Establishing Core Stability in Rehabilitation
Barbara J. Hoogenboom, EdD, PT, SCS, ATC Jolene L. Bennett, MA, PT, OCS, ATC, CertMDT Michael Clark, DPT, MS, PT, PES, CES
After reading this chapter,
the athletic training student should be able to:
- Describe the functional approach to kinetic chain rehabilitation.
- Define the concept of the core.
- Discuss the anatomic relationships between the muscular components of the core.
- Explain how the core functions to maintain postural alignment and dynamic postural equilibrium during functional activities.
- Describe procedures for assessing the core.
- Discuss the rationale for core stabilization training and relate to efficient functional performance of activities.
- Identify appropriate exercises for core stabilization training and their progressions.
- Discuss the guidelines for core stabilization training.
A dynamic, core stabilization training program is routinely incorporated as a component of all comprehensive functional rehabilitation programs.11,23,24,31,34,59 For athletes at all levels, core strengthening and stability exercises have become key components of training and conditioning programs.14 A core stabilization program improves dynamic postural control, ensures appropriate muscular balance, and affects joint arthrokinematics around the lumbo-pelvic-hip complex. A carefully crafted core stabilization program allows for the expression of dynamic functional strength and improves neuromuscular efficiency throughout the entire kinetic chain.1,12,17,31,32,34,55,65,68–70,94,95 A core stabilization program can enhance functional movement patterns and dynamic postural control.6
WHAT IS THE CORE?
The core is defined as the lumbo-pelvichip complex.1,31 The core is where our center of gravity is located and where all movement begins.36,37,83,84 There are 29 muscles that have an attachment to the lumbo-pelvichip complex.8,9,31,85 An efficient core allows for maintenance of the normal length-tension relationship of functional agonists and antagonists, which allows for the maintenance of the normal force-couple relationships in the lumbo-pelvic-hip complex. Maintaining the normal length-tension relationships and force-couple relationships allows for the maintenance of optimal arthrokinematics in the lumbo-pelvic-hip complex during functional kinetic-chain movements.94,95,103 This provides optimal neuromuscular efficiency in the entire kinetic chain, allowing for optimal acceleration, deceleration, and dynamic stabilization of the entire kinetic chain during functional movements. It also provides proximal stability for efficient lower and upper extremity movements.1,31,36,37,46,59,83,84,94,95
The core operates as an integrated functional unit, whereby the entire kinetic chain works synergistically to produce force, reduce force, and dynamically stabilize against abnormal force.1 In an efficient state, each structural component distributes weight, absorbs force, and transfers ground reaction forces.1 This integrated, interdependent system needs to be trained appropriately to allow it to function efficiently during dynamic kinetic chain activities.
Core stabilization exercise programs have been labeled many different terms, some of which include dynamic lumbar stabilization, neutral spine control, muscular fusion, and lumbo-pelvic stabilization. We use the phrase butt and gut to educate our patients, colleagues, and health care students. This catchy phrase illustrates the importance of the entire abdominal and pelvic region working together to provide functional stability and efficient movement.
CORE STABILIZATION TRAINING CONCEPTS
Many individuals develop the functional strength, power, neuromuscular control, and muscular endurance in specific muscles that enable them to perform functional activities.1,31,49,59 However, few people develop the muscles required for spinal stabilization.46,49,50 The body’s stabilization system has to be functioning optimally to effectively use the strength, power, neuromuscular control, and muscular endurance developed in the prime movers. If the extremity muscles are strong and the core is weak, then there will not be enough trunk stabilization created to produce efficient upper and lower extremity movements. It has been suggested that a weak core is a fundamental problem of many inefficient movements that leads to injury.46,49,50,59 While deficits in various aspects of core stability have been identified as potential risk factors for lower extremity injuries,30 exercising the trunk muscles is supposed to prevent injuries via protection of the spinal column.105 However, while it is generally accepted that having good core strength improves athletic performance, a correlation between trunk muscle strength and performance has not been clearly identified in the research literature.53,80,86,97
