Module #6
IN J U R Y P R E V E N T IO N
Core Concepts: Understanding the Complexity of the Spinal Stabilizing Systems in Local and Global Injury Prevention and Treatment
Lindsay Warren DAT, CSCS • California Baptist University; Russell Baker, DAT, AT, Alan Nasypany, EdD, AT, and Jeffrey Seegmiller, EdD, AT • University of Idaho
The core is central to almost all extremity movements, especially in athletics. Running, jumping, kick- ing, and throwing are dependent on core function to create a stable base for movement. Poor core strength, endurance, stiffness, control, coordination, or a combination thereof can lead to decreased performance and increased risk of injury. Due to the core’s many complex elements, none of which are more or less important than the next, it is imperative that athletic trainers have a systematic and comprehensive plan for assessing and treating patients with stability or motor control dysfunctions of the entire spinal stabilizing system. The purpose of this clinical commentary is to outline the structural (anatomical) components of the core and their functions, establish the elements of core stability (functional), review these elements’ importance in decreasing the risk of injury, and discuss the application of this information in athletic training.
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D,espite the common use of the term core in rehabilitation, its definition, struc-
ture, purpose, and role in rehabilitation is still disputed among health care professions. The discussion of its impor tance to clinical practice continues as more is learned (through anal ysis of regional inter dependence) about the role the core plays in injury management and prevention. To move forward, understanding is needed on the foun
dational purpose of the core in movement. Many agree that the core’s primary function
K e y Po in t s Stabilization of the spine is a dynamic and complex task.
Poor dynamic core stabilization results in increased risk of injury to the spine and extremities.
A patient w ill be unable to complete ideal movement patterns w ithout proper muscu lar control, coordination, timing, strength, and endurance.
is to act as a singular unit, provide a stable foundation for movement (with or without the extremity), and provide local and global balance and strength. During movement this task is accomplished with the use of passive and active core structures.'
While researchers in this area agree on the function of the core, debate continues as to what anatomical structures truly encom pass the core. Many researchers propose the core is an integrated system, comprised of the passive spinal column of bony and liga mentous structures, the active spinal muscles and thoracolumbar fascia, and the neural control unit. 1-5 Kibler et al2 postulate the core contains the musculoskeletal structures of the spine, hips, pelvis, abdomen, and the proximal lower limb. Akuthota and Nadler, 1 in contrast, define the core as a box, with the
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diaphragm as the roof; the pelvic floor and hip girdle as the floor; and the abdominals, spinal, and gluteal muscles serving as the walls.
Attempting to use a more holistic approach, Frank et al6 coined the term integrated spinal stabilizing system (1SSS). The 1SSS is com prised of the deep cervical flexors, deep spinal extensors of the cervical and thoracic regions, diaphragm, pelvic floor, and all sections of the abdominals and spinal extensors of the lower thoracic and lumbar regions.6 Frank and colleagues’ inclusion of the cervical spine is unique, as traditional models of the core focused on the lumbar and pelvic regions. The inclusion of the cervical spine, however, is im portant as the cervical spine plays an integral role in global stabilization. An example to illustrate this point is dem onstrated through the relationship betw een the progressive nature of the developmental kinesiology of infants and their devel oping central nervous system (CNS).6’7 Newborns, for instance, are only able to stabilize their head in a sitting position for a few seconds.7 While a more developed infant, with a more developed ISSS, is able to perform more elaborate movements (e.g., reaching while sitting upright) while simultaneously maintaining the stability of the entire spinal column. To control extremity move m ent, the ISSS must brace in order for movement to be achieved against gravity while providing protection for the cervical spine. Under ideal conditions, synergy of neck flexors and spinal extensors is in balance, allowing for controlled movements and stabilization of the cervical and thoracic spine.6’7
