Core Stability Principles

By Marc Heller, DC 2008

I want to share what I've learned recently regarding principles of core stabilization. I
always am surprised to learn how much I don't know. I have been forever confused by
the differences between the approaches of the Australian PTs, who have pioneered our
understanding of the inner core muscles, and other teachers in the rehab world, who
follow Stuart McGill's approach (a more global abdominal- and back-training
approach).

I have been looking for something that would make sense of this divide, and I think I
finally have found it. The teacher with whom I recently studied is Mark Comerford, an
Australian PT of Kinetic Control (UK). Comerford has attempted to integrate,
synthesize and understand the principles of both rehab and performance-oriented
exercise training. I will attempt to share the basic principles in this article, using the
lower back as the model. Future articles will share more specifics. For this article, I am
just going to reference the course I attended and Comerford's Web site.1 (I will reference
more peer-reviewed material for future articles.)

First, you have to understand how different types of muscles function. We are all aware
of tonic or postural muscles and that they are different than phasic or power muscles.
Postural/tonic muscles are designed for endurance and are able to be active continually
for a long time. They are not designed as prime movers but are designed to stabilize and
maintain the center as the arms and legs move around them. The phasic muscles are
designed to fire with more power to move the limbs, especially in the sagittal plane for
throwing, running or explosive action.

Comerford further divides the postural or stability muscles into local (the inner core)
and global (the outer core). The inner core muscles are mostly single-joint, shorter
muscles. They are designed to control translation and the small glides that joints make.
For the trunk and low back, these would include the transverse abdominals, deep
multifidi, pelvic floor and posterior fibers of the psoas.

Moving outward from the inner core, we find the outer core - the global stabilizer
muscles. For the trunk and low back, these include the abdominal obliques, anterior
psoas, gluteal muscles, quadratus lumborum and the superficial multifidi. These are still
tonic, one-joint muscles. These are considerably stronger than the inner core and work
in tandem with it. They control specific directions of movement such as flexion,
extension and rotation.

The final grouping of muscles is our prime movers - the phasic mobilizers. These are
about strength and sagittal plane movements. These are trained by traditional resistance
training in gym exercises.

Local Stabilizers

We'll start with an exploration of the inner core. These muscles increase stiffness and
tension via their pulls on the fascia. This is a good stiffness, a good tension that
promotes stability and gives something solid for the other muscles to pull on. See my
"Why Fusions Fail" article2 for a better understanding of the positive role of muscles
and fascia in creating stiffness. The inner core muscles allow movement but maintain
alignment of vertebrae. They activate in any and all directions of movement. Research
shows they have a protective response and function to anticipate. In a healthy, pain-free
back, they pre-activate for predictable stresses. Before you ever move your arm, your
transverse abdominals fire about 50 milliseconds before the main movement starts. This
pre-activation sets the core and allows arm or leg movements to occur without too much
movement in the trunk and the back.

After a back injury or when you have back pain, these muscles are slow to start firing.
Think about how hard and painful it is for your acute patient to turn over on the table.
This timing delay is the key dysfunction of the inner core. When these muscles don't
activate at the right time, it means every time you move, your back suffers microtrauma.
Every time you move, thousands of times per day, too much motion occurs in the back.
This sets the stage for instability, creating excessive loads and contributing to wear and
tear.

The good news is this timing delay can be corrected. Research shows a few weeks of
consciously learning to pre-activate these inner core muscles (when they are not
working right) will correct the timing delay and begin to restore this component of
stability. These exercises are very specific, highly cognitive and nonfunctional; they are
not easy to learn and are somewhat counterintuitive. You enhance these exercises not by
adding load, but by unloading - putting less weight or load on the involved joint. These
exercises are about recruitment and motor control training, not strength or hypertrophy.
These exercises directly relate to pain control by stopping uncontrolled translation.
These muscles are retrained by low-load, non-fatiguing exercise (at 20-30 percent of
maximum), done in a slow and static way. These exercises can be boring, but they are
necessary if these muscles have diminished function.

These are the abdominal hollowing exercises. What can these muscles do? These
muscles are not strong enough, even when pre-activated, to control a direction of
movement. They are not strong enough to take a load. Their job is simple: fire quickly
(before the main action) and prevent translation (aberrant movement in the lower back).

These tonic muscles are low threshold and need early activation. The exercises to
reawaken them are not physically demanding; you are only firing up to 30 percent of
maximum, but they might require a high sensation of effort. They need to be done for
one to two minutes, twice per day. This really is about neural adaptation and skill
acquisition. The Feldenkrais model addresses this. The lessons consist of the student
paying attention to simple or not so simple movements of their body and learning new
pain-free ways to perform them.

