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Core stability

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Admin2, Mar 1, 2006.

  1. Admin2

    Admin2 Administrator Staff Member


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    We keep hearing how important this is for lower limb function. Here is a good commentary on it from Chiroweb
    Full article
     
  2. DaVinci

    DaVinci Well-Known Member

    I have heard that a lot too, but no one I have talked to can explain how and why it is. They just state that it is. Anyone?
     
    Last edited by a moderator: Mar 4, 2006
  3. DaVinci,

    You first need to understand the division of muscles into mobilizers and stabilizers, the differentiation of their function and physiology and the theory of muscle imbalance.

    Try googling muscle imbalance.
     
  4. Atlas

    Atlas Well-Known Member

    I am in the minority. I think that IF weakness is an underlying issue, THEN strength, or should I say, control, is necessary.

    But the assumption that the literature and most physiotherapists (and personal trainers and the local masseur) are making is that muscle control and strengthening is the egg, and not the chicken. Big assumption IMO, but good for my hip pocket (patients need a lot a sessions to improve control/strength), good for my body (too easy to stand back, hands off and instruct the patient to "pull their belly button in" and "squeeze their private parts").

    The best analogy I can put is that if someone limps in with an acute ankle sprain, being concerned about strength and control is an nth-order issue. Pain relief; removing tensile forces; restricting the inflammation process to acceptable limits would by my cake. Strength control and propriobabble is the icing.

    Take another look at the chiroweb paragraph; in particular "Muscles are inhibited when pain signals are present in an area". It's self-defeatist. That is the thing I keep throwing back at those that have swollowed "core strengthening" as a panacea for every musculo-skeletal condition. Pain inhibits muscle activity. Invariably, exercising through pain is too much brawn, and not enough brain.

    Get rid of the pain first. Break the cycle. Then you put your icing on your cake.

    Core strengthening is supposed to be the one solution for a plethora of musculo-skeletal signs and symptoms. If that is the case, why bother assessing at all? No need.

    But it is the flavour-of-the-decade, so, like orange vinyl chairs, I will wait for common-sense to prevail.
     
    Last edited by a moderator: Mar 5, 2006
  5. Janda has demonstrated that muscle length is key, not strength. Understanding this is key to muscle imbalance theory. If you focus on strength you just move the length/ tension curves "up" not "along". As a physio I am sure you understand the concepts of inner and outer range?

    IMO, this is a woeful analogy. Someone with an acute ankle sprain is completely different from someone with longstanding sub-acute overuse injury.

    I don't think anyone with an ounce of common sense would agree that core stability is the one solution, anymore than orthoses are the one solution. But then perhaps things are different in the Oz. Personally, I paint with all the colours all the time. How's the world look in black and white down under? :cool:
     
    Last edited by a moderator: Mar 5, 2006
  6. Atlas

    Atlas Well-Known Member

    Go back and read what I am saying. I said strength and control is only relevant in cases where strength and control are in deficit. "If weakness is an underlying issue, THEN strength...and control is necessary...". As I said, I am in the minority. As an Australian physiotherapist, I think the importance of core stability is over-estimated and over-diagnosed. I would dare to suggest that even Janda might agree.

    How on earth do you think longstanding sub-acute overuse injuries arise? Lets use my 'woeful analogy'. What happens with this typical acute ankle sprain, when I as treating practitioner, suggest that "taping and bracing and rest don't work otherwise it will 'weaken' you"..."get on the wobble board"..."remain active"..."ignore the pain"..."stay on your feet". The workers compensation mantra.

    What is this ankle condition going to be like down the track?

    You must realise that chronic conditions only exist because they were not well managed in an acute sense.
     
    Last edited by a moderator: Mar 5, 2006
  7. Go back and read what I am saying. I said, if you try to strengthen long weak muscles, you will not get the correct return of length/ tension.

    I don't think that anyone would take this approach, like I said paint with all the colours all the time. However, early mobilization is recommended following ankle sprain and that a lack of proprioceptive control and muscle weakness is seen in poorly rehabilitated cases- I'm one. I think that we may be talking at cross-purposes here. You seem to me to be suggesting that stretching and strengthening work combined with proprioceptive control is unnecessary. Now I'm fairly certain you don't believe this. So perhaps I'm getting the wrong message from you. Perhaps what you are saying is that in Australia, people are only doing this with complete disregard for the presenting complaint?

    Let's go back a step:

    What determines the ROM of a joint and what determines the position of this joint in space?
     
