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REHABILITATION

By Mark Comerford, MCSP

The development of strength andstability training programmesfor sport has been a priorityin the attempt to optimiseperformance and acceleratethe post-injury rehabilita-t ion process. To date,attempts to do this havemainly centred on testingand regaining joint range,muscle strength (both powerand endurance) and muscleextensibili ty. Some at tempts havefocused on developing functional tests andretraining programmes based on sport-specific skills.

Most of these training programmes end up becoming ‘protocols’for ‘core stability’ training or ‘protocols’ for a particular injury;such as a patellar malalignment protocol, a shoulder instabilityprotocol or a post-surgical protocol. Some of the benefits of a pro-tocol-based training regime is that it can be designed with cleargoals, performance targets, structured time frames and the proto-col can be readily disseminated to a large number of people. Thedevelopers of these protocols have the unenviable task of produc-ing a programme that is simple and at the same time comprehen-sive enough to deal with the wide range of variability in patientpresentation and complications. It is difficult for one protocol tocover the time-frame from injury to return to competitive sport.One of the weaknesses with protocol-based training programmesis that there has to be an assumption that all people who use theprotocol have, to a large extent, the same problem. Most proto-cols are designed along a linear framework. That is, there are aseries of linear progressions from one skill or stage to the next.Consequently, in the attempt to account for individual differencesin participant presentation (especially if injury and pathology isinvolved) many of these protocols are modified or adapted, oftenmany times over.

The primary problem then with protocol-based training pro-grammes is that they are forced to become ‘recipes’. The recipeworks well for one particular goal or a ‘classic’ / ’textbook’ presen-tation of a problem, but therapists and trainers who regularlywork with injured athletes know that they rarely present as thetextbook case. They all have their own differing variations, com-plications and expectations. What is needed is a paradigm shifttowards a process of systematic assessment and analysis that canbe used to guide rehabilitation of dysfunction and retraining ofperformance deficits. It should be based on a systematic assess-ment of an individual’s ‘weak links’ and lead to the development

of a client-specific retraining programme to more appropriatelyaddress the real priorities in injury rehabilitation and performancetraining. The retraining programme is designed along a multidi-mensional and parallel framework, rather than a linear recipe.

It is well accepted in today’s professional sporting environmentthat power, endurance and flexibility are important and are anecessary and integral part of any sports training programme.McGill (1), Chek (2) and many other rehabilitation specialistsand strength and conditioning trainers advocate high-load

power and endurance training as the end goal of the retrainingprocess and base their training programmes and protocols aroundstrengthening the core and limbs to increase core stability andsporting performance. They eloquently argue the relationshipbetween force and power and stability. However, there is an underrepresentation (if present at all) of low-load motor control train-ing in many of these training programmes. If low-load motor con-trol training is used it is often presented as part of a linear pro-gression along the path to achieve high load strengthening.

Hodges (3) argues that strengthening the muscles of range andforce potential is one process while training the deeper (forceinefficient) muscles of motor control is a distinctly separateprocess. Both are required to perform to high levels of activitysuch as competitive sport. One analogy for this is to think of themusculoskeletal system as a computer. High speed or high-loadstrength training changes muscle structure and can be likened toupgrading the computer’s hardware. This can make the computerwork faster and run more complex programs. Low-threshold motorcontrol training doesn’t change the muscle structure to any greatextent, but instead improves the central nervous system’s abilityto fine tune muscle co-ordination and improve the efficiency ofmovement. This is like upgrading the software in a computer toperform its tasks more efficiently and to get the most out of thehardware already present. Pain is like a computer virus, which pri-marily affects the software causing the computer to run slowlyand crash more often. In the human body pain has more consis-tent effects on the motor control aspects of movement rather thandirectly affecting muscle structure.

Contemporary neurophysiological and clinical research into move-ment dysfunction associated with musculoskeletal injury, chronic-ity and recurrence of injury, highlight deficits of low-thresholdmuscle recruitment and motor control inefficiency (4-16). Thesedeficits are only clinically and functionally identified with veryspecific tests of low-load recruitment efficiency. Some of thesedysfunctions develop prior to the onset of symptoms and injuryand appear to be precursors or contributing factors to the devel-opment of injury and symptoms (9,12). There is mounting evi-dence that failure of low-load recruitment efficiency is a consis-tent and reliable predictor of recurrence (6,17).

