/90 position and hold neutral spine HL vs. supine

3 Able to hold bilateral 90/90 position with neutral spine (lift LEs individually)

4 Able to perform single leg extension from double 90/90 position with neutral spine

5 Able to perform double leg extension from 90/90 position with neutral spine




Hip and trunk extensors , bridging

• Arms crossed over chest

• Lift pelvis to neutral hip alignment

• Note if hamstrings cramp or if movement is not segmental

• Trunk and thighs are aligned

test /exercise to lengthen and strengthen

1 Able to assume bridging ¼ ROM

2 Able to assume bridging ½ ROM

3 Able to assume bridge position

4 Able to perform cross-legged bridging bilaterally

5 Able to maintain stable bridge position while alternating unilateral static knee extension


Side plank or dynamic horizontal side support test (perform on floor)

• Trunk and thighs are aligned

• Stack joints: wrist under shoulder, protect elbow

• Consider UQ strength needed, may substitute quadratus lumborum MMT upper body lift

1 Palpable contraction or initiates motion

2 Able to assume position on bent knee and forearm (bent elbow)

3 Able to assume position on bent knee and hand (straight elbow)

4 Able to assume position with straight knee and forearm (bent elbow)

5 Able to assume and maintain position with straight knee and hand (straight arm)




Lumbar Protective Mechanism, standing • Based on LPM by Gregg Johnson PT, FFCFMT,

Institute of Physical Art • Staggered stance, push in diagonal of patient’s

rearfoot • Compare in usual posture and corrected

alignment • Responsiveness, strength, endurance • Compare to pushing a heavy door, lawn mower,

grocery cart, etc. • Able vs. unable to stabilize

Lumbar Protective Mechanism



Facilitation of Transversus Abdominis and Multifidus

• Our goal is to activate selected muscles and help the patient develop their ability to repeatedly and consistently recruit these muscles. Facilitation is part of the beginning phase of stabilization training and may be performed frequently during the day throughout the entire home exercise program progression.


Techniques • Verbal and visualization cues and instructions Scoop, navel to spine, button, bring front of ribs together, zip up • Breathing (be able to do in all positions) Polite cough, sniff, and/or clear throat (also examination techniques) Forced exhalation, pursed lips • Tactile cues Palpate neutral spine and muscle contractions • PNF rhythmic stabilization (RS) and alternating isometrics (AI)




Props basic, low tech • Magic Circle, (swiss) balls, and/or manual resistance • Table/counter/desk for multifidus: Finger Lift (bent elbow) • Table/counter/desk for transversus abdominis: Arm Press FW (straight elbow) Positions functional, practical, patient can understand/feel • Prone and supine / hooklying • Functional postures Sitting Standing: feet parallel and stride stance


Sitting

Finger Lift and Arm Press Forward = M and TA

RS: Through arms and knees = TA, M

AI: Through extended arms (down/up, diagonals), through ball = TA, M

Magic Circle: Arm Press FW x2 angles, Arm Squeeze = TA; Arm Spread = M

Standing RS and AI through shoulders and/or pelvis = TA, M

Finger Lift and Arm Press, Magic Circle Arm Press = M and TA

Shift and Squeeze Magic Circle at side = M and TA



Finger Lift

P

C

P

Arm Press Forward

P

C

P



Rhythmic Stabilization (RS)

P

C

P

Magic Circle

Sitting and standing

• Arm Press Forward, 2 angles

• Arm Spread

• Arm Squeeze

Standing

• Shift and Squeeze

– Feet staggered vs feet parallel




Prone

Cue lift navel off egg or navel to spine (Clinician’s hand under abdomen) = TA Prone heel squeeze and/or bent elbow lift = M

Supine / Hooklying

Scoop, navel to spine, bring front of ribs together = TA Forced exhalation, cough, sniff, clear throat = TA RS: through extended arms and knees = TA, M AI: through extended arms, through ball = TA Magic Circle and/or ball: --Hand Press, arms extended = TA and/or Ankle Press, knees extended = M

Rhythmic Stabilization (RS)

P

C

P



Alternating Isometrics (AI)

P

C

P

Hand Press

P

C

P May use Magic Circle also



Ankle Press

P

C

P May use Magic Circle also

Training Core Stabilization

Progressions • Beginner: activate, initiate limb movement, isolate,

facilitate as needed with isometrics…repeatedly! • Intermediate: movement and challenge, stabilize lumbar

spine while superimposing extremity movement in single planes

• Advanced: increase resistance and duration, functional

activities moving multiple extremities in multiple planes



Training Core Stabilization Techniques

• Pressure biofeedback – Supine, prone, and sitting

• The Pilates Method • PNF rhythmic stabilization (RS) and alternating isometrics (AI)