Here is a simple way to tune into the activation of the multifidi. Stand in a walking gait
position, right leg in front of the other (as if you are about to walk). Put your fingers on
your lower back at L5, next to the spine on the left side. Now shift your weight slowly
forward. As you rock forward, feel the activation, the swelling of the muscle on the rear
left side. If you or your patient cannot feel it at all, put all the weight on the front foot
by lifting the rear foot backward, and feel the muscle swell. In more normal function,
the activation will occur early as you begin to rock forward. If the multifidi have a
timing delay, you won't feel the swelling as early in the forward weight shift. Typically,
the right side of the multifidi has more timing problems; the left side usually activates
earlier, even after injury.

To make this into an inner core rehab exercise, consciously keep the multifidi muscles
turned on as you bring the weight back toward the rear foot. This is an example of
unloading, using the conscious mind to override and train motor control. Initially, a high
sensation of effort might be needed to perform this low-load motion. This implies an
inefficient facilitation of slow motor unit recruitment and dysfunction of normal muscle
spindle responses. Once these inner core muscles are working, we shouldn't need to
consciously pre-activate them, unless another injury or pain episode has intervened.

Global Stabilizers

The global stabilizer muscles need two different training strategies. First, they need
motor control or recruitment training. The goal here is to control the core movement in
multiple directions. In the dysfunctional back, the larger, faster muscles (the phasic
mobilizers) are dominant and have taken over. So we need to get these global stabilizers
active as they help maintain movement control in specific directions. This requires non-
fatiguing, low-load exercise in the range of 20 percent to 30 percent of maximum effort.
The definition Comerford uses is that the patient can hold the static position or do the
slow movement for four minutes without pain or fatigue. This doesn't mean they are
going to do the exercise that long. He recommends 10 reps of a 10-second hold with a
brief release of contraction between reps.

We will keep the trunk in neutral (especially at the beginning stages) as we do these
repetitions. We will challenge the trunk's stability by using different directions of slow
limb movement. A unilateral, asymmetrical limb or trunk load can be used to facilitate
this challenge. This critical stage of rehab often is ignored or misunderstood. You have
to re-establish better motor control before you can effectively strengthen these key
muscles. We are challenging the core, waking up the core, but doing it in a static or slow
manner with a light load. This is a topic I will expand upon in my next article.

The second aspect of training the global stabilizers is to use asymmetrical trunk loading
to strengthen the core. This is what most Pilates and other core stabilization programs
usually emphasize. You are using the legs and/or arms to create a load, usually an
asymmetrical load, and asking the core to stay stable. These are fatiguing exercises,
done at slow or high speed in the training range of 40 percent to 70 percent of max
effort. In this phase, we really emphasize rotation control with higher loads. We again
attempt to discourage the global mobilizers from taking over; we are primarily using the
global stabilizers. In my opinion, this is frequently done poorly, at least for those who
have back issues. Not enough attention is paid to whether these muscles are able to
maintain a proper postural hold before asking them to assume a larger load.

The global mobilizers, the bigger phasic muscles, can be trained in traditional gym
exercise. Training these does not automatically improve the core function. On the
contrary, it can tend to further reinforce mobilizer dominance over stabilizers. For our
patients, the key is for them to do these exercises at the right time and pay attention to
optimizing postural control while doing them, keeping the stabilizers doing their job.
This article is just an introduction. Rehab research is expanding our understanding of
proper rehab exercise. I want my patients to hold their adjustments, get well, stay well
and have the tools to help themselves. This requires specific, individualized rehab, not
cookie-cutter exercises. Unfortunately, in chiropractic, physical therapy and the personal
trainer/gym exercise world, this is not the usual level of care. Remember, you are
providing the cues, both verbal and nonverbal. If you don't think specific exercise has
value, neither will your patient. If you know and effectively communicate to the patient
that they can change their patterns through exercise, you will get better compliance and
better results.

Global Stabilizers for the Lower Back

By Marc Heller, DC and Chad Brenzikofer, CSCS

Let's continue our stabilization series with an article on low-load training of the global
stabilizers. I suggest you read my first article, "Core Stabilization Principles,"1 as
background.

Why more on rehab? We can't change our cultural authority or our image as a profession
strictly through a PR campaign, or by shutting down the "bad apples" in our profession.
It is up to each one of us to change what we do. Our profession is too often thought of
as, "You'll have to go to the chiropractor forever." Chiropractic is viewed as only good
for acute pain.

I don't think adjustments (no matter how perfectly targeted) and/or soft-tissue work are
enough to solve chronic pain patterns. I don't think laser, microcurrent, decompression,
etc., are enough to solve chronic pain. I love all of these tools, and they do affect
muscular function, but they are not enough. Chronic pain has a critical motor-control
component. The patient needs to learn to use their body differently. If you become a
rehab-oriented chiropractor, you will reach a whole different population of patients. You
won't have as many "fix me" patients draining your energy. You'll have more patients
who will fully engage in their own healing process.

Global Stabilizer Muscles and Their Function

What are the global stabilizers?"2,3 These are the "outer" core muscles. They are the only
joint stabilizers whose main role is to control direction-specific stress and strain. They
include the more superficial multifidi, the lateral QL fibers, the oblique abs, the anterior
psoas and all of the gluteals. These are the larger postural muscles of the core.