The core musculature is an integral component of the protective mechanism that relieves the spine of deleterious forces inherent during functional activities.15,105 A core stabilization training program is designed to help an individual gain strength, neuromuscular control, power, and muscle endurance of the lumbo-pelvic-hip complex. However, the focus of a core stabilization program should not be primarily on strength, but instead on stability, balance, and proprioception.25 This approach facilitates a balanced muscular functioning of the entire kinetic chain.1 Greater neuromuscular control and stabilization strength will offer a more biomechanically efficient position for the entire kinetic chain, thereby allowing optimal neuromuscular efficiency throughout the kinetic chain. It has been shown that core stability exercise was more effective than general exercise for decreasing pain and increasing back-specific functional status in patients with low back pain.26
Neuromuscular efficiency is established by the appropriate combination of postural alignment (static/dynamic) and stability strength, which allows the body to decelerate gravity, ground reaction forces, and momentum at the right joint, in the right plane, and at the right time.13,34,58 If the neuromuscular system is not efficient, it will be unable to respond to the demands placed on it during functional activities.1 As the efficiency of the neuromuscular system decreases, the ability of the kinetic chain to maintain appropriate forces and dynamic stabilization decreases significantly. This decreased neuromuscular efficiency leads to compensation and substitution patterns, as well as poor posture during functional activities.32,94,95 Such poor posture leads to increased mechanical stress on the contractile and noncontractile tissue, leading to repetitive microtrauma, abnormal biomechanics, and injury.17,32,66,67
Clinical Decision-Making Exercise 5-1
A gymnast has been experiencing low back pain. She is otherwise a very fit and healthy athlete. You suspect that her pain might be disc related. How might core weakness be contributing to her problem, and how can core strengthening benefit her?
REVIEW OF FUNCTIONAL ANATOMY
To fully understand functional core stabilization training and rehabilitation, the athletic trainer must fully understand functional anatomy, lumbo-pelvic-hip complex stabilization mechanisms, and normal force-couple relationships.4,8,9,85
A review of the key lumbo-pelvic-hip complex musculature will allow the athletic trainer to understand functional anatomy and thereby develop a comprehensive kinetic chain rehabilitation program. The key lumbar spine muscles include the transversospinalis group, erector spinae, quadratus lumborum, and latissimus dorsi (Figure 5-1B). The key abdominal muscles include the rectus abdominis, external oblique, internal oblique, and transversus abdominis (TA; Figure 5-1A). The key hip musculature includes the gluteus maximus, gluteus medius, and psoas (Figure 5-1B).
Transversospinalis Muscle Group
The transversospinalis group includes the rotatores, interspinales, intertransversarii, semispinalis, and multifidus. These muscles are small and have a poor mechanical advantage for contributing to motion.29,85 They contain primarily type I muscle fibers and are therefore designed mainly for stabilization.29,85 Researchers85 have found that the transversospinalis muscle group contains 2 to 6 times the number of muscle spindles found in larger muscles. Therefore, it has been established that this group is primarily responsible for providing the central nervous system with proprioceptive information.85 This group is also responsible for inter- or intrasegmental stabilization and segmental eccentric deceleration of flexion and rotation of the spinal unit during functional movements.4,85 The transversospinalis group is constantly put under a variety of compressive and tensile forces during functional movements; consequently, it needs to be trained adequately to allow dynamic postural stabilization and optimal neuromuscular efficiency of the entire kinetic chain.85 The multifidus is the most important of the transversospinalis muscles. It has the ability to provide intrasegmental stabilization to the lumbar spine in all positions.29,104 Wilke and Wolf104 found increased segmental stiffness at L4-L5 with activation of the multifidus. Additional key back muscles include the erector spinae, quadratus lumborum, and latissimus dorsi. The erector spinae muscle group functions to provide dynamic intersegmental stabilization and eccentric deceleration of trunk flexion and rotation during kinetic chain activities.85 The quadratus lumborum muscle functions primarily as a frontal plane stabilizer that works synergistically with the gluteus medius and tensor fascia lata. The latissimus dorsi has the largest moment arm of all back muscles and, therefore, has the greatest effect on the lumbo-pelvic-hip complex. The latissimus dorsi is the bridge between the upper extremity and lumbo-pelvichip complex. Any functional upper extremity kinetic chain rehabilitation must pay particular attention to the latissimus and its function on the lumbo-pelvic-hip complex.85