Core S t a b i li t y T h e o r y in P ra c tic e
With the purpose and com ponents of the core iden tified, a clinician can begin to evaluate and apply the concept of core stability. Core stability is another com monly used term with variation in its application. Most agree that proper functioning of the core is necessary to create stability and that dysfunction creates instabil ity,1-4 but identifying the key elem ents is necessary for implementation in practice. Much of the recent focus in the literature regarding core stability has focused on the following elements: muscular capacity, motor control, and coordination and stiffness.34
Muscular capacity is a muscle’s ability to generate or maintain force.8 Endurance and strength are compo nents of muscular capacity and are necessary for the spinal stabilizing musculature to achieve movement
and sustain postures. The anatomical orientation of a m uscle’s origin and insertion determ ines its per formance during certain tasks, w hether strength or endurance oriented. The trunk muscles may be clas sified by their function into local or global muscles. The local muscles (e.g., intertransversarii, rotatores, multihdus) have direct attachm ents to the vertebrae and are limited in their ability to generate torque. The primary contribution of local muscles is precise control of the individual spinal vertebrae. Due to their small m om ent arm and type I fibers, the local muscles are well equipped to sustain posture and are resistant to fatigue.9
Conversely, global muscles (e.g., rectus abdominis, longissimus thoracis, external obliques) cross several spinal joints and attach to the hip and the thorax. As the global muscles have a larger m om ent arm with which to create torque, the ability to resist greater external forces is provided through these structures. Without sound muscular capacity in local and global muscle groups, the risk of injury and incidence of pain increases. Poor endurance of the trunk muscles is a predictor of occurrence of low back pain in m en 10 and is commonly found in patients suffering from chronic low back pain.1112 Lehman,13 Faries and Greenwood,9 and McGill et al14 believe endurance to be more import ant than strength in the spinal stabilizing musculature.
To improve muscular capacity of the core, many clinicians chose to design comprehensive strengthen ing programs. A common solution to muscular capacity issues in the core is comprehensive strengthening pro grams, which have been advocated for the prevention of various musculoskeletal disorders'5 as well as per formance enhancem ent.3 However, there are problems with traditional core strengthening programming.
First, assessing for and diagnosing muscle weak ness are not as simple as strength or endurance testing. Individuals without proper CNS integration, for exam ple, may be unable to adjust muscle strength to the dem ands of a movement or recruit accessory muscles for stabilization, making movement patterns inefficient and weak. A strengthening program then does not target what may be the primary etiology. Consequently, balance or strengthening exercises prescribed to a patient with poor stabilization or motor control may promote pathological m ovem ent patterns, increase the patient’s pain, and ultimately be unsuccessful.16'7
Second, the activation of specific trunk muscles is dependent on several factors. Completing an exercise
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or m aintaining a position on a stable or unstable surface results in differing muscle activation patterns and contraction intensities, as studied by intramus cular electromyography (EMG) . 17 The body segment initiating motion during an exercise (e.g., trunk or pelvis) also changes the activation of trunk muscula ture. 18 The overload principle of strengthening is not advocated for the core musculature due to lumbar spine involvement. For example, the traditional sit-up increases compressive load on the lumbar spine and is considered an unsafe exercise. 16 Pelvic tilts also create increased spinal loading, as do back extensor strength ening machines. As a result, traditional strengthening often creates an unsafe load of the spine and may cause injury. 1’16 Several researchers, including Saal and Saal, 19 McGill, 20 and Sahrm ann, 21 have recommended safer programs that are focused on sparing the spine in progressive stabilization exercises to address these problems. 1 Unfortunately, some programs emphasize a rigid, rod-like spine during activity20 instead of pro moting functional dynamic movement patterns.