CORE STABILITY: PRIORITIES IN REHABILITATION OF THE ATHLETE

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CORE STABILITY

■ One joint (mono-articular)■ Broad aponeurotic insertions (to distribute and absorb force

and load)■ Leverage for load maintenance, static holding and joint

compression ■ Postural holding role associated with eccentrically deceler-

ating or resisting momentum (especially in the axial plane -rotation)

■ Two joint (bi-articular or multi-segmental)■ Superf ic ial (longer lever, larger moment arm and

greatest bulk)■ Unidirectional fibres or tendinous insertions (to direct force

to produce movement)■ Leverage for range and speed and joint distraction ■ Repetitive or rapid movement role and high strain/ force

loading

STABILISER ROLE CHARACTERISTICS MOBILISER ROLE CHARACTERISTICS

TABLE 2. LOCAL AND GLOBAL MUSCLE ROLES (20,21)

■ Deepest, 1 joint■ Minimal force /stiffness■ No or minimal length change■ Does not produce or limit range of motion■ Controls translation motor control■ Maintains background motor control in all ranges, all

directions■ No antagonists

■ Deep 1-joint or superficial multi-joint■ Force efficient■ Concentric shortening to produce range■ Eccentric lengthening or isometric holding to control range■ No translation control■ Direction specific / antagonist influenced

LOCAL MUSCLE SYSTEM CHARACTERISTICS GLOBAL MUSCLE SYSTEM CHARACTERISTICS

TABLE 3. LOCAL MOTOR CONTROL ROLE

■ Muscle stiffness to control segmental translation■ No or minimal length change in function movements■ Anticipatory recruitment prior to functional leading provides protective stiffness■ Act ivi ty is continuous and independent of the direct ion of movement

(eg. tranversus abdominis, segmental lumbar multifidus, posterior fasciculus ofpsoas major)

TABLE 4. GLOBAL STABILITY ROLE

■ Generates force to control / limit range of movement■ Functional ability to (i) shorten through the full inner range of joint motion

(ii) isometrically hold position (iii) eccentrically control the return■ Low threshold eccentric deceleration of movement (rotation)■ Activity is non-continuous and is direction dependent

(eg. external obliquus abdominis, superficial multifidus iliacus)

TABLE 5. GLOBAL MOBILITY ROLE

■ Generates force to produce range of movement■ Concentric acceleration of movement ( sagittal plane - power)■ High load shock absorption■ Activity is especially phasic (on/off pattern) and is direction dependent

(eg. rectus abdominis, iliocostalis, rectus femoris, hamstrings)

TABLE 1. STABILISER AND MOBILISER MUSCLE ROLES (12,18,19)

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MUSCLE CATEGORISATIONThe concepts of stabiliser and mobiliser muscle roles (see table 1)and local and global muscle systems (see table 2), provide usefulframeworks to classify muscle function. However, alone, thesemodels have some deficiencies.

By inter-linking these two concepts a useful model of musclefunctional roles can be developed(9,21) where muscles can be cate-gorised as having three functionalroles: i) a local stability role (table 3)ii) a global stability role (table 4)iii) a global mobility role (table 5).

CORE STABILITY The core is best represented as adouble walled cylinder consisting ofthe lower back and abdomen and theupper back and chest (the trunk)(22,23).

The inner wall of the core cylinder ismade up of the deep local musclesystem (inner core). These musclesinclude: ■ respiratory diaphragm■ transversus abdominis■ segmental multifidus■ posterior psoas■ pelvic floor

The outer wall of the core is madeup of the outer global muscle sys-tem (outer shell). These consist of the muscles which have a glob-al stability role along with the muscles having a global mobilityrole. These muscles influence postural alignment and contributeto the production and control of range of motion. The global sta-bilisers here include the oblique abdominals, superficial multifidusand spinalis, anterior psoas, oblique fibres of quadratus lumborumand contributions from the pelvic floor.