  8. Felicity Prentice

    Felicity Prentice Active Member

    Dear Simon,

    Personally I love your avatar (I want that one......yeah....I know....); and regardless of the academic/practical arguments contained within this thread, I have one request. Could you please avoid generalising to an entire nation? While I have had the pleasure of working with Atlas (he is one of the few Podiatry students who I let loose on my best friend's children when they needed biomechanical intervention), he is also one member of our vast continent's practitioners. As are all people who post here - he is an individual. Colin does not speak entirely on behalf of the UK, Kevin is not the sole voice of America. Can we keep the "So that is what ALL people in Australia..." out of the argument. N=1 is a rotten basis for any research.

    cheers,

    Felicity
     
  9. Sorry if it seems that is what I was doing. Perhaps I was being a little facetious after Atlas had castigated the entire profession of chiropractors. What I am trying to ascertain is whether what Atlas is saying is an Australian thing, since I don't know of any podiatrist (or other health professional) here in the UK who would work only on core stability when a patient presents with an acute ankle sprain.
     
  10. Simon and Atlas:

    So that I can write a posting now that Admin won't delete, I'll need to, I suppose, stay on topic:

    First of all, for those of us less familiar with "core stability" please provide a concise definition of "core stability".

    Second, please define which anatomical parts (i.e. joints, muscles, ligaments) of the body are included in the "core".

    Third, please provide a concise definition for "stability".
     
  11. Atlas

    Atlas Well-Known Member



    Simon, it is a pity this thread has been edited, because the point I made was that this whole core-stability vogue is starting to replace meticulous assessment and undermining solid Kirbyesque understanding of compression/tension forces that cause injury and continue to prevent tissue healing. I am a physiotherapist, and I am actually elevating and praising the continued assessment and hands-on work done by some chiropractors. My brother is now one (chiropractor) actually. I reckon some chiropractors are fantastic, and guess what, I have referred some difficult necks and SIJ's to them in the past.

    Physiotherapists in Australia have swollowed core stability hook, line, sinker rod and arm. Not many of us bother assessing what type of back pain we are dealing with anymore. Instead, we conveniently label it "non specific" and hand out the recipe core stability stuff as the entire panacea. Traditionally, physiotherapists don't respect chiropractors and vice versa. (I am not a traditional physiotherapist) If you read what I stated, you would be enlighted that the physiotherapy profession at large would think that "I am as useless as a chiropractor" because I still use a majority of hands-on techniques and don't jump straight for the exercise tool immediately.

    You have totally misrepresented what I was saying, and that may be in part due to my delivery. In fact it seems that we agree on some things. However, I wouldn't mobilise a typical acute ankle sprain into inversion!!!!
     
  12. Atlas

    Atlas Well-Known Member



    Kevin, I am the wrong person to ask. But ask most physical therapists in Australia and they could quote you a thesis backwards. The cake for me, is (compressive or tensile) forces that underpin tissue damage and delay tissue healing.

    I gave core/proximal stability a good hearing in the late 90's, but it was difficult to teach and be taught by fellow professionals, let alone the prospect of teaching a patient. Further, when I applied it, it was like watching grass grow in terms of waiting for objective changes and improvements. From what I remember, the musculature of transversus abdominus {(a deep muscular layer that attaches to one side of the spine as a fascia, continues around the abdomen as a muscular layer toward the other side of the spine as fascial tissue once more. When it contracts (suck your belly button toward your spine) it acts like a brace and the fascial attachments become taut and essentially compress the lumbar spine}, multifidus {a muscle that is located posteriorly either side of the lumbar spinous process, and because of its fibre orientation and proximity to the axis, has more of a compressive rather than an extension influence on the lumbar spine, pelvic floor, glutes etc...

    Proximal stability I guess is the capability through strength, control and endurance to maintain proximal structures (spine, pelvis, hip....cervico-thoraco-scapulo-humeral) as a solid foundation on which to base distal activity upon. From my physiotherapy undergraduate days, I remember that babies/toddlers develop these proximal structures first. For instance, reaching up to grab, necessitates good proximal control first about the shoulder girdle. The fine motor dexterity comes later.

    But I believe everything is not proximal to distal. Physios look at repetitive single leg squating for instance to ascertain proximal stability. If excessive unwarranted movment in 1/more planes occur, such as pelvic shifting, tilting and rotation, this is deemed unstable proximal control. Bill Vincenzo, for memory showed that strapping distally had a significant influence on re-assessment. This hopefully illustrates my view that core-stability and proximal control is not the underlying basis for everything.
     