Props

• Foam Roll, (swiss) balls of different sizes, Magic Circle

Positions • Prone and supine • Side plank or side lifts • Sitting on chair or ball • Standing and ambulation activities

– Apply facilitation techniques to functional activities


Prone Pressure biofeedback, 70 mmHg, decrease 6-10 mmHg Move individual extremities LE movements with trunk stabilized -- knee flexion, hip IR/ER, hip extension Plank on forearms or POE plank (FEP) Prone walkouts with ball (FEP) Prone holds off table -- navel, ASIS, groin



Pressure Biofeedback

70 mmHg, decrease 6-10 mmHg in prone

LE Movements with Trunk Stabilized

P

C

P

Start passive to train active stabilization



Plank on Forearms or POE Plank

P

C

P

Prone Walkouts with Ball

P

C

P



Prone Holds Off Table

P

C

P

At navel

At ASIS

At groin


Supine / Hooklying Pressure biofeedback, 40 mmHg, no change with extremity movements Foam Roll PPLRTT for core strength Hinging at hips or knees (flexion/extension) holding ball or foam roll Bridging progression according to level of control (FEP) Abdominal progression according to level of control (FEP) Heavy ball overhead/diagonals, 2 handed, 3 angles “11:00-12:00-1:00”

Side Plank Progression according to level of control (FEP), or side lifts with feet stabilized




40 mmHg, no change with extremity movements in supine

Foam Roll PPLRTT

P

C

P



Hinging at Hips

P

C

P

Hinging at Knees

P

C

P



Heavy Ball Overhead/Diagonals

P

C

P

Apply Functional Tests for Progressions

• Bridging progression

• Abdominal progression

• Side plank progression

Also reference other handouts in email




Sitting (hips higher than knees)

Pressure biofeedback, 40 mmHg with no change when flexing hip/knee Extremity lifts on large ball; commonly needs verbal and tactile cues Push and pull using dowel or MC in chair or on ball, isometric to RROM ; progress to diagonals with bands or weights Foam Roll PPLRTT for core strength Heavy ball overhead/diagonals, 2 handed, 3 angles “11:00-12:00-1:00”

Standing

Push and pull using dowels or MC, isometric to RROM; progress to diagonals with bands or weights Pilates stance: Standing Hundred, wrist roller, Bodyblade Balance board or ½ foam roll Heavy ball overhead/diagonals, 2 handed, 3 angles “11:00-12:00-1:00” Airdyne arms only, partial ROM, stop and start, vary base of support and staggered stance


40 mmHg, no change with extremity movements in sitting



Extremity Lifts

P

C

P

Push and Pull

P

C

P



FR PPLRTT

P

C

P


P

C

P



Push and Pull

P

C

P

Pilates Stance

P

C

P

Wrist roller

Bodyblade




P

C

P

Airdyne, UEs only

P

C

P




Ambulation activities

Facilitate reciprocal arm swing and trunk rotation, resist shoulder extension with B dowels High march (slow), facilitate by squeezing Magic Circle Retro walk (slow), facilitate by spreading Magic Circle Sidestepping and braiding Steps Nordic pole walking (see Specialty and Novel Approaches section)

Functional activities or functional movements with alignment pole/cue

Forward bending via hip hinging in sitting and standing Squat ½ kneel stand, lunge

Reciprocal Arm Swing and Trunk Rotation

P

C

P



High March

P

C

P

Retro Walk

P

C

P



Slow Ambulation Activities

• To increase stance time on involved LE.

• Manual contact at pelvis for approximation or VC to engage stance side immediately before lifting opposite LE to march.

Add Magic Circle to facilitate core stabilizers: • Arm Squeeze when

marching forward. • Arm Spread when

walking backward.

Balance board or ½ foam roll

P

C

P



Hip Hinging with Pole

P

C

P

Squat with Pole

P

C

P



½ Kneel Stand with Pole

P

C

P

Examination: Functional tests specific to the upper quadrant

Lower and middle trapezius

• Shoulder flexion overhead for lower trapezius control of scapula

• Shoulder abduction overhead for middle trapezius control of scapula

• Assess concentric and eccentric control

• Assess symmetry of scapular movement



Examination: Functional tests specific to the upper quadrant

Scapular stabilization

1. POE with protraction

2. Shift weight on forearms

3. Shift weight and UE reach

4. POE plank

5. POE plank with hip extension vs. UE reach

Cervical spine and scapular stabilization

Neck isometrics

• Consider supine vs. upright, use eye movements to facilitate

1. Manual resistance

2. Ball into wall

3. Stabilizer or blood pressure cuff




Fab 5

• Consider supine vs. upright position, no resistance vs. use of band or cord

1. Pilates 100 / Shoulder extension

2. Rowing

3. Horizontal abduction

4. Overhead adduction

5. Bow & Arrow


Prone scap series 5 (lie on foam roll and forehead pad)

• Consider standing and 4 point vs. prone and bilateral vs. unilateral. Also may use Stabilizer to insure core stabilization. Total Gym or slant board can modify effect of gravity.