Researchers studying muscle weakness patterns associated with injury have discovered weakness in the load transferring muscles (i.e., hip abductors and hip external rotators), not the local stabilizing or global mobilizing core musculature, as the primary predictor of injury8 and low back pain. 22 Most studies report mus cular recruitment changes of the core muscles, such as timing and control, both before and resulting from injury. 8 ’15’2 3 -2 5 ’27' 28' 30'31 The implication of such findings suggest neuromuscular control (i.e., motor control) is of more importance than strength. 3 '4 '8 ’15’23" 32 '3 4 '40 '42’45
Motor control, an unconscious action, is the process of the CNS’s generation and monitoring of movement com m ands through feed-forward (e.g., anticipation) and sensory feedback mechanisms (e.g., propriocep tion, vision) . 32 The brain plays an important role in spinal stability in anticipatory and reactive capacities. During this process, the brain subconsciously adjusts and adapts to internal and external forces and also anticipates m ovem ents of the extremities and the trunk. In fact, motor control performance is more effi cient when subjects are not focusing on the movement being measured and instead have an external focus.33 Training to improve motor control is accomplished by using the motor learning approach to retrain the unconscious use of a more functional pattern over the dysfunctional pattern. For the core, this involves preactivation of the deep trunk muscles and integra
tion of the global trunk muscles in a progression from static to dynamic to functional tasks. 34'35 Any extremity movement is preceded by an anticipatory contraction of the core musculature to create the stable base for that m ovem ent. 36 Therefore, in order for a movement progression to be successful, this preactivation must be attained. Cocontraction exercises, balance training, proprioceptive training, plyometrics, and sport-specific skills have been identified as essential com ponents in reestablishing and strengthening motor control. 37
Dynamic core function is of paramount importance in injury prevention and rehabilitation. Sensory-motor control deficiency and neurom uscular im balances of the core have been linked to the occurrence of low back and lower extremity injuries, especially in females. 25’30'31 Inadequate motor control and poor mus cular recruitment are among the causes of nonspecific low back pain. The reduced stability of the segments of the spine creates altered and dysfunctional distribution of loads. 38'39 Additionally, neuromuscular imbalances result in poor control and decreased stability, which in turn cause compensatory m ovement patterns and poor motor recruitment down the chain in an attem pt to maintain function. 16 Motor relearning of inhibited core muscles in patients with low back pain28 and restoration of core motor control in patients at risk for anterior cruciate ligament injury37 is more important than strengthening and endurance training of the core musculature.
The importance of proper motor control in prevent ing and treating extremity injuries is often associated with the term regional interdependence. Zazulak et al30 dem onstrated that proprioceptive deficits in the core contributed to decreased neuromuscular control of the lower extremity. Decreased motor control of the lower extremity led to increased valgus m om ent and strain to the ligaments of the knee. 25 Poor proxi mal neuromuscular control is one etiological factor in patellofemoral pain syndrome (PFPS). Earl and Hoch40 determ ined that improving neurom uscular control of the core decreased pain and increased functional ability in female patients with PFPS. Nadler and col leagues also dem onstrated that patients complaining of lower extremity overuse injuries were significantly m ore likely to seek tre a tm e n t for low back pain within the following year. 28-29 In a systematic review, Macedo et al39 reported the outcomes of motor control exercise compared with other interventions for the treatm ent of patients with nonspecific low back pain.
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The researchers indicated that motor control exercise was favored over minimal intervention and produced clinical outcomes that equaled the success of surgical L4-L5 fusion.39
Appropriate motor control allows for the last ele ment, a combination of coordination and stiffness, to produce core stability. Through coordinated contraction of the spinal stabilizing system, stiffness is produced in the core, which determines joint stability. Stiffness of the spinal column is increased with the coordinated coactivation of the core musculature, which protects the structures of the spine during any activity.41 Even under heavily loaded conditions, such as a heavy dead lift, spinal ligaments are not strained and stability is the responsibility of the musculature.3 For example, the coordinated and balanced coactivation of the internal obliques, transverse abdominis, and external obliques tensions the thoracolumbar fascia and creates stiffness like a stabilizing corset. Coupled with the regulation of intra-abdominal pressure (IAP) and control of the pelvic floor, spinal stability is created that precedes any conscious m ovem ent and is under autonomic control.23'30 Immense, albeit unconscious, coordination of muscle activation is needed to successfully create uniform stiffness necessary to stabilize the spine in all three cardinal planes. If contractions were not coordi nated, an imbalance in force or direction would arise, resulting in movement dysfunction and compromised spinal stability.