  13. Ron (A.K.A. Atlas):

    The problem of a healthcare profession tending to use one therapy over another, such as physiotherapists using "core stability" techniques over other approaches, is fairly common. For example, here in the US, it is common for podiatrists to offer a surgical solution to the patient for many foot complaints that to an Australian podiatrist or a physiotherapist, may rarely need to be treated surgically. So I can "feel" your frustration with individuals within your physiotherapy profession not taking the proper time to assess pathology the way you think they should.

    However, you must also understand, with your new, broader scope of knowledge that you have now accumulated by entering the podiatric profession, that this will be a continual battle for you in not being able to understand how others within the physiotherapy profession can't see things as clearly as you can with your new knowledge. I have been battling this for over 20 years after doing my Biomechanics Fellowship and have expressed my exasperation with my profession for their lack of biomechanics knowledge many times in this forum, other forums, in my books and in my lectures.

    I have learned over the past two decades that it is best to try and have the patience of Job when discussing topics that are not readily understood by the other members of your profession. In the end, this not only helps your colleagues collectively elevate their knowledge and understanding, but also will earn you great respect from your colleagues for your ability to teach complex subjects with a depth of knowledge that they will never have the opportunity to obtain within their professional careers.
     
  14. Atlas

    Atlas Well-Known Member


    On the contrary Kevin, a few years of podiatric undergraduate training have put more uncertainty into my mind. It was so simple before hand just thinking 'high arch' v. 'low arch'; 'inversion' v. 'eversion'. Now there are more options (skives, cut-outs, rocker-bars, FF posts, kinetic wedges, morton's extensions). When you go to a restaurant that serves hamburgers, you make up your mind in 15 seconds. When you go to a restaurant that serves everything, it can take 15 minutes. Efficiency traded off.

    OK, I can now make some devices, but they look like an old icecream left on the porch on a summer day. And yes, my distal lower-limb anatomy is better than it once was.

    What has remained though, even before post-grad physiotherapy studies and long before podiatry studies, is just a simple understanding of tissue healing; particularly causative forces and the importance of removing them totally in the acute stage. And these principles can apply to every part of the musculo-skeletal system.

    If you have a look at my academic record, it is not flash at all. More C's and D's than A's and B's. But does getting top marks in 'complex pathophysiology' and 'complex histology' and 'complex pre-embrionic development' and 'cardio-thoracic physiotherapy' make you a better musculo-skeletal clinician? And apparently, the chiropractic course here in Melbourne goes into more detail over 2 more years!

    In my opinion, musculo-skeletal courses should go into less detail in such complex clinically irrelevant subjects, and have more emphasis on the basics; such as principles in physics (that you know 2nd to none that I have witnessed...maybe Kapandji) and principles of tissue healing.

    We do the complex stuff well as a general rule; but we do the ordinary stuff ordinarily.

    When we get the basics done well across the board, only then will we have less 'frustration', and finally, these workers compensation victims can get the proper assessment and treatment that most of them deserve.
     
  15. I think the reason core stability exercises have become a bit of a panacea for lower back pain, is because there was a study were they compared outcomes of hands on physiotherapy with so called "back classes"- essentially group pilates type work led by one physio. I can't remember the exact trial or were it was published or the exact result- which is crap :confused: but I seem to recall, that the back class was as good as, if not better than traditional physio in terms of outcome. Given that one physio can lead a back class with numerous patients, compared to the one-on-one traditional care, there is obviously a cost advantage. Sorry I can't be more specific with the ref, the memory for papers ain't what it used to be since I stopped teaching full-time: maybe in physiotherapy or manual therapy journals?

    Also, for more positive outcomes from core stability work check the last post in the iliotibial band thread ;)
     
  16. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
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    The latest issue of Sports Medicine has a good review on core stability for those who can access it:
    The Role of Core Stability in Athletic Function
    Sports Medicine, Volume 36, Number 3, 2006, pp. 189-198(10)
     
  17. Pigsney

    Pigsney Member

    Pull belly button in and squeeze private parts in (hold pelvic floor up 3/4) and notice when you stand in this ideal posture, MLA's lift up off the floor. Release those muscles and let lumbar spine relax into lordosis (esp if core muscles are weak?) and MLA's collapse. Interesting. :eek:
     
  18. Scorpio622

    Scorpio622 Active Member

    I am surprised that I missed this thread when it was ongoing in March. (I was painting the house then, and probably didn’t want to get paint on the keyboard). Anyway, I am both a PT and DPM in the US. Core stability IMHO in nothing more than a glorified description of improving dynamic posture. This is nothing new. In the early 80’s there were DLSEs (Dynamic Lumbar Stabilization Exercises). I believe the term was coined by a physiatrist in San Francisco. The concept of core stability is essentially the same. I have found here in the states that the traveling continuing education road shows introduce these unfounded bastardized concepts and then the scientists investigate because many clinicians are employing them with touted success.