The ‘core’ also consists of the pelvic and shoulder girdles. Thescapula provides a mechanical linkage between the arms and thetrunk, while the pelvis provides thelink between the legs and the trunk.

In normal function the limbs andtrunk often counter rotate relativeto each other and these rotationforces are co-ordinated and con-trolled at the two girdles.

The global outer shell frequentlydevelops muscle imbalance wherevarious global mobiliser musclesbecome dominant and ‘take over’from the stabiliser muscle functionor create restrictions resulting incompensatory movement patterns.

MOTOR CONTROL STABILITY VERSUS STRENGTHMotor control stability assessment is based on the accepted andextensive research on muscles like transversus abdominis. Stabilityfunction (or dysfunction) is reliably tested under low-load situa-tions. It is based on the ability to pass or fail a low threshold testof motor recruitment. The benefit of having good stability functionof both the local and global stabiliser muscles is in improved low

threshold motor control and indecreasing mechanical musculo-skeletal pain (Figure 2).■ Pass - no movement induced

pathology and pain free function■ Fail - development of pathology

and pain.

Muscle strength is measured as theability to pass or fail a test of resist-ing or supporting a high load. Thegrading of muscle strength as 1 to 5with manual muscle testing is anexample of muscle strength testingthat physiotherapists are trained toperform. This testing is often per-formed using force dynamometers toprovide more objective measure-ments. The benefit of having goodstrength is that performance isimproved or maintained. Strengthtraining does not demonstrate con-sistent improvement in pain andpathology or low threshold motorcontrol function (see figure 2).■ Pass - good power, endurance

and high load performance■ Fail - weakness and the loss of performance.

Definitions and terminology Because the term ‘core stability’ no longer is used in the way itstarted off, and it has now achieved generic status in the exerciseand fitness industry it is necessary to differentiate and re-definestability concepts.

■ The term ‘core stability’ is now used to describe exercises thatrange from an almost imperceptible activation of the deep

abdominal muscles to l if t ingweights overhead while balancingon an inflatable physio ball. ■ The term ‘motor control stability’

may be an appropriate new labelfor low threshold stability con-cepts and is best defined as cen-tral nervous system modulationof efficient integration and lowthreshold recruitment of localand global muscle systems.

■ ‘Core strength training’ may bemore appropriate for highthreshold or overload strengt-training of the global stabilisermuscle system.

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REHABILITATION

GOOD MOTORCONTROL

STRONG

WEAK

Good performance

Pain free Painful

Poor performance

POOR MOTORCONTROL

+++–

– +– –

Figure 2 Motor control stability (software) versus strength (hardware) (24)

Figure 1. The core Cylinder consists of a local muscle innercylinder and a global muscle outer shell

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■ ‘Symmetrical strength training’ may be more appropriate forthe more traditional high threshold or overload strength train-ing of the global mobiliser muscle system.

There are some defining differences between ‘motor control sta-bility’ and ‘core strengthening’ (see table 6).

In contrast, symmetrical or traditional strength training has cer-tain differences and benefits. ■ High threshold training (muscle adapting to overload demand)

■ Biased for the global mobiliser muscles ■ Sagittal plane prevailing (+/ - coronal plane)■ The need to control a rotation challenge or load is eliminated■ Predominantly isotonic with emphasis on concentric (also iso-

metric and isokinetic)

CORE STABILITY SUMMARYCore stability now encompasses a large range of exercise process-es. These processes include: a) local muscle system motor controlb) global muscle system motor controlc) strength training of the core (trunk)d) symmetrical or traditional strengthening of the trunk and limbsusing limb loading (22,24).