C l i n i c a l A s s e s s m e n t I m p l i c a t i o n s
The correlation betw een inappropriate core stabili zation and injury, at the core and in the extremities, provides evidence for treating the core as the center of the foundational kinetic chain. The utility of the core is dependent on the coordinated action of the ISSS structures. The dynamic relationship of these structures makes the assessm ent and treatm ent of patients with core stability or motor control dysfunctions difficult to address. As a result, some have shifted clinical evalu ation to focus on movement screens and the regional interdependence paradigm.6'7-42 The goal of any move m ent pattern analysis is not to isolate structures, but to achieve a global understanding of a system and how structures interact with one another on a functional level to achieve a movem ent.42
Using the knee as an example, a clinician could attem pt to isolate the different structures needed to
perform a movement (e.g., seated knee extension) to determ ine potential involvement in a patient present ing with knee pain. In its simplest form, the knee would need functioning local bone (e.g., medial and lateral femoral condyles, tibial epicondyles) and articular (e.g., capsule, ligaments) and muscular components (e.g., quadriceps muscle and tendon) to perform the movement, given proper neuromuscular control and balance with the antagonistic hamstrings. The local exam, however, would ignore the feed-forward antic ipation of the weight of the leg and the force needed to create the movement against gravity; the feed-back sensory information of the proprioception of the leg in space, communicating with the central nervous system to control the speed and direction of the movement, would also be missed. If any element of the system were damaged or inhibited, a dysfunctional movement would be created. The dysfunctional movement pattern would, in turn, begin affecting the other surrounding structures at the knee and along the kinetic chain. In short, dysfunction at the core could produce dysfunc tion, pain, and impairm ent at the knee. A physical exam evaluating the knee in isolation would create a local pathoanatomic diagnosis that would not address that cause of the pathology and would produce an insufficient rehabilitation program.6-42
The belief that the body does not function in isola tion and that dysfunction in one part of the body has direct implications for other parts of the body is the premise of regional interdependence.42 Motion at one segment will influence that of all other segments in the chain.19 Thus, it is fitting that the dynamic system that comprises spinal stability would be best assessed using a movement assessm ent to help create a complete picture of a patient’s core motor control function.43̂ 45
C o n c l u s i o n
Based on the literature evidence, a logical conclusion is that core perform ance is a com prehensive task comprised of multiple elements with potentially equal importance that have significant implications in the prevention and m anagem ent of injury. Performance of the core is not simply determ ined by its strength or endurance, but also the coordination, timing, and control of multiple structures. As more is learned about the core stabilizing system, less emphasis is being placed on the passive structures in rehabilitation and more focus is being placed on the motor control and
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muscular capacity of the lumbo-pelvic complex. 8 '46 '47 With its complex nature and significant implications on the m anagem ent of injuries, it is important for athletic trainers to have a comprehensive understanding of core motor control and stability. It is critical to understand the function of each structure, the coordination of each structure to those related to it, and the role the brain plays in controlling those structures in order to provide effective prevention and rehabilitation programs to our patients. Implementation of assessm ent and rehabil itation strategies that incorporate motor control and stability dysfunctions of the spine has the potential to positively improve patient care across a variety of clinical setting and patient presentations.
R e feren ce s
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L in dsay W arren is th e Clinical E d u ca tio n C o o rd in a to r o f A thletic Train ing E d u c a tio n in th e D e p a r tm e n t o f K inesiology a t C alifornia B a p tist U niversity, R iverside, CA.
R u ssell B aker is th e Clinical E d u c a tio n C o o rd in a to r o f A thletic T raining E d u c a tio n in th e D e p a r tm e n t of M o v e m e n t S c ie n c e s a t th e U niversity o f Id a h o , M oscow, ID.
A la n N a sy p a n y is th e D ire c to r o f A th letic T ra in in g E d u c a tio n in th e D e p a r tm e n t o f M o v e m e n t S c ie n c e s a t th e U n iv e rsity o f Id a h o , M oscow, ID.
Jeffrey Seegm iller is th e D ire cto r of Id a h o WWAMI M edical E d u c a tio n P ro g ra m a t th e U n iversity o f Id a h o , Moscow, ID.
M onique Mokha, PhD, ATC, N ova S o u th e a s te rn University, is th e re p o rt e d ito r fo r th is article.
INTERNATIONAL JOURNAL OF ATHLETIC THERAPY &. TRAINING NOVEMBER 2 0 1 4 I 33
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