The abdominals are composed of 4 muscles: rectus abdominis, external oblique, internal oblique, and, most importantly, the TA.85 The abdominals operate as an integrated functional unit, which helps maintain optimal spinal kinematics.4,8,9,85 When working efficiently, the abdominals offer sagittal, frontal, and transversus plane stabilization by controlling forces that reach the lumbo-pelvic-hip complex.85 The rectus abdominis eccentrically decelerates trunk extension and lateral flexion, as well as providing dynamic stabilization during functional movements. The external obliques work concentrically to produce contralateral rotation and ipsilateral lateral flexion, and they work eccentrically to decelerate trunk extension, rotation, and lateral flexion during functional movements.85 The internal oblique works concentrically to produce ipsilateral rotation and lateral flexion and works eccentrically to decelerate extension, rotation, and lateral flexion. The internal oblique attaches to the posterior layer of the thoracolumbar fascia. Contraction of the internal oblique creates a lateral tension force on the thoracolumbar fascia, which creates intrinsic translational and rotational stabilization of the spinal unit.37,46 The TA is probably the most important of the abdominal muscles. The TA functions to increase intraabdominal pressure (IAP), provide dynamic stabilization against rotational and translational stress in the lumbar spine, and provide optimal neuromuscular efficiency to the entire lumbo-pelvic-hip complex.46,49–51,62 Research demonstrates that the TA works in a feed-forward mechanism.46 Researchers have demonstrated that contraction of the TA precedes the initiation of limb movement and all other abdominal muscles, regardless of the direction of reactive forces.28,46 Cresswell et al27,28 demonstrated that, like the multifidus, the TA is active during all trunk movements, suggesting that this muscle has an important role in dynamic stabilization.49
Key hip muscles include the psoas, gluteus medius, gluteus maximus, and hamstrings.8,9,85 The psoas produces hip flexion and external rotation in the open chain position, and produces hip flexion, lumbar extension, lateral flexion, and rotation in the closed chain position. The psoas eccentrically decelerates hip extension and internal rotation, as well as trunk extension, lateral flexion, and rotation. The psoas works synergistically with the superficial erector spinae and creates an anterior shear force at L4-L5.85 The deep erector spinae, multifidus, and deep abdominal wall (transverses, internal oblique, and external oblique)80 counteract this force. It is extremely common for patients to develop tightness in their psoas. A tight psoas increases the anterior shear force and compressive force at the L4-L5 junction.85 A tight psoas also causes reciprocal inhibition of the gluteus maximus, multifidus, deep erector spinae, internal oblique, and TA. This leads to extensor mechanism dysfunction during functional movement patterns.55,65,67,69,70,85,95 Lack of lumbo-pelvic-hip complex stabilization prevents appropriate movement sequencing and leads to synergistic dominance by the hamstrings and superficial erector spinae during hip extension. This complex movement dysfunction also decreases the ability of the gluteus maximus to decelerate femoral internal rotation during heel strike, which predisposes an individual with a knee ligament injury to abnormal forces and repetitive microtrauma.15,20,55,69,70
The gluteus medius functions as the primary frontal plane stabilizer of the pelvis and lower extremity during functional movements.85 During closed chain movements, the gluteus medius decelerates femoral adduction and internal rotation.85 A weak gluteus medius increases frontal and transversus plane stress at the patellofemoral and tibiofemoral joints.85 A weak gluteus medius leads to synergistic dominance of the tensor fasciae latae and quadratus lumborum.20,55,57 This leads to tightness in the iliotibial band and lumbar spine. This will affect the normal biomechanics of the lumbo-pelvic-hip complex and tibiofemoral joint, as well as the patellofemoral joint. Research by Beckman and Buchanan10 demonstrates decreased electromyogram (EMG) activity of the gluteus medius following an ankle sprain. Therapists must address the altered hip muscle recruitment patterns or accept this recruitment pattern as an injury-adaptive strategy and, thus, accept the unknown long-term consequences of premature muscle activation and synergistic dominance.10,32
The gluteus maximus functions concentrically in the open chain to accelerate hip extension and external rotation. It functions eccentrically to decelerate hip flexion and femoral internal rotation.85 It also functions through the iliotibial band to decelerate tibial internal rotation.85 The gluteus maximus is a major dynamic stabilizer of the sacroiliac (SI) joint. It has the greatest capacity to provide compressive forces at the SI joint secondary to its anatomic attachment at the sacrotuberous ligament.85 It has been demonstrated by Bullock-Saxton16,17 that the EMG activity of the gluteus maximus is decreased following an ankle sprain. Lack of proper gluteus maximus activity during functional activities leads to pelvic instability and decreased neuromuscular control. This can eventually lead to the development of muscle imbalances, poor movement patterns, and injury.
