The Importance of Developing a

Primary Core Stability Protocol

Angela M. Homan, SPT
Duke University
Doctor of Physical Therapy Intern
SportsMedicine of Atlanta

Dr Robert E DuVall
PT, DHSc, MMSc, ATC, OCS, SCS, FAAOMPT, DAC, MTC, PCC, CSCS

Shenandoah University, Associate Professor

Alabama State and Northeastern University, Clinical Assistant Professor
SportsMedicine of Atlanta, Inc.
Residency & APTA Fellowship Curricula Director
reduvall@bellsouth.net www.SportsMedicineofAtlanta.com
SportsMedicine of Atlanta, Inc.

NMR Research Shown Beneficial

to Reduce Pain and Disability

"In America alone, the treatment cost of back pain is

estimated to be $86 billion per year or 9% of the country's
total health expenditure. The search for new ways to
manage this old problem is critical in order to improve the
health and quality of life of individuals who struggle with
this condition.
According to researchers not only do patients feel less pain,
but patients performing these types of exercises are able to
be more physically active and experience positive effects
over a longer period of time than those who receive other
treatments.

Macedo, Luciana G. Maher, Christopher G. Latimer, Jane. McAuley, James H. Motor Control Exercise for
Persistent, Nonspecific Low Back Pain: A Systematic Review. PTJ 2009;89(1).9-95.

Primary Core
Transverse Abdominis (TrA)

Multifidus

Transverse Abdominis Anatomy

Origin: inner surface of cartilages of lower 6
ribs, interdigitation with diaphragm,
thoracolumbar fascia, anterior of internal lip
of iliac crest, and lateral 1/3 of inguinal ligament
Insertion: linea alba (broad aponeurosis), pubic
crest, and pecten pubis
Nerve Innervation: T7-T12, L1
(iliohypogastric and ilioinguinal)

Kendall et al.

Actions of TrA

Flattens abdominal wall and compress the

abdominal viscera
Decrease infrasternal angle of ribs in expiration
(upper portion of TrA)
No Action in lateral trunk flexion, except to
compress the viscera and to stabilize linea alba
(= better action of anterolateral trunk muscles)

Kendall et. al.

Weakness in TrA (observations)

Standing position: Permits bulging of

anterior abdominal wall (= increases
lordosis)
Supine position: during flexion a lateral
bulge tends to occur
Prone position: hyperextension of
trunk with lateral bulge tends to occur

Kendall et al.

Multifidus Anatomy

Origin: Sacral region: posterior surface of sacrum,

medial surface of posterior iliac spine & posterosacroiliac ligaments. Lumbar, thoracic, & cervical
regions: transverse processes of L5-C4
Insertion: Spanning two to four vertebrae,
inserting onto spinous process of one of
vertebra above from last lumbar to axis (second
cervical vertebra
Nerve Innervation: Spinal

Kendall et al.

Actions of Multifidis

Extends vertebral column and rotation toward

opposite side.

Kendall et al.

Functions of TrA & Deep Multifidus

Deep Multifidus and TrA provide intersegmental

spinal stability
Deep fibers of Multifidus control intervertebral
motion
Superficial fibers of Multifidus control spine
orientation

Moseley GL, Hodges PW, Gandevia SC. Deep and superficial fibers of the lumbar multifidus muscle are differentially active during voluntary arm movements. Spine.
2002;27:E29E36.

TrA Muscle Activation Patterns

TrA may be controlled independently of the motor

command for limb movement in contrast to the other
abdominal muscles.

Feedforward TrA activation pattern with Lower

extremity movement

Hodges P, Richardson C. Contraction of the abdominal muscles associated with movement of the lower limb. Physical Therapy. 1997;77:132-144.

Feedforward activation TrA activation pattern with

upper extremity movement

Hodges PW, Richardson CA. Transversus abdominis and the superficial abdominal muscles are controlled independently in a postural task.
Neuroscience Letters. 1999;265:91-94.

Hodges P, Richardson C. Feedforward contraction of transversus abdominis is not influencedby the direction of arm movement. Experimental Brain
Research. 1997;114:362-370.

Preparatory trunk movement precedes upper extremity

movement

Hodges P, Cresswell AG, Daggfeldt K, Thorstensson A. Preparatory trunk motionaccompanies rapid upper limb
movement. Experimental Brain Research. 1999;124:69-79
Hodges P, Cresswell AG, Daggfeldt K, Thorstensson A. Three dimensional preparatory trunk motion precedes
asymmetrical upper limb movement. Gait and Posture. 2000;11:92-101.

