Anatomy & Function of the Core. Ellen Casey, MD Assistant Professor Associate Director Sports Medicine Fellowship

Transcription

1 Anatomy & Function of the Core Ellen Casey, MD Assistant Professor Associate Director Sports Medicine Fellowship

2 Disclosures None

3 Objectives Define core stability Review the components of the core Discuss the role of coordination vs. strength in achieving a stable core

4

5 Functional Spinal Stability Panjabi, 2003 Neural Control Spine Stability Spinal Column Muscles

6 Osseoligamentous Structures Lucas & Bresler, 1961

7 Thoracolumbar Fascia 7

8 Core Musculature 8 Hodges 1999

9 Muscles of the Lumbar Spine Global Rectus abdominus External oblique Internal oblique (ant) Iliocostalis (thoracic) Local Multifidi Psoas Transversus abdominis Quadratus lumborum Internal Oblique (post) Iliocostalis Longisimus Akuthota & Nadler, 2004

10 Paraspinals

11 Quadratus Lumborum

12 Psoas major

13 Diaphragm Ceiling of the Core Respiration Reciprocal with pelvic floor Descends with inspiration Spine stability Increase IA pressure Pts with LBP and SIJ abnormal recruitment O Sullivan, 2002

14 Pelvic Floor Floor of the Core Respiration Reciprocal with diaphragm Spine Stability Support lumbopelvis and pelvic organs Co-activation withtra (Sapsford 2001) Specialized Functions Sphincteric control Sexual function

15 Abdominal Wall Musculature

16 EXTERNAL OBL Increases IAP Trunk rotation Side bending Controls ant pelvic tilt INTERNAL OBL Increases IAP Trunk rotation Side bending

17 Transversus Abdominis (TrA) 1. Increase Intra-abdominal Pressure Symmetric Active in both sagittal flex/ext (Barker 2005) 2. Contributes to control of trunk rotation Asymmetric Ipsilateral > Contralateral (Urquhart 2005) Feed forward/anticipation (Hodges 1996) 3. Different types of activation Tonic during gait Phasically active with breathing and heel strike (Saunders 2004)

18 Core Controversy 18 HOLLOWING Drawing in Selective recruitment of TrA and multifidi (Urquhart 2004) Incr spine stiffness (Hodges 2003) Early in rehabilitation BRACING EO > TrA, multifidi, IO (Urquhart 2004) Greater spine stiffness than hollowing (Grenier 2007) Incr ability to stabilize against trunk perturbations (Vera-Garcia 2006) More functional

19 Stability of Hip Joint Bones Ligaments Muscles *Neuromuscular Control

20 Stability of the hip joint

21 Stability of Hip Joint LIGAMENTS/CAPSULE

22 Functional Hip Stability Maintaining an appropriate femoral head position within the joint capsule and labral complex (Stewart, 2006)

23 Neuromuscular Control Stability of hip in normal daily activities are provided almost entirely by the action of muscle forces (Stewart 2006) Muscles contribute to 95% of hip joint contact forces during normal walking (Correa 2010)

24 Stability of the hip joint MUSCLES Flexors Extensors Abductors Adductors Internal Rotators External Rotators

25 Hip flexors Iliopsoas Rectus Femoris* Sartorius* Tensor fascia latae Gracillis Adductor longus Adductor brevis Pectineus *Anterior thigh; Femoral N

26 Hip extensors Gluteus maximus Gluteus medius Hamstrings* -Semitendinosus -Semimembranosus -Biceps femoris Posterior thigh; Sciatic Nerve

27 Hip abductors Gluteus maximus Gluteus medius* Gluteus minimus* TFL* Lateral thigh; Superior gluteal N

28 Hip adductors Adductor brevis* Adductor longus* Adductor magnus* Pectineus* Gracillis* Medial thigh; Obturator Nerve

29 Hip external rotators

30 Hip internal rotators

31 Putting it all together functionally Driver of the kinetic chain Proximal stability distal mobility Small contraction = big effect (Cholewicki & McGill 1996) 5% MVC for ADLs 10% MVC for vigorous activity Controlled by neural subsystem Constant feedback Continued refinement of movement Contribution of each muscle changes based on the demand (Zazulak 2007)

32 References Akuthota V & Nadler S. Core strengthening. Archives of Physical Medicine and Rehabilitation. 2004; 85(S1):S86- S92 Barker P, Guggenheimer K, Grkovic I, et al. Effects of tensioning the lumbar fasciae on segmental stiffness during flexion and extension. Spine 2005;31: Cresswell AG, Thorstensson A. Changes in intraabdominal pressure, trunk muscle activation and force during isokinetic lifting and lowering. Eur J Appl Physiol Occup Physiol 1994;68: Crisco JJ, Panjabi M. The intersegmental and multisegmental muscles of the spine: A biomechanical model comparing lateral stabilizing potential. Spine. 1991; 7: Gracovetsky S, Farfan H, Helleur C. The abdominal mechanism. Spine. 1985; 10(4): Grenier SG, McGill SM. Quantification of lumbar stability by using 2 different abdominal activation strategies. Arch Phys Med Rehabil Jan;88(1): Hagins M, Pietrek M, Sheikhzadeh A, Nordin M, Axen K. The effects of breath control on intra-abdominal pressure during lifting tasks. Spine (Phila Pa 1976) Feb 15;29(4): Hides JA, Jull GA, Richardson CA. Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine Jun 1;26(11):E Hodges PW, Richardson CA. Contraction of the abdominal muscles associated with movement of the lower limb. Physical Therapy Feb;77(2):132-42; discussion

33 References, cont. Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis. Spine Nov 15;21(22): Hodges PW, Cresswell AG, Daggfeldt K, et al. Three dimensional preparatory trunk motion precedes asymmetrical upper limb movement. Gait Posture 2000;11: Hodges P, Kaigle Holm A, Holm S, et al. Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm: in vivo porcine studies. Spine 2003;28: Hodges P, Van den Hoorn W, Dawson A, et al. Changes in the mechanical properties of the trunk in low back pain may be associated with recurrence. J Biomech O'Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine Dec 15;22(24): Rho, ME et al. Gender Differences on Ultrasound Imaging of Lateral Abdominal Muscle Thickness in Asymptomatic Adults: A Pilot Study. PMR 2013 Saunders SW, Rath D, Hodges PW. Postural and respiratory activation of the trunk muscles changes with mode and speed of locomotion. Gait Posture 2004;20: Urquhart DM, Hodges PW. Differential activity of regions of transversus abdominis during trunk rotation. Eur Spine J 2005;14: Urquhart DM, Barker PJ, Hodges PW, et al. Regional morphology of the transversus abdominis, obliquus internus and obliquus externus abdominis muscles. Clin Biomech 2005;20: Vera-Garcia FJ, Elvira JL, Brown SH, McGill SM. Effects of abdominal stabilization maneuvers on the control of spine motion and stability against sudden trunk perturbations. J Electromyogr Kinesiol. 2007;17