    I recently sent a patient to PT after immobilization for a partial posterior tibial tendon tear. The therapist focused on “core stability” claiming proximal weakness and imbalance as the original cause of the PTTD, as if all faulty foot mechanics emanate from the spine. I asked her where she got this information; her answer—a weekend seminar.

    I do agree that improving posture overall helps the entire chain, whether it is at the top links or bottom links- however we must identify the weakest link and focus on that area. With most foot conditions, it is in the foot.
     
  19. Atlas

    Atlas Well-Known Member


    Agree. Core stability is the icing on the cake, irrespective of how important the literature makes it out to be.

    There is a lot of half-inch cake with 8 inch icing being served out there.


    Most patients are happy to eat cake like this, so the problem may not be as big as I think it is.
     
  20. Ann PT

    Ann PT Active Member

    One thing that hasn't been mentioned in the conversation about whether core stability exercises is important is consideration of the patient's goal. One of the reasons I enjoy being a PT is because I can look at muscle length, strength and mostly function-is the muscle doing what it is meant to do? If not, why? My goal is to facilitate efficient, safe and hopefully painfree movement. If focus on the "core" is important, I'm more interested in "functional stabilization" i.e. can the patient actively alter muscle tension as loads on the body change? As PTs we are trained in the biomechanics of all joints at a basic level in school and in more detail through continuing education. Options for treatment can be as varied as options for designing an orthotic, and like orthotics these options have varying degrees of success. I like to start with what will make the most difference. If the patient has a posterior tib. problem I never start with stabilization exercises. Like wise if the patient has back pain, I never start with orthotics (unless the patient demands it which sometimes happens!)

    Atlas,
    Pain inhibits muscle activity but working on stabilization exercises doesn't imply working through pain. And couldn't a patient's pain be due to inefficient or biomechanically incorrect movement patterns that are most directly treated with strengthening or neuromuscular re-education? Plenty of patients have pain due to hypermobility at a given joint and respond well to "strengthening." Obviously strengthening is a very broad term.

    Simon,
    I am a big proponent of achieving muscle balance through obtaining proper length and strength/muscle function. The principles of Florence kendall and Shirley Sahrmann guide much of my practice. I am not aware, however, of how one would test the length of some of the trunk stabilizers i.e. multifidii, transverse abdominis. In the case of these muscles I can assess whether they are contracting when they should and whether the patient can activate them on demand. Is length important here?

    Also, even if there was sound evidence-based research documenting the benefits of group exercise vs. individual treatment, insurance companies generally do not reimburse for group treatment.

    Thanks for reading and considering my response.

    Ann
     
  21. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
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    Core Stability Relates to Distal Segments
    Dynamic Chiropractic September 10, 2007, Volume 25, Issue 19
    Full article.
     
  22. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Relationship between cycling mechanics and core stability.
    Abt, J.P., J.M. Smoliga, M.J. Brick, J.T. Jolly, S.M. Lephart, and F.H. Fu.
    J. Strength Cond. Res. 21(4):1300-1304. 2007.
     
  23. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
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    The lastest Dynamic Chiropractic has the full text of this:
    Core Stability Principles
    Full article
     
  24. Sicknote

    Sicknote Active Member

    Hi Simon, Could you please post the link?.

    I have done an advanced search for a good hour without success.

    It would be appreciated.
     
  25. Griff

    Griff Moderator

    That post was from 5 years ago.
     
  26. Sicknote

    Sicknote Active Member

    Right?.

    Does that mean it's been deleted?.
     
  27. Griff

    Griff Moderator

  28. Sicknote

    Sicknote Active Member

    Much appreciated Ian. :good:
     
  29. At times like this, I wish I could force students like Sick to have to go to the library like I did when I was a student...it often took me an hour just to get to the library and get back home again....then there was the time required to look through books or articles until I found what I was looking for.....and then I would often need to spend another 30 minutes using the copy machine to allow me to have the information so I could read it at my leisure at home before I did my report.....

    This new "instant access student" has no clue how easy it is for them now...............unfortunately, this ease of information access has also bred a type of laziness that I find almost too difficult to deal with.....:craig::bang::mad:
     
  30. Sicknote

    Sicknote Active Member

    And don't us students just love it. [​IMG]


    Come on Kev, show me your horns?. [​IMG]
     
  31. What a prick. No more help from me. And I suspect, just guessing, that you've just burnt your bridges with Professor Kirby too.

    Nice work fella!
     