The hamstrings work concentrically to flex the knee, extend the hip, and rotate the tibia. They work eccentrically to decelerate knee extension, hip flexion, and tibial rotation. The hamstrings work synergistically with the anterior cruciate ligament.85 All of the muscles mentioned play an integral role in the kinetic chain by providing dynamic stabilization and optimal neuromuscular control of the entire lumbo-pelvic-hip complex. These muscles have been reviewed so that the athletic trainer realizes that muscles not only produce force (concentric contractions) in one plane of motion, but also reduce force (eccentric contractions) and provide dynamic stabilization in all planes of movement during functional activities. When isolated, these muscles do not effectively achieve stabilization of the lumbo-pelvic-hip complex. It is the synergistic, interdependent functioning of the entire lumbo-pelvic-hip complex that enhances stability and neuromuscular control throughout the entire kinetic chain.
TRANSVERSUS ABDOMINIS AND MULTIFIDUS ROLE IN CORE STABILIZATION
The TA muscle is the deepest of the abdominal muscles and plays a role in trunk stability. The horizontal orientation of its fibers has a limited ability to produce torque to the spine necessary for flexion or extension movement, although it has been shown to be an active trunk rotator.87 The TA is a primary trunk stabilizer via modulation of IAP, tension through the thoracolumbar fascia, and compression of the SI joints.27,98 For many decades, IAP was believed to be an important contributor to spinal control by the pressure within the abdominal cavity putting force on the diaphragm superiorly and pelvic floor inferiorly to extend the trunk.7,38,77 It was hypothesized that IAP would provide an extensor moment and, thus, reduce the muscular force required by the trunk extensors and decrease the compressive load on the lumbar spine.102 Research by Hodges et al45 applied electrical stimulation to the phrenic nerve of humans to produce an involuntary increase in IAP without abdominal or extensor muscle activity. IAP was increased by the contraction of the diaphragm, pelvic floor muscles, and TA with no flexor moment noted. Research has demonstrated that IAP may directly increase spinal stiffness.48 Hodges et al45 used a tetanic contraction of the diaphragm to produce IAP, which resulted in increased stiffness in the spine. Bilateral contraction of the TA assists in IAP, thus enhancing spinal stiffness.
The role of the thoracolumbar fascia in trunk stability has also been discussed in the literature, and it has been theorized that the contraction of the TA could produce an extensor torque via the horizontal pull of the TA via its extensive attachment into the thoracolumbar fascia.37 This theory was tested by Tesh and Shaw-Dunn100 by placing tension on the thoracolumbar fascia of cadavers. No approximation of the spinous processes or trunk extension movement was noted, although a small amount of compression on the spine was noted. This small amount of compression may play a role in the control of intervertebral shear forces. Hodges et al45 electrically stimulated contraction of the TA in pigs and demonstrated that, when tension was developed in the thoracolumbar fascia, without an associated increase in IAP, there was no significant effect on the intervertebral stiffness. In the next step of that same research study, the thoracolumbar fascial attachments were cut, and an increase in IAP decreased the spinal stiffness. This demonstrates that the thoracolumbar fascia and IAP work in concert to enhance trunk stability.45
Trunk stability is also dependent on the joints caudal to the lumbar spine. The SI joint is the connection between the lumbar spine and the pelvic region, which ultimately connects the trunk to the lower extremities. The SI joint is dependent on the compressive force between the sacrum and ilia. The horizontal direction and anterior attachment on the ilium of the TA produces the compressive force necessary for spinal stability. Richardson and Snijders90 used ultrasound to detect movement of the sacrum and ilium while having subjects voluntarily contract their transverse abdominals. They demonstrated that a voluntary contraction of the TA reduced the laxity of the SI joint. This study also pointed out that this reduction in joint laxity of the SI joint was greater than that during a bracing contraction. The researchers did note that they were unable to exclude changes in activity in other muscles such as the pelvic floor, which may have reduced the laxity via counternutation of the sacrum.90 The aforementioned research findings illustrate that the TA plays an important role in maintaining trunk stability by interacting with IAP, thoracolumbar fascia tension, and compressing the SI joints via muscular attachments.