1. Lower trapezius

2. Middle trapezius

3. Rhomboids

4. Latissimus dorsi

5. Subscapularis




Prone on elbows (POE) progression

1. Protraction plus weight shifting, add MRE

2. Alternate UE reaching without then with resistance band or weight

3. ER with resistance band

4. POE plank

5. POE plank with hip extension vs. UE reach


Head lifts

1. Prone for long neck extensors, co-contraction of deep/short neck flexors also

2. Supine for deep/short neck flexors



Prone Head Lift

P

C

P

Supine Head Lift

P

C

P




BUE CKC progression

1. Push-up progression: Wall -> table -> floor -> ball and/or bosu

2. UE CKC step up/down, 2” to 4”

3. Prone walkouts with ball (FEP)

Push-up Progression

P

C

P



UE CKC step up/down

P

C

P

Prone walkouts with ball

P

C

P Pelvis -> thighs -> knees -> shins -> ankles




• Functional activities and functional movements with posture cue: – Yoga strap XUQ or pole

– Progress to 5+ mins

1. Forward bending via hip hinging in sitting and standing

2. Squat, ½ kneel stand, lunge

Hip Hinge Wearing Yoga Strap, Sitting and Standing

P

C

P



Squat Wearing Yoga Strap

P

C

P

Creative Isometric Programs (CIP)

Cues, variations, and modifications

• Abdominal bracing (A)

• Breathing (B)

• Elongation (E)

• Oppositional energy (O)

• Overflow, facilitation (F)

• Reciprocal vs. symmetrical (R S)

• Placement, support of prop (P)



Extremity joint stabilization and co-contraction

Lower extremity

• Magic Circle

• Multi-angle magic

• RS and/or AI

• Golfer’s lift progression

• Nordic pole walking

Upper extremity

• POE progression

• BUE CKC progression

• Gripping exercises

• Multi-angle magic

• RS and/or AI

• Shoulder motions with neutral wrist

Introduction to Wii-hab

Applications

• Equal weight bearing and center of balance for correct posture

• Weight shifting

• Balance

• Muscle performance (strength, endurance)

Indicators of skilled intervention

• Verbal and/or tactile cues

• Manual contacts or assistance

• Impairment based

• Functional measurements



Introduction to Wii-hab Sample core stabilization exercises using

Wii Fit exercises & activities: Half Moon


Wii Fit exercises & activities: Plank




Wii Fit exercises & activities: Push-up Sideplank


Wii Fit exercises & activities: Single-leg extension



Specialty and novel approaches

Bodyblade 1. “Promotes wellness, functional exercise, and core training

essential for good health” 2. “Reactive flexing device that uses the laws of inertia to

generate muscle contraction” 3. “Uses rapid muscle contractions to develop the body’s

core”

BOSU 1. Exceptional tool for balance activities that address core

and/or joint stability also 2. Use inflated dome side or flat side for dynamic challenges 3. Can be used in a variety of body positions

Specialty and novel approaches: Bodyblade

2 handed horizontal grip push/pull with varying base of support 2 handed vertical grip side-to-

side motion in partial squat



Specialty and novel approaches: BOSU

Plank position on either side Supine or prone balance

Both Sides Up


Nordic Pole Walking 1. Increases energy expenditure without significant increase

in perceived exertion 2. Pushing poles with arms activates trunk and core

musculature 3. Using poles reduces load on lower extremity joints

Kettlebells 1. Proper form and technique are necessary for safety 2. Shape provides momentum force 3. Common kettlebell exercise movement patterns are

unique to this prop



Specialty and novel approaches: Nordic Pole Walking

Specialty and novel approaches: Kettlebells

Turkish Get Up

Swings, 2 handed




Foot Fidget 1. Lightweight, portable, and versatile prop 2. Similar applications as Magic Circle plus many more

Indo Boards 1. “Indo Board Balance Trainer's provide a progression

from the linear and lateral movements of other traditional stationary balance boards. The movement of the board on the roller or the full circle range of the IndoFLO® Balance Cushion creates a greater challenge to the proprioreceptors of the activated muscles thus intensifying the therapeutic effects.”

Specialty and novel approaches: Foot Fidget



Specialty and novel approaches: Indo Boards

Balance Trainer

Specialty and novel approaches: Indo Boards

Bridging POE Planks



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