The similarities and differences between these different processescan be analysed under several different headings (see table 7):

■ Activation threshold: Low threshold (non fatiguing low load)and high threshold (fast movement or fatiguing high load)

■ Muscle emphasis: The muscle functional role predominantlyemphasised or trained (local stability or global stability orglobal mobility role)

■ Position or direction of primary loading: eg. local stabiliserswork independently of direction so no specific direction isloaded. Global stabilisers control all directions of motion(especially rotation). So, in motor control training these mus-cles are trained to resist all directions trunk movement againstlow functional loads, while in core strength training they aretrained to resist high load rotation challenges. In symmetricalor traditional strength training the muscles with the greatestbiomechanical potential to lift the heaviest load are the glob-al mobilisers and they do this best if rotation can be eliminat-ed from the exercise

■ Type of contraction: Isometric holding of contraction to resistmovement strain or isotonic contraction involving emphasis ofthe shortening against load (concentric) or lengthening tocontrol or decelerate load (eccentric)

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CORE STABILITY

TABLE 6: DIFFERENCES BETWEEN MOTOR CONTROL STABILITY AND CORE STRENGTH

Muscle specific: That is, training can be biased for either alocal stabiliser muscle or a global stabiliser muscle.

Recruitment specific: That is, because all these exercises uselow load or functional normal loads then slow motor units arepredominately recruited

Central nervous system modulated: That is, afferent spindleinput influences tonic motor output (‘software upgrade’).

Muscle non-specific: Because of high load resistance orendurance overload to the point of fatigue all relevant synergistsare significantly activated. There is co-contraction of local sta-bilisers, global stabiliser and global mobiliser muscles.

Recruitment non-specific: Again, because of overload, bothslow and fast motor units are strongly recruited.

Central nervous system modulated: That is, afferent spindleinput influences tonic motor output (‘software upgrade’).

MOTOR CONTROL STABILITY CORE STRENGTH

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REHABILITATION

Based on the evidence to date, high threshold re-training (tradi-tional strengthening and core strengthening) does not appear tocorrect motor control dysfunction in the local stability system(5,25). However, specific low threshold training does appear tocorrect local and global motor control stability dysfunction(17,26,27). Low load training does not appear to correct highthreshold dysfunction or atrophy (28,29). Both the local and

global muscle systems must integrate together for efficient normalfunction (3,9). Both low threshold and high threshold functionare required for return to manual work or sport (22,24,30).

TRAINING GUIDELINESTable 8 highlights the key elements that provide the guidelines totrain one process or another.

TABLE 7: THE SIMILARITIES AND DIFFERENCES BETWEEN THE DIFFERENT EXERCISE PROCESSES (22,24)

SYMMETRICAL‘TRADITIONAL’

STRENGTHENING (LIMBS)

High

Global stabilisers

Flexion-extension:symmetrical /sagittal

loading+/ - sidebend+/ - abduction-adduction(no axial rotation control)(rotation eliminated)

■ Isotonic: move limbsand trunk throughrange (concentric)

■ Symmetrical and bilat-eral limb movement

■ +/ - isometric and iso-kinetic

CORESTRENGTHENING

(TRUNK)

High

Global stabilisers

Neutral position:asymmetrical loading(axial rotation)+/ - rotation resistance+/ - rotation throughrange

(rotation challenged)

■ Isometric: resisttrunk motion

■ Isotonic: move trunkthrough rotation(concentric)

MOTOR CONTROLSTABILITY (GLOBAL)

Low

Global stabilisers

Neutral position anddissociate all threeplanes especially rota-tion control but includ-ing flexion and extensioncontrol

(three directions)

■ Isometric: resist trunkmotion (dissociation)

■ Isotonic: move limbsthrough range (iso-metric hold in short-ened range andeccentric lowering)

MOTOR CONTROLSTABILITY (LOCAL)

Low

Local stabilisers

Neutral position

(no direction)

■ Isometric: hold indifferent trunk pos-tures eg. sit, stand,lying

Activation threshold

Muscle emphasis

Position /direction of1° Loading

Type of contraction

TABLE 8: KEY ELEMENTS OF TRAINING FOR EACH EXERCISE PROCESS (22)

SYMMETRICAL‘TRADITIONAL’

STRENGTHENING (LIMBS)

■ fatiguing high loadexercise

■ +/ - speed■ bilateral or symmet-

rical limb load■ no rotation

challenge■ limb or trunk lifting

in the flexion-exten-sion plane

■ allow global mobiliser dominance

■ encourage core‘rigidity’

CORESTRENGTHENING

(TRUNK)