The multifidi are the most medial of the posterior trunk muscles, and they cover the lumbar zygapophyseal joints, except for the ventral surfaces.87 The multifidi are primary stabilizers when the trunk is moving from flexion to extension. The multifidi contribute only 20% of the total lumbar extensor moment, whereas the lumbar erector spinae contribute 30%, and the thoracic erector spinae function as the predominant torque generator at 50% of the extension moment arm.60 The multifidus, lumbar, and thoracic erector spinae muscles have a high percentage of type I fibers and are postural control muscles similar to the TA.60 The multifidus has been shown to be active during all antigravity activities, including static tasks such as standing and dynamic tasks such as walking.104
Clinical observation and experimental evidence confirm that when the TA contracts, the multifidi are also activated.87 A girdle-like cylinder of muscular support is produced as a result of the coactivation of the TA, multifidus, and thick thoracolumbar fascial system. EMG evidence suggests that the TA and internal obliques contract in anticipation of movement of the upper and lower extremities, often referred to as the feed-forward mechanism. This feed-forward mechanism gives the TA and multifidus muscular girdle a unique ability to stabilize the spine regardless of the direction of limb movements.47,48 As noted previously, the pelvic floor muscles play an important role in the development of IAP and, thus, enhance trunk stability. It has also been demonstrated that the pelvic floor is active during repetitive arm movement tasks independent of the direction of movement.52
Sapsford and Hodges96 discovered that maximal contraction of the pelvic floor was associated with activity of all abdominal muscles, and submaximal contraction of the pelvic floor muscles was associated with a more isolated contraction of the TA. In this same study, it also was determined that the specificity of the response was better when the lumbar spine and pelvis were in a neutral position.96 Clinically, this information is helpful in guiding the patient in the process of TA contraction by instructing the patient to perform a submaximal pelvic floor isometric hold. Another interesting fact to note is that men and women with incontinence have almost double the incidence of low back pain as people without incontinence issues.33 In summary, the lumbo-pelvic region may be visualized as a cylinder with the inferior wall being the pelvic floor, the superior wall being the diaphragm, the posterior wall being the multifidus, and the TA muscles forming the anterior and lateral walls. All walls of the cylinder must be activated and taut for optimal trunk stabilization to occur with all static and dynamic activities.
Clinical Decision-Making Exercise 5-2
Last year, a tennis player suffered a knee injury. She tore her anterior cruciate ligament, medial collateral ligament, and meniscus. She is competing now, but complains of recurrent back pain. She has rather poor posture and significant postural sway. Could she benefit from core training, and how would you go about selecting exercises for her?
The core functions to maintain postural alignment and dynamic postural equilibrium during functional activities. Optimal alignment of each body part is a cornerstone to a functional training and rehabilitation program. Optimal posture and alignment will allow for maximal neuromuscular efficiency because the normal length-tension relationship, force-couple relationship, and arthrokinematics will be maintained during functional movement patterns.15,31,32,54,55,57,62,66,69,94,95 If one segment in the kinetic chain is out of alignment, it will create predictable patterns of dysfunction throughout the entire kinetic chain. These predictable patterns of dysfunction are referred to as serial distortion patterns.31 Serial distortion patterns represent the state in which the body’s structural integrity is compromised because segments in the kinetic chain are out of alignment. This leads to abnormal distorting forces being placed on the segments in the kinetic chain that are above and below the dysfunctional segment.15,31,32,59 To avoid serial distortion patterns and the chain reaction that one misaligned segment creates, we must emphasize stable positions to maintain the structural integrity of the entire kinetic chain.17,31,59,69,70,93 A comprehensive core stabilization program prevents the development of serial distortion patterns and provides optimal dynamic postural control during functional movements.