Core Dysfunction: Anatomy

Transverse Abdominis:
Isometric Knee extension/flexion
tasks identified subjects with LBP had
smaller increase in TrA thickness and
less EMG activity
Ferreira PH, Ferreira, Hodges PW. Changes in recruitment of the abdominal muscles in people with low back pain
ultrasound measurement of muscle activity. Spine. 2004;29:2560-2566.

Core Dysfunction: Anatomy

Multifidus:
Atrophy of multifidus has been used as a rationale for
spine stabilizing exercises.
Barker et al, found selective ipsilateral atrophy of
multifidus in patients with unilateral LBP (low back
pain)
MRI analysis of the CSA of Multifidus

At level of pain: 21.7 % decrease

Above level of pain: 15.8% decrease
Below level of pain: 16.8% decrease
Decreased CSA at level of pain was positively correlating with
duration of pain.

Barker KL, Shamley DR, Jackson D. Changes in the cross-sectional area of multifidus and psoas in patients with unilateral back
pain. The relationship to pain and disability. Spine. 2004;29:E515-E519.

Core Dysfunction: Activation

Patterns

Subjects with chronic LBP do not pre-activate

TrA prior to rapid upper and lower limb tasks.

Barr KP, Griggs M, Cadby T: Lumbar stabilization: Core concepts and current literature, part 1. Am J Phys Med Rehabil. 2005;84:473-480.
Hodges P, Richardson C. Inefficient muscular stabilisation of the lumbar spine associated with low back pain: a motor control
evaluation of transversus abdominus. Spine. 1996;21:2640-2650.

Onset of internal obliques, multifidus, &

gluteus maximus was delayed on the
symptomatic side (>20ms)= no feed-forward
activation in subjects with sacroiliac joint pain

Hungerford B, Gilleard W, Hodges P, Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine.
2003;28:1593-1600.

TrA Muscle Activation

Three different techniques used in clinical

practice:
Drawing-in Maneuver
Abdominal Bracing
Posterior Pelvic Tilt

Drawing-in Maneuver is more selective in

coactivating the TrA and multifidus than the
other 2 techniques.
Hodges, PW, Richardson, GA, and Jull, G: Evaluation of the relationship between laboratory and clinical tests of transversus abdominis function. Physiother
Re Internat 1(1):30, 1996.
Richardson, C, Jull, G, et al: Techniques for activae lumbar stabilisation for spinal protection: A pilot study. Austral J Physiother 38:105, 1992.

Drawing-In Manuever

Recommended for stabilization training

Functions to intra-abdominal pressure by
inwardly displacing the abdominal wall.
Increases CSA (cross sectional area) of TrA on
MRI (TrA contracts bilaterally to form a
musculofascial band that appears to tighten like
a corset and most likely improves stability of
lumbopelvic region.

Hides J, Wilson S, Stanton W, et al. An MRI investigation into the function of the transversus abdominis muscle during
drawing-In of the abdominal wall. Spine. 2006;31:E175-E178

Drawling-in Maneuver:

Patient starts in hook-lying position and assumes a

neutral spine position & attempts to maintain it
while drawing in and hollowing the abdominal
muscles.
Kendal, F, McCreary, E, and Provance, PG: Muscles: Testing and Function, ed 4. Williams & Wilkins, Baltimore, 1993.

Subtle posterior pelvic tilt & flattening of lumbar spine.

No flaring of lower ribs, bulging out of abdominal wall
or pressure through feet.
Instructions: draw the belly button up and in toward
the spine while exhaling

Feedback Techniques

If patient is having difficulty activating the

Transverse Abdominis, the following has been
used to assist with learning:
Pressure transducer for clinical testing and
visual feedback (Pressure Bio-Feedback
Chatanooga Pacific)
Biofeedback with surface electrodes

Hagins, M, et al: Effects of practice on the ability to perform lumbar stabilization exercises. J Orthop Sports Phys Ther 29(9):546, 1999.
Jull, GA, and Richardson, CA: Rehabilitation of Active Stabilization of the Lumbar Spine. In Twomy, LT and Taylor (eds): Physical Therapy of the
Lumbar Spine, ed 2. Churchill Livingstone, New Yourk, 1994.
Richardson, C, Jull, G, et al: Techniques for active lumbar stabilization for spinal protection: A pilot study. Austral JPhysiother 38:105, 1992.
Richardson C, and Jull, G: An historical perspective on the development of clinical techniques to evaluate and treat the active stabilizing system of the
lumbar spine. Austral J Physiother Monograph 1:5, 1995.