■ fatiguing high loadexercise

■ +/ - speed■ unilateral or asym-

metrical limb ortrunk load

■ high rotation chal-lenge

■ resist rotation forceat trunk

■ rotate trunk againstresistance

■ discourage globalmobiliser dominance

MOTOR CONTROLSTABILITY (GLOBAL)

■ non fatiguing lowload exercise

■ unilateral or asym-metrical limb ortrunk load

■ trunk does not moveout of neutral

■ dissociate rotation,flexion and exten-sion

■ emphasise rotationcontrol at trunk andgirdles

■ shortened range holdfor postural control

■ discourage core‘rigidity’

MOTOR CONTROLSTABILITY (LOCAL)

■ non-fatiguing lowload exercise

■ trunk does notmove out of neutral

■ allow slight globalstabiliser co-activa-tion

■ discourage globaldominance

■ discourage core‘rigidity’

Guidelines for training

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spine. Hold this position and keeping the back stable (nopressure change) slowly lower one heel to just above thefloor and extend it out into extension unsupported. As soon

as any pressure change or movementof the back or pelvis is registeredthe movement must stop and moveback in to the rest position. The legmay extend as far as stability ismaintained (no pressure change).Repeat this movement, slowly alter-nating legs, for 10 seconds, andthen return both feet to the floor.Repeat the whole process unti lfatigue makes it difficult to maintainthe stable lumbo-pelvic position. Donot allow loss of position due tofatigue.

Example 4Symmetrical ‘traditional’ strength-ening: Co-contraction of all abdom-inals wi th the rectus abdominisemphasised (Figures 6 and 7)

Start in crook lying and tighten theanterior abdominals to flatten theback and posterior tilt the pelvis.Then actively lift the head andshoulders by sliding the hands upthe thighs to flex the trunk andshorten rectus abdominis. Sustainthe hold in this position for 10 sec-onds and slowly unroll down main-taining the posterior tilt. Repeat thewhole process until fatigue makes itdifficult to maintain the hold for 10seconds.

Progress by lying supine with thelegs out straight and feet unsupport-ed. With the arms above shoulderheight the patient actively posterior-ly tilts the pelvis and lifts the headand shoulders to flex the trunk fully.Then, while maintaining the posteri-or tilt and trunk flexion the hips flexto lift the trunk over the pelvis androll up to a sitting position. Sustainthis position for a few seconds andthen slowly unroll down, keeping theposterior tilt. Stop and hold half-wayfor 10 seconds before curling upagain. Hold the curl up for a few sec-onds then unroll to half-way again.Repeat the whole process unti lfatigue makes it difficult to maintainthe half-way hold.

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CORE STABILITY

Examples of these concepts and guidelines in practiceAbdominal muscle training examples can be used to illustrate theapplication of these concepts and guidelines.

Example 1Local motor control stability:Transversus abdominis (Figure 3)

Pull in or ‘hollow’ the lower abdominalwall (especially the lateral aspect) with-out excessive overflow to the upperabdominal wall. This ‘drawing in’ actionshould be isolated to lower muscularregion and should attempt to minimisespinal or rib cage movement and notcause lateral flaring of the waist.

Example 2Global motor control stability: Externalobliquus abdominis (Figure 4) Slowly lift one foot off the floor and thenlift the second foot off the floor andbring it up beside the first leg. Use thisposition with hips flexed to 90° and bothfeet off the floor as the starting position.Place one hand under the back to moni-tor back stability. Hold this position andkeeping the back stable (no pressurechange on hand), pull the lower andupper abdominal wall in towards thespine. Slowly lower one heel to the floorand lift it back to the start position.Repeat this movement, slowly alternatinglegs for 10 seconds so long as stability ismaintained (no pressure change), andthen return both feet to the floor. Repeatthe whole process 10 times. Safety note: as soon as any pressureincrease or decrease is registered themovement must stop and return to theresting position (feet on floor). The pointof greatest risk of losing stability is whenthe heel is lowering to the floor. Do notallow bracing or fatigue.