An optimally functioning core helps to prevent the development of muscle imbalances and synergistic dominance. The human movement system is a well-orchestrated system of interrelated and interdependent components.17,66 The functional interaction of each component in the human movement system allows for optimal neuromuscular efficiency. Alterations in joint arthrokinematics, muscular balance, and neuromuscular control affect the optimal functioning of the entire kinetic chain.17,94,95 Dysfunction of the kinetic chain is rarely an isolated event. Typically, a pathology of the kinetic chain is part of a chain reaction involving some key links in the kinetic chain and numerous compensations and adaptations that develop.66 The interplay of many muscles about a joint is responsible for the coordinated control of movement. If the core is weak, normal arthrokinematics are altered. Changes in normal length-tension and force-couple relationships, in turn, affect neuromuscular control. If one muscle becomes weak, becomes tight, or changes its degree of activation, then synergists, stabilizers, and neutralizers have to compensate.17,32,66,68,70,94,95
Muscle tightness has a significant impact on the kinetic chain. Muscle tightness affects the normal length-tension relationship.95 This impacts the normal force-couple relationship. When one muscle in a force-couple relationship becomes tight, it changes the normal arthrokinematics of 2 articular partners.14,61,89 Altered arthrokinematics affect the synergistic function of the kinetic chain.17,32,66,95 This leads to abnormal pressure distribution over articular surfaces and soft tissues. Muscle tightness also leads to reciprocal inhibition.17,32,54,57,66,99,103 Therefore, if one develops muscle imbalances throughout the lumbo-pelvic-hip complex, it can affect the entire kinetic chain. For example, a tight psoas causes reciprocal inhibition of the gluteus maximus, TA, internal oblique, and multifidus.50,55,57,81,85 This muscle imbalance pattern may decrease normal lumbo-pelvic-hip stability. Specific substitution patterns develop to compensate for the lack of stabilization, including tightness in the iliotibial band.32 This muscle imbalance pattern leads to increased frontal and transverse plane stress at the knee. Dr. Vladamir Janda proposed a syndrome, named the crossed pelvis syndrome, in which a weak abdominal wall and weak gluteals are counterbalanced with tight hamstrings and hip flexors.55
A strong core with optimal neuromuscular efficiency can help to prevent the development of muscle imbalances. Consequently, a comprehensive core stabilization training program should be an integral component of all rehabilitation programs. A strong, efficient core provides the stable base upon which the extremities can function with maximal precision and effectiveness. It is important to remember that the spine, pelvis, and hips must be in proper alignment with proper activation of all muscles during any core-strengthening exercise. Because no one muscle works in isolation, attention should be paid to the position and activity of all muscles during open and closed chain exercises.
A strong and stable core can optimize neuromuscular efficiency throughout the entire kinetic chain by helping to improve dynamic postural control.40,46,50,61,89,94,95 A number of researchers have demonstrated kinetic chain imbalances in individuals with altered neuromuscular control.10,15–17,46,49–51,54–58,65–70,81,82,89,94 Research demonstrates that people with low back pain have an abnormal neuromotor response of the trunk stabilizers accompanying limb movement, significantly greater postural sway, and decreased limits of stability.49,50,75,82 Research also demonstrates that about 70% of patients suffer from recurrent episodes of back pain. Furthermore, it has been demonstrated that individuals have decreased dynamic postural stability in the proximal stabilizers of the lumbo-pelvic-hip complex following lower extremity ligamentous injuries,10,15–17 and that joint and ligamentous injury can lead to decreased muscle activity.32,99,103 Joint and ligament injury can lead to joint effusion, which, in turn, leads to muscle inhibition. This leads to altered neuromuscular control in other segments of the kinetic chain secondary to altered proprioception and kinesthesia.10,17 Therefore, when an individual with a knee ligament injury has joint effusion, all of the muscles that cross the knee can be inhibited. Several muscles that cross the knee joint are attached to the lumbo-pelvichip complex.85 Consequently, a comprehensive rehabilitation approach should focus on reestablishing optimal core function so as to positively affect peripheral joints.
Research also demonstrates that muscles can be inhibited from an arthrokinetic reflex.15,66,99,103 This is referred to as arthrogenic muscle inhibition. Arthrokinetic reflexes are mediated by joint receptor activity. If an individual has abnormal arthrokinematics, the muscles that move the joint will be inhibited. For example, if an individual has a sacral torsion, the multifidus and gluteus medius can be inhibited.44 This leads to abnormal movement in the kinetic chain. The tensor fasciae latae become synergistically dominant and the primary frontal plane stabilizer.85 This can lead to tightness in the iliotibial band. It can also decrease the frontal and transverse plane control at the knee. Furthermore, if the multifidus is inhibited,44 the erector spinae and psoas become facilitated. This further inhibits the lower abdominals (internal oblique and TA) and the gluteus maximus.46,49 This also decreases frontal and transverse plane stability at the knee. As previously mentioned, an efficient core improves neuromuscular efficiency of the entire kinetic chain by providing dynamic stabilization of the lumbo-pelvic-hip complex and improving pelvifemoral biomechanics. This is yet another reason why all rehabilitation programs should include a comprehensive core stabilization training program.
Clinical Decision-Making Exercise 5-3
As part of a preparticipation screening, you want to look for athletes who may be prone to low back pain. What evaluative test can you use to do this?