Visual Feedback- hook-lying

Place small inflatable bladder with pressure sensor

(similar to BP cuff) under lumbar spine and inflate it to
40-mm Hg.
Correct Activation: 10-mm Hg increase in pressure
Large increase occurs if activating rectus abdominis
and/or increased lumbar flexion (posterior pelvic tilt).
No change in pressure = no activation of TrA

Visual Feedback- hook-lying

Biofeedback with surface electrodes

Electrodes placed over rectus abdominis &

external obliques (near attachment on the 8th
rib).
Correct activation: minimal to No activation of
these muscles
Can be used in conjunction with inflatable cuff.

Abdominal Bracing

Occurs by setting the abdominals and actively

flaring out laterally around the waist
Technique has been taught years
It has been shown to activate the oblique
abdominal muscles

Richardson, C, Jull, G, et al: Techniques for active lumbar stabilization for spinal protection: A pilot study. Austral JPhysiother 38:105,1992.

Posterior Pelvic Tilt

Activates Rectus Abdominis: it is NOT a core

spinal stabilization muscle
Only useful for teaching awareness of the
movement of the pelvis and lumbar spine.
Activated when patient explores lumbar ROM
with pelvic tilts to find neutral spine position.

Richardson, C, Jull, G, et al: Techniques for active lumbar stabilization for spinal protection: A pilot study. Austral JPhysiother 38:105,1992

Lower Abdominal Progression

Levels developed by Shirley A. Sahrmann

Purposes:
To improve the performance of abdominal muscles
(external obliques, rectus abdominis, transverse
abdominis)
To learn to prevent lumbar spine motions associated with
leg motion

Starting Position -Sahrmann

Supine with hips and knees flexed and feet on

the floor. Contract abdominal muscles by
flattening the abdomen and reducing the
arch in the lumbar spine. Patient is instructed to
place fingers on abdominal muscles and pull
the navel in toward the spine.

Level 0.3 (E1)-Sahrmann

Lift one foot with alternate foot on floor

Method:
Flex one hip while keeping knee flexed.
Return the LE to starting position and repeat with
opposite LE.

Level 0.4 (E2)- Sahrmann

Hold one knee to chest & lift the alternate foot

Method:

Flex one hip and use hands to hold knee to chest.

While maintaining contraction of abdominal muscles, flex the
other hip. Hold for a count of 3 and return the LE to starting
position.
Perform with opposite extremity.
Repeat 5-6 times

Level 0.5- Sahrmann

LIGHTLY hold one knee toward the chest and lift

the alternate foot
Methods:

Flex one hip and use one hand to hold knee to chest, but
hold it less firmly than level E2 (0.4).
While maintaining contraction of abdominal muscles, flex
other hip.
Hold for a count of 3 and return the LE to starting position
Perform with the opposite extremity.
Repeat 5-6 times

Level 1A- Sahrmann

Flex the hip to > 90and lift the alternate foot

Methods:
Contract the abdominal muscles; flex one hip to > 90 degrees
by lifting the foot from the table.
Contract the abdominal muscles and flex the other hip by
lifting the foot off the table.
Maintain the contraction of
abdominal muscles and lower
the legs, one at a time, to
starting position.
Repeat by starting the
sequence with opposite leg.

Level 1B- Sahrmann

Flex the hip to 90 and lift the other foot.

Methods:
Contract abdominal muscles and flex one hip to 90 degrees.
Contract abdominal muscles and lift other leg to same
position. Maintain contraction of abdominal muscles, lower
the legs one at a time to starting position.
Repeat by starting the sequence
with the opposite LE.
Repeat, alternating legs, correctly
10 times to progress to Level 2.

Level 2-Sahrmann

Flex one hip to 90 and lift & slide the other foot to extend
the hip and knee.
Methods:

Contract abdominal muscles and flex hip to 90 degrees, lifting foot off
the table.
Maintain contraction of abdominal muscles; lift other leg up to same
position.
Maintain one leg at 90 degrees, place other heel on table and slowly slide
heel along table until hip and knee are extended.
Return leg to starting position by sliding hell along table.
Repeat extension motion with other LE and return it to starting position.
Repeat, alternating legs, correctly 10 times to progress to Level 3.

Level 3-Sahrmann

Flex one hip to 90 degrees, and lift the foot and extend the
leg without touching the support surface.
Methods:

Flex hip to 90 degrees, lifting foot from the table.

Maintain contraction of abdominal muscles and lift other leg up to same
position.
Maintain one hip at 90 degrees, extend the other hip and knee while
holding the foot off the table until hip and knee are resting in an
extended position on the table.
Return leg to the hip and knee flexed position.
Maintain contraction of abdominal muscles, extend and lower the other
leg and return it to the 90 degree position.
Repeat, alternating legs, correctly 10 times to progress to Level 4.