Example 3Core strengthening: Co-contraction ofall abdominals with the obliques empha-sised (Figure 5)

Slowly lift one foot off the floor and thenlift the second foot off the floor andbring it up beside the first leg. (Use thisposition with hips flexed to 90° and bothfeet off the floor as the starting posi-tion). Place one hand under the back tomonitor back stability. Pull the lower andupper abdominal wall in towards the

Figure 3: Local motor control training of transversus abdominis

Figure 4: Global motor control training of external obliquusabdominis

Figure 5 Core strength training of the abdominals - empha-sising the obliques

Figure 6 Abdominal curl

Figure 7 Trunk sit up

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CLINICAL INDICATIONS In the clinical scenario there appears to be an assumption thatrehabilitation and stability retraining must start with local motorcontrol training and progress in a linear framework through glob-al motor control then to core strengthening and finally to high-end symmetrical traditional strengthening. There is no evidence inthe research literature to support this notion of structured linearprogression. Individuals present to the clinic with different symp-toms and injuries that cause varying levels of disability andimpairment. By taking a thorough case history and performing anexamination that assesses each of the four elements of core sta-bility for deficiencies or ‘weak links’ a multi-factorial picture of theproblem becomes clear. Based on current biomechanical and phys-iological understanding of movement function and dysfunction,clinical anecdotal evidence and sound clinical reasoning, somespecific clinical indications for prioritising different ‘weak links’can be suggested (31).

INTEGRATION OF ‘CORE’ STABILITY SYSTEMS There are many differing interpretations of stability and stabilitytraining. With increasing demands on therapists for therapeuticexercise programmes it is often difficult to know where to start.Core stability is a term that encompasses a variety of differingtraining processes that affect the stability, efficiency, performance

and symptoms within the movement system. By analysing and and

and symptoms within the movement system. By analysing andprescribing exercise based on this framework (Figure 8), it is pos-sible to move away from the idea of stability and performancetraining being a linear progression from low threshold motor con-trol training to high loads strength training.

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REHABILITATION

BOX 1: INDICATIONS FOR LOW LOAD TRAINING OF THELOCAL SYSTEM AS A CLINICAL PRIORITY

1. Relevant symptom presentation:a. associated with low load normal daily functionb. direction specific pain - associated with a particular

direction of movement provocation2. Direction related mechanical pain (one movement ≠

symptoms and another movement Ø symptoms)3. Low threshold recruitment imbalance between stabilisers

(inefficient / force inhibited) and mobilisers(dominant /overactive)

4. Length – tension imbalance between stabilisers(long/ force inefficient inner range) and mobilisers (lackextensibility)

5. History of recurrence - usually related to a precipitatingincident where a specific direction of stress or strain isimplicated in the mechanism of injury (prevention?)

■ Non-symptomatic uncontrolled (direction specific) ‘give’ (itmay be possible to prevent onset or minimise risk)

BOX 2: INDICATIONS FOR LOW LOAD TRAINING THE GLOBALSYSTEM AS A CLINICAL PRIORITY

Symmetrical ‘traditional’ strength training1. Relevant symptom presentation:

a. midline painb. only associated with high load activity (not associated

with low load normal daily function or postures)c. direction specific pain - associated with a particular

direction of movement provocation d. symptoms provoked with symmetrical or sagittal

(flexion/ extension) activity2. Atrophy (disuse) or load related weakness3. Sagittal (flexion or extension) ‘give’ under high load

testing:a. with bilateral or symmetrical (sagittal) loadb. with unilateral or asymmetrical (rotational) load

BOX 4: INDICATIONS FOR HIGH LOAD TRAINING THE GLOB-AL SYSTEM AS A CLINICAL PRIORITY

Figure 8: Parallel integration of core stability training

Low threshold recruitment (low load / force)

High threshold recruitment (speed or high load / force)

‘Core’ trunk strengthening

Symmetrical ‘traditional’ limb strengthening

Local ‘motor control’ stability

Global ‘motor control’ stability

1. Relevant symptom presentation:a. associated with low load normal daily functionb. non direction specific painc. associated with static position and all postures (sit, standand lying)2. Uncontrolled compensatory articular translation3. History of insidious recurrence (prevention)4. Poor voluntary low threshold recruitment efficiency■ Pain in the region