  32. Simon:

    I said some much more vulgar words under my breath when I read this last note from Ms. Sick.....pathetic........
     
  33. markjohconley

    markjohconley Well-Known Member

    Sicknote, you sound very young. Prof Kirby and Dr Spooner (yep they earned those titles) have given unbelievable advice and opinion (nearly 10,000 posts). You just cut some BIG bridges, good luck with the rest of your life, Mark
     
  34. Sicknote

    Sicknote Active Member

    Power breathing & reverse abdominal breathing (compression) are in my eyes the optimal way of increasing core stability, through the increase of intraabdominal pressure (IAP).

    The way to go about it.


    Let out a small breath through he mouth.
    Place the tongue to the palate.
    Take a DEEP/POWER inhalation through the nose.
    Breath right down into the stomach (send the pressure into your stomach—not your chest or head.)
    Exhale 75-100% of breath from the lungs through the mouth (the higher %, the greater your stability gain).
    After exhalation, place the tongue back upto to the palate, holding the compression.
    Aim for increasing the desired time (compression).

    Too be done while walking (maybe in the park) not sitting.

    In a Russian study the subjects’ strength was compared during three different phases of breath: inhalation, breath holding, and exhalation. In a landmark slap to the Western gym beliefs, the exhalation group showed the lowest scores! The “inhalers” did better and the breath holders kicked everyone's butt.

    Muscles which stabilize the spine such as transversus abdominus, multifidus etc are developed optimally through stomach vacuum/reverse abdominal breathing training.


    A good book on the subject is Pavel Tsatsouline's: The naked warrior.


    http://www.maximumtrainingsolutions.com/Core-Muscle-Training.html
     
  35. David Wedemeyer

    David Wedemeyer Well-Known Member

    I’m really late to this thread but I have a few comments on Core Stability.

    First Sicknote I mirror Mark’s thoughts above. My advice is should you ever require surgery, refrain from calling the surgeon a nasty epithet or flashing him/her the “horns” before you before you go under ;). Do you have a name, a professional affiliation? I’d like to afford you a copy of “How to Win Friends and Influence People by Dale Carnegie, the least that I can do…

    The bigger problem with the core as panacea is that often I see very athletic people with very strong cores who present with acute, mechanical low back pain. They sprain ankles at a rate higher than the general population as well, ostensibly because they are more active and perform more high-risk activities. These are not your couch potato types obviously and often it is a combination of improper loading on the spinal architecture (discs, facet joints) vs/and/or muscle strain, ligamentous or disc sprain.

    With these patients I am in full agreement with Ron where he says:

    I see the issue as a remedial one of performing the appropriate assessment in the first place and trying to fit the treatment to the presentation and not the other way around (I see this a great deal with orthotic therapy as well). From the assessment the first goal should always be to reduce their pain, reduce the chance of re-injury, control inflammation etc...

    I see core strength as more pertinent to the chronic low back and peripheral injury and as more of an adjunct to primary modes of therapy (icing as Ron would say and I totally agree) and in prevention and rehabilitation. I send a number of patients out to PT’s and pilates once their goals are met in my office and they can safely integrate into active care. The ones who are compliant see me less in the future, I don’t keep stats on that but I can say that assuredly looking back over the years.

    Finally Ron said (and Simon mirrored this with his own example):

    Amen. And many were not diagnosed appropriately in the first place; many more that I see were not managed beyond the acute complaint (which is where I feel core training fits in most appropriately). I am completely against early, active exercise in the acute phase of care. Many insurers have adopted this EBM mindset to limit passive treatment and payment (especially in work comp in my state) when clinical experience and common sense say otherwise.

    Our approaches are very similar Ron, as disparate as our professions may be. Great posts.Core training has its place but it doesn’t replace proper clinical evaluation and quality passive care, especially in the acute and sub-acute stages.
     
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  38. NewsBot

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    Articles:
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    An Investigation of Simulated Core Muscle Activation during Running and its Effect on Knee Loading and Lower Extremity Muscle Activation Using OpenSim
    Creps, Justin Michael
    2014, Master of Science, Ohio State University, Mechanical Engineering.
     
  39. NewsBot

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    Articles:
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    The efficacy of a supervised and a home-based core strengthening programme in adults with poor core stability: a three-arm randomised controlled trial
    V H Chuter, A K Janse de Jonge, B M Thompson, R Callister
    Br J Sports Med doi:10.1136/bjsports-2013-093262
     
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    Core stability exercises for low back pain in athletes: a systematic review of the literature.
    Stuber KJ, Bruno P, Sajko S, Hayden JA.
    Clin J Sport Med. 2014 Nov;24(6):448-56.
     
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