Level 4-Sahrmann

Slide both feet along the supporting surface into

extension and return to flexion
Methods:
Begin in supine position with both legs in extension.
Contract abdominal muscles and slide heels along table,
flexing both hips and knees while bringing them toward the
chest.
Once hips and knees are flexed, pause
and reinforce abdominal contraction.
Slide both legs back into extension.
Repeat correctly 10 times to
progress to Level 5

Level 5-Sahrmann

Lift both feet off the supporting surface, flex the hips to 90
degrees, extend the knees, and lower both extremities to
supporting surface.
Methods:
Begin with LE extended position.
Contract abdominal muscles
while simultaneously flex hips
and knees, lifting both feet
off the table to bring the hips
to 90 degrees.
Reinforce the contraction of
abdominal muscles, extend the
knees and lower LEs to table.

Primary Core Protocols

Transverse Abdominis (Levels I-V)

Multifidus (Levels I-III)

http://lowerabexercises.blogspot.com/

The TrA Level Progression

These proposed levels were designed from the

research and are clinically applied to strengthen
the Transverse Abdominis in isolation.
Purpose:
To have a common terminology among practicing
clinicians in the same physical therapy setting.
To improve the performance of TrA muscle.
To prevent lumbar spine motion (neutral spine)
during functional activity.

Starting Position: TrA Level I

Method:
Supine with hips & knees flexed and feet on the
floor.
Patient is instructed keep a Neutral lumbar spine
using the Drawing-in Maneuver and place two
fingers on transverse abdominus and one hand on
superficial abdominal muscles.
Next, patient is asked to pull the navel in toward
the spine without tightening superficial abdominal
muscles and only the TrA.

TrA Level I

Level I will be the starting position for all levels

I-V.

TrA Level II

Lift one foot to 90

degrees with alternate
foot on table
Method:
Contract TrA and flex one
hip to 90 degrees while
keeping knee flexed.
Return the LE to starting
position and repeat with
opposite LE.

TrA Level III

Flex the hip to 90 and lift the other foot.

Methods:
Contract TrA and flex one hip to 90 degrees.
Lift other leg to same position. While maintaining contraction
of TrA, lower the legs one at a time to starting position.
Repeat by starting the sequence
with the opposite LE.
Repeat, alternating legs, correctly
10 times to progress to Level 4.

TrA Level III

TrA Level IV

Flex one hip to 90 degrees, and lift the other foot. Extend
the one leg without touching the support surface.
Methods:
Flex hip to 90 degrees, lifting foot from the table.
Maintain contraction of TrA and lift other leg up to same
position.
Maintain one hip at 90 degrees, extend the other hip and knee
while holding the foot off the table.
Return leg to the hip and knee flexed position.
Maintain contraction of abdominal muscles, extend other leg
and return it to the 90 degree position.
Repeat, alternating legs, correctly 10 times to progress to
Level 5.

TrA Level IV

TrA Level V

Flex the hips to 90 degrees and extend the knees

without touching the support surface.

Methods:
Flex hip to 90 degrees, lifting foot from the table.
Maintain contraction of TrA and lift other leg up to
same position.
Extend both hips and knees while holding the feet
off the table.
Return legs to the hip and knee flexed position.
Repeat correctly 10 times.

TrA Level V

Multifidus Level Progression (I-III)

These proposed levels were designed from the

research and are clinically applied to strengthen
the Multifidus in isolation.
Purpose:
To have a common terminology among practicing
clinicians in the same physical therapy setting.
To improve the performance of Multifidus muscle.
To prevent lumbar spine motion (neutral spine)
during functional activity.

Multifidus Level Ia

Start position:
Quadriped
Neutral lumbar spine
Have patient lift one
lower extremity (LE) (
knee) ~ 1 inch from
table
Hold position ~ 5
seconds
Alternate with the
other LE.

Multifidus Level Ib

Start position: Quadriped

Neutral lumbar spine
Have patient lift one LE
(knee) and the
contralateral upper
extremity (UE) (hand) ~ 1
inch from table
Hold ~ 5 seconds
Alternate with the other
LE and contralateral UE

Multifidus Level II

Starting position: Prone

Maintain neutral lumbar spine (i.e. placement of
pillow)
Lift one UE and contralateral LE from the table
Alternate with other UE and contralateral LE.

Multifidus Level III

Starting position:
standing on stool facing
wall
Extend one UE and
contralateral LE
Alternate with other UE
and contralateral LE

Clinical Biomechanics:
Intervention Skill Sets
NMR (97112)

Longus Colli Isolation

Text References

Kendall, FP et al. Muscles Testing and Function

with Posture and Pain. Fifth edition, 2005.
Sahrmann, SA. Diagnosis and the Treatment of
Movement Impairment Syndromes. 2002.
Kisner, C & Colby LA. Therapeutic Exercise:
Foundations and Techniques. Fourth edition,
2002.