Core strength training

1. Relevant symptom presentation:a. unilateral pain

b. only associated with high load activity (not associatedwith low load normal daily function or postures)

c. direction specific pain - associated with a particular direc-tion of movement provocation

d. symptoms provoked with asymmetrical activity2. Atrophy (disuse) or load related weakness3. Rotation ‘give’ under high load testing:

a. with unilateral or asymmetrical (rotational) loadb. with bilateral or symmetrical (sagittal) load

BOX 3: INDICATIONS FOR HIGH LOAD TRAINING THE LOCALSYSTEM AS A CLINICAL PRIORITY

Extensibility / flexibility

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CORE STABILITY

Therapeutic exercise prescription should be based on a process ofassessment of where the real weak links in function and perfor-mance lie and then the rehabilitation or performance training pro-gramme should be devised to train different weak links in parallelwith individually assessed starting points and progressions basedon correcting relevant dysfunctions and achieving predeterminedlevels of performance.

If there is at least a clear understanding of the differencesbetween symmetrical / ’tradit ional’ strength training, ‘core’strength training and local and global ‘motor control’ stabilitytraining then therapists, rehabilitation specialists, exercise phys-iologists, coaches and trainers are in a better position to make athorough assessment of dysfunction related to symptoms and per-formance and make more reasoned clinical decisions regarding theappropriate type of intervention. Then it will become possible toadvance from the era of protocol-based rehabilitation and perfor-mance training for the athlete.

THE AUTHORMark Comerford MCSP, B.Phy, MAPA graduated from the Universityof Queensland, Australia in 1980. He worked for seven years as asenior musculoskeletal physiotherapist and in 1987 started teach-ing in the Physiotherapy Department at the University ofQueensland for the undergraduate and postgraduate programmes,lecturing in electrotherapy, sports physiotherapy and therapeuticexercise. In 1992 he moved to the UK and established postgraduatecourses in dynamic stability and muscle balance. This processevolved into Kinetic Control of which Mark is the senior director.Mark continues to teach and present throughout the UK and Europe,Australia, USA and Canada. He has moved back to Australia butcont inues to deliver courses through Kinet ic Control andPerformance Stability across the world.

Performance Stability is a training company which delivers firstclass core stability and performance training courses to profession-als in the sports, health and fitness industries. PerformanceStability courses focus on the evidence-based Performance Matrix,which is a unique and simple method of high and low stabilityassessment and retraining which can be used to find and fix weaklinks in an individual’s functional performance chain. For moreinformation visit www.performance-stability.com or see the adver-tisement on the back inside cover.

References1. McGill S. Low Back Disorders: Evidence based prevention and rehabili-tation. Human Kinetics 2002. ISBN 07360424152. Chek P 2004 Should athletes train like bodybuilders? Chek Institutewebsite http: / /www.chekinstitute.com/ articles.cfm?select=463. Hodges PW. Core stability exercise in chronic low back pain. OrthopClin North Am 2003;Apr;34(2):245-2544. O’Sullivan PB, Twomey L, Allison G. Dysfunction of the neuro-muscularsystem in the presence of low back pain - implications for physical thera-py. Journal of Manual and Manipulative Therapy 1997(a);5(1):20-265. O’Sullivan PB, Twomey L, Allison G. Evaluation of specific stabilisingexercise in the treatment of chronic low back pain with radiological diag-nosis of spondylosis or spondylolisthesis. Spine 1997(b);22(24):2959-29676. Richardson C, Jull G, Hides J, Hodges P. Therapeutic Exercise for SpinalStabi l isat ion: Scientif ic basis and pract ical techniques. ChurchillLivingstone 1998. ISBN 04430580247. Jull GA. Deep cervical flexor muscle dysfunction in whiplash. Journalof Musculoskeletal Pain 2000;8(1/2):143-154

