The Core If you were to ask which muscle group you could focus on to provide your patients with the greatest benefits in the shortest amount of time, it would be the core. What is the core? The core consists of all the muscles in the abdominal and lower back areas. This includes the abdominal muscles: rectus abdominus, internal and external obliques; the transverse abdominus and the intercostals. It also includes the muscles associated with the spine: the erector spinae group and the hip flexors (iliacus and psoas, collectively known as the iliopsoas). The basis of core training is to increase the recruitment efficiency of the smaller, deeper stabilizing muscles around the hip and pelvis. The aim of core training is to recruit the trunk musculature and then learn to control the position of the lumbar spine during dynamic movements. Why Is the Core So Important? Weak core muscles contribute to all kinds of problems in the body, the most prevalent of which is lower back pain. Strengthening the muscles that help support the spine and improve posture dramatically decreases the symptoms of lower back pain. Picture the spine as a column of cans stacked one on top of the other. If you wanted to keep that column standing up under stress, what do you think would work better: a "tenser" bandage, as is used for wrapping injured ankles, or Scotch tape? The tape would keep the cans together, but the cans wouldn't receive a whole lot of support, would they? When you strengthen the muscles of the core, you are, in effect, turning that Scotch tape into a nice, tight "tenser" bandage, increasing the amount of support that the spine receives. Four Mechanisms of Active Support The lumbar spine area is inherently unstable and relies upon support from four mechanisms that actively support the area for sufficient stability. These four mechanisms include tension from the thoracolumbar fascia; the intra-abdominal pressure mechanism; the paraspinal muscles; and the deep lumbar extensors. The thoracolumbar fascia provides a tensile support to the lumbar spine via deep-trunk muscle activity. The intra-abdominal pressure mechanism can provide a supportive effect to the whole lumbar area. The paraspinal and deep lumbar muscles act with a static contraction to resist lumbar extension and rotational forces. The deep-trunk muscles, transversus abdominus, multifidus, internal oblique, paraspinal, and pelvic floor are key to the active support of the lumbar spine. It is not just the recruitment of these deep-trunk muscles, but how they are recruited that is important. The co-contraction of the transversus abdominus and multifidus muscles occurs prior to any movement of the limbs. These muscles anticipate dynamic forces, which may act on the lumbar spine and stabilize the area prior to any movement. The timing of coordination of these muscles is very significant. Back injury patients are unable to recruit their transversus abdominus and multifidus muscles early enough to stabilize the spine prior to movement. The onset of the contraction before any force can act on the lumbar spine is essential for these muscles to act as stabilizers. Specificity of Training Having identified the key muscles and how they act, the next step is to establish how best to train these muscles. As with any type of strength and conditioning training, the training protocol for improving the function of the deep-trunk muscles must be specific to the task required. The deep-trunk muscles act as stabilizers and are not involved in producing movement but, instead, involve static, or isometric, contractions. They must act as stabilizers continuously throughout everyday activities as well as fitness training, and require very good endurance of low-level forces. The deep-trunk muscles do not need to be very strong, but they must be correctly coordinated and capable of working continuously. These stabilizer muscles must hold the lumbar spine in the neutral position, which is the correct alignment of the pelvis that allows for the natural S-curve of the spine. Warm-ups Begin core training with a three- to four-minute cardiovascular warm-up, such as walking on a treadmill. "Scouring the Joints" is an excellent warm-up that stimulates nutrition in the joint capsule. This warm-up is performed with the patient in the standing position. Instruct the patient to actively rotate his or her pelvis clockwise three times and then counter-clockwise three times. The patient should feel a "scouring" sensation in the acetabulae. Follow this lower body warm-up with a warm-up of the shoulder joints. Instruct the patient to lower the shoulder blade on one side and then to move the humeral head through the hours of the clock three times in one direction, then three times in the opposite direction and, finally, to repeat the warm-up with the opposite shoulder. The Basics: Co-contraction Core-stability training begins with learning to co-contract the transversus abdominus and multifidus muscles effectively as the key to the lumbar-support mechanism. To perform this co-contraction requires mastering the abdominal hollowing technique with the spine in the neutral position. Begin by instructing the patient to lie on his or her back with knees bent. The lumbar spine should be neither arched up nor flattened against the floor, but aligned normally with a small gap between the floor and the back. This is the neutral lumbar position the patient must learn to achieve. Instruct the patient to breathe in deeply and to relax all the stomach muscles. Ask the patient to breathe out and, as he or she does, to draw the lower abdomen inward, as if the belly button were going back toward the floor. Pilates teachers describe this movement as "zipping up," as if you were fastening up a tight pair of jeans. Instruct the patient to hold the contraction for ten seconds, while breathing in and out and holding the tension in the lower stomach area. This exercise should be repeated five to ten times. Important Coaching Points It is vital for patients to master the performance of the abdominal hollowing exercise correctly, otherwise they will not learn to recruit their transversus abdominus and multifidus effectively. Don't allow patients to let the whole stomach tense up or upper abdominals bulge outward, as this means they are using the large rectus abdominus muscle instead of transversus abdominus. Coach patients not to brace their transversus abdo-minus muscles too much. A gentle contraction is enough. Be sure that patients do not tilt the pelvis or flatten the back while performing abdominal hollowing, as this means they have lost the neutral position they are learning to stabilize. Patients should breathe normally while maintaining the co-contrac- tion of transversus abdominus and multifidus. Breath holding means the patient is not relaxed. Once a patient has mastered abdominal hollowing while lying in the supine position, it's time to practice it while lying prone, in a four-point kneeling position, sitting and standing. Be sure that the patient resumes a neutral lumbar spine position in each posture before performing the hollowing movement. Functional Stability Once a patient has learned to recruit the transversus abdominus and multifidus muscles correctly in various positions, it is time to increase the challenge. Core stability is not defined by the ability to recruit deep stabilizing muscles in isolation. Instead, it is defined by the ability of the core muscles to work in an efficient and coordinated fashion to maintain correct alignment of the spine and pelvis while the limbs are moving. It is important that, once patients have achieved proficiency of the simple abdominal hollowing exercises, they progress to achieving stability during more functional movements. You can achieve this by adding limb movements, such as leg raises, while the patient performs abdominal hollowing in the lying, kneeling, sitting and standing positions. Use your imagination to think of ways to improve your patients' dynamic sta- bility. The approach only works, however, if the patient focuses 100% on posture and alignment. The aim is always to develop the correct and efficient core muscle recruitment patterns. Dr. Mark Sauna is the CEO of Breakthrough Coaching. For more information on core training or to attend a Core Workout Training Seminar, contact Breakthrough Coaching at 1-800-723-8423 or visit www.mvbreakthroush.com.
