Sports Medicine: Just the Facts

• Quadratus lumborum
  
  
  1. Fibers cross link the vertebrae.
  
  
  2. From transverse process to rib cage to iliac crests
     can buttress shearing of spine in all planes.
     3.Active during flexion, extension, and lateral
     bending—not just a frontal plane muscle
  
  
  
  


• Diaphragm
  
  
  1. In order to minimize the displacement of the
     abdominal contents within the abdomen and
     pelvis, it is necessary to elevate the intra-abdomi-
     nal pressure by simultaneously contracting the
     diaphragm, the pelvic floor, and the abdominal
     muscles (Cholewicki, Juluru, and McGill, 1999;
     Daggfeldt and Thorstensson, 1997).
     2.Diaphragm increases intra-abdominal pressure,
     segmental unloading of the spine, and increased
     trunk stability as a consequence.
  
  
  
  


• Pelvic floor
  
  
  1. Coactivation of the TrA and pelvic floor muscles
     studies support idea of muscle synergy between TrA,
     abdominals, multifidi, and pelvic floor (Sapsford
     et al, 2001).
     •Lower extremity muscles—gluteus maximus, ham-
     strings
  
  
  2. Hip and pelvic muscles: Base of support for lumbar
     spine and upper limbs
  
  
  3. Thoracolumbar fascia
     a. Covers the deep muscles of the back and trunk
     (including multifidi)
     b.Connects the lower limbs to the upper via the
     latissimus dorsi
     c. Internal obliques, TrA, latissimus dorsi, gluteus
     max
     d. Enhances stiffness of the lumbar spine
  
  
  4. Multifidi blend with superior medial aspect of Gmax
  
  
  5. Multifidi attach to sacrotuberous ligaments and
     mechanically linked to Gmax
  
  
  
  

HOW DO WE STRENGTHEN CORE MUSCLES?

• Principles: Eccentric loading prior to concentric con-
  traction


• Combines stretching


• Strengthening


• Balance: Control center of gravity(COG) as it moves
  through various planes of motion shift the COG
  through various planes.


• Goals of core strengthening exercise:
  
  
  1. Improve multifidus activity and endurance.
  
  
  2. Restore the control of deep abdominal muscles.
  
  
  3. Restore coordination and position sense.
  
  
  4. Restore mobility, especially in rotational and lat-
     eral flexion directions.
     5. Restore normal gluteal muscle activity and lum-
     bopelvic rhythm.
     6. Train motor and postural control and balance.
     7. Make exercises functional.
  
  
  
  

THE PRACTICAL STUFF

•Turn on the light.

1. Abdominal bracing: May require cueing and instruc-
   tion.
   a. Need core stability for global mobility.
   2.Reeducation of stabilization muscles—pelvic
   clocks.
   a. Learn how to turn on pelvic and hip muscles.

• Get the engines going.

1. Abdominal bracing in supine>prone, side lying>
   quadriped


2. Progress to kneeling>sitting>standing

• Make it functional and fun to do

1. Start in pain free ranges


2. Multiple planes of motions
   a. Frontal plane core
   b.Sagittal plane core
   c. Transverse plane core


3. Dynamic challenges—easy to hard


4. Include balance/proprioception


5. Need to make it subconscious

REFERENCES

Aruin AS, Latash ML: Directional specificity of postural muscles

in a feed-forward postural reaction during fast voluntary arm

movements. Exp Brain Res103:323–332, 1995.

Bergmark A: Stability of the lumbar spine: a study in mechanical

engineering. Acta Orthop Scand Suppl230:1–54, 1989.

Bouisset S, Zattara M: Biomechanical study of the programming

and anticipatory postural adjustments associated with volun-

tary movement. J Biomech20:735–742, 1987.

Cholewicki J, Juluru K, McGill SM: Intra-abdominal pressure for

stabilizing the lumbar spine. J Biomech 32:13–17, 1999.

Clark MA, Fater D, Reuteman P: Core (trunk) stabilization and

its importance for closed kinetic chain rehabilitation. Orthop

Phys Ther Clin North Am9:2, 119–132, June 2000.

Cresswell AG, Oddsson L, Thorstensson A: The influence of

sudden perturbations on trunk muscle activity and intraab-

dominal pressure while standing. Exp Brain Res98:336–341,

1994.

Daggfeldt K, Thorstensson A: The role of intra-abdominal pres-

sure in spinal unloading. Spine30:1149–1155, 1997.

Gardner-Morse M, Stokes IAF, Lauble JP: Role of the muscles in

lumbar spine stability in maximum extension efforts. J Orthop

Res13:802–808, 1995.

414 SECTION 5 • PRINCIPLES OF REHABILITATION