8. Comerford MJ, Mottram SL. Functional stability retraining: Principles &strategies for managing mechanical dysfunct ion. Manual Therapy2001(a);6(1):3-149. Comerford MJ, Mottram SL. Movement and stability dysfunction - con-temporary developments. Manual Therapy 2001(b);6(1):15-2610. Gibbons SG, Comerford MJ. Strength versus stability - part 1 conceptand terms. Orthopaedic Division Review 2001(a);March /April:21-2711. Gibbons SG, Comerford MJ. Strength versus stability - part 2; limita-t ions and benef i ts. Orthopaedic Division Review 2001(b);March /April:28-3312. Sahrmann SA. Diagnosis & Treatment of Movement ImpairmentSyndrome. Mosby 2002. ISBN 080167205813. Hodges PW, Richardson CA. Inefficient muscular stabilisation of thelumbar spine associated with low back pain: a motor control evaluation oftransversus abdominis. Spine 1996;21(22):2640-265014. Hodges PW, Richardson CA. Transversus abdominis and the superficialabdominal muscles are controlled independently in a postural task.Neurosci Lett 1999;265(2):91-9415. Hodges PW. 2001 Changes in motor planning of feedforward posturalresponses of the trunk muscles in low back pain. Experimental BrainResearch 2001;141:261-26616. Hodges PW, Gurfinkel VS, Brumagne S, Smith TC, Cordo PC. Coexistenceof stability and mobility in postural control: evidence from postural com-pensation for respiration. Experimental Brain Research 2002;144(3):293-30217. Hides JA, Jull GA, Richardson CA. Long term effects of specific stabi-lizing exercises for first episode low back pain. Spine 2001;26(11):243-24818. Goff B. The application of recent advances in neurophysiology to MissR Rood’s concept of neuromuscular facilitation. Physiotherapy 1972;58:2409-41519. Janda V. Evaluation of muscle imbalance. In: Liebenson C (eds)Rehabilitation of the Spine. Lippincott, Williams & Wilkins 1996. ISBN068305032X20. Bergmark A. Stability of the lumbar spine. A study in mechanical engi-neering. Acta Orthopaedica Scandinavica 1989;230(60):20-2421. Comerford MJ, Mottram SL, Gibbons SG. Understanding movement andfunction ‘concepts’. Kinetic Control Movement Dysfunction CourseKinetic Control UK 200422. Comerford MJ. Core stability training: the performance matrix.Performance Stability Course Kinetic Control UK 2004 (b)23. Comerford MJ and Mottram SL. Dynamic Stability and Muscle Balanceof the Lumbar Spine and Trunk. Kinetic Control Movement DysfunctionCourse Kinetic Control UK 2004(a)24. Comerford MJ. Core Stability for Return to Work and Return to Sport:Kinetic Control Movement Dysfunction Course Kinetic Control UK2004(a)25. O’Sullivan P, Twomey L, Allison G. Altered abdominal muscle recruit-ment in back pain patients following specific exercise intervention. JOrthopaedic Sports Physical Therapy 1998;27(2):11426. O’Sullivan PB. Lumbar segmental ‘instability’ clinical presentation andspecific stabilizing exercise management. Manual Therapy 2000;5(1):2-1227. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J,Marschner I , Richardson C. A randomized controlled trial of exercise andmanipulat ive therapy for cervicogenic headache. Spine2002;27(17):1835-184328. Danneels LA, Vanderstraeten GG, Cambier DC, Witvrouw EE. Effects ofthe three different training modalities on the cross sectional area of thelumbar multifidus muscles in patients with chronic low back pain. BritishJ Sports Med 2001;35:186-18929. Danneels LA, Coorevits PL, Cools AM, Vanderstraeten GG, Cambier DC,Witvrouw EE, De CH. Differences in electromyographic activity in the mul-tifidus muscle and the iliocostalis lumborum between healthy subjects andpatients with sub-acute and chronic low back pain. Eur Spine J2002;11(1):13-1930. Comerford MJ. What comes 1st - The pain or the dysfunction? -Integration of local and global stability systems in rehab Proceeding 1stInternational Conference on Movement Dysfunction Edinburgh UK 2001.31. Comerford MJ and Mottram SL. The Integration of Dynamic Stabilityand Muscle Balance Concepts into Clinical Problem Solving: Kinetic ControlMovement Dysfunction Course Kinetic Control UK 2004(b).

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