Table 1: Core Stability Overview

Symmetrical "Core" Trunk "Motor- "Motor-

Strengthening Strengthening Control" Control"
(Limb) Stability: Stability:
Global Local
 Training high high threshold low
Threshold

Muscle Bias global mobilizers global stabilizers global local

stabilizers stabilizers

Position/Plane flex-ext plane +/- neutral position rot plane +/- neutral
of 10 Loading SB / ab-ad Rot +/- rot plane Rot neutral position No
eliminated challenge position 3 D D

Type of isotonic (conc) isometric +/- isotonic isometric

Loading +/- isometric & isotonic (eccentric) &
isokinetic (concentric) isometric

Global stabilizers have three primary functions: first, to concentrically shorten through
full available range; second, to isometrically hold inner range (shortened) positions; and
third, to eccentrically control the return to neutral. They must be able to do all of these
with efficient slow motor-unit recruitment. If you understand and know how to train all
of the above, you are way ahead in your rehab understanding. I'll try to explain these
concepts in the rest of this article. I've included a table outlining the way this model
looks at the various muscles of the body.4 [Please see Table 1 and Table 2.]

Specific movement dysfunctions develop from states of pain, tissue pathology or

patterns of habitual misuse. This observation was one of the genius concepts from
Vladimir Janda and has been validated via research. The patient loses the ability to
perform the three functions of the global stabilizers listed above.This is significant both
for treatment/rehab of painful conditions and for prevention of recurrence. The primary
indication for needing/doing global stability training is a recurrence of movement
related pain or direction-specific stress or strain. The classic examples are the patients
who always seem to get worse when brushing their teeth, loading dishes, gardening, etc.
A common theme here is flexion-related stress and/or flexion that hurts, but is relieved
by extension. Global stabilizers are also critical to control extension and rotation, but
this article will focus on the most common deficit: lack of control of flexion.

Slow, Low-Load Recruitment

Why low load? To understand this, first let go of the word strength. Strength and low-
load stability are totally different physiological concepts. Stability is referring to
recruitment efficiency, while strength is referring to the ability to produce force. In low-
load exercise, we are training for low-threshold recruitment and motor-control training,
rather than hypertrophy or strength. To accomplish this requires nonfunctional training
that takes the person out of their normal motor habits. We will have the patient move
one joint system while maintaining neutral position in an adjacent joint system.
Coordinating this type of movement is the basis for both testing of global motor control
and for global stability exercises.

Table 2: Training Principles for Core Stability

 Symmetrical "Core" Trunk "Motor- "Motor-
"Traditional" Strengthening Control" Control"
Limb Stability: Global Stability:
Strengthening Local

fatiguing high- fatiguing high- no-fatigue low- no-fatigue

load exercise load exercise load exercise low- load
exercise

+/- speed +/- speed asymmetrical trunk stays

limb or trunk load in neutral

symmetrical limb asymmetrical Maintain trunk only slight

load limb or trunk neutral global
load muscle
activity

limb or trunk resist rotation emphasize discourage

Guidelines
lifting in the force at trunk rotation control at core
for
flexion-extension trunk and girdles "rigidity"
Training
plane +/- flex-ext
control

No rotation rotate against Short-range hold

resistance for postural
control

discourage
global mobilizer
global mobilizer
dominance
dominance

encourage core
"rigidity"
Reproduced with permission from Kinetic Control International.

Low-load exercise is defined as an exercise the patient can do for four minutes without
fatigueor substitutions. We are attempting to retrain and recruit the slow postural
muscles that we use to stand, sit and accomplish simple activities of daily living. By
going slow and doing sustained activities, we are primarily recruiting the slow-motor
units - the postural and tonic motor units within the muscles. The movements must be
done with slow, continual movements void of substitutions by other muscle groups,
must not have a respiratory cost (breath holding), and must be done in the low-threshold
environment.
These types of exercises will optimize postural control and stability. So, what day-to-
day activities or exercises enhance global stabilizers? Ballroom dancing, yoga,
Feldenkrais, tai qi or qigong come to mind.

Once we add a higher load (weights, machines, etc.) or more speed, we are primarily
utilizing the fast-motor units. This recruits the bigger mobilizer muscles and the fast-
motor units within the stabilizer muscles. For global-stabilizer training, we are not
trying to change muscle structure. What we are attempting to do is improve the nervous
system's ability to coordinate and improve efficiency. Sounds like a chiropractic
principle to me!

Low-load exercises are mentally challenging. First, it's hard to get "athletes" to slow
down. Second, when proprioception is diminished, the sense of effort increases during
low-load exercises. The principles for both testing and training are fairly simple. Can
these patients control direction-related stress and strain? Our example will be testing for
lack of global-extensor function for patients who fail to control flexion. We are testing
and/or recruiting primarily the global multifidi. Have the patient flex below the lumbar
spine and see if they can maintain the lordosis and hold neutral in the lumbar spine.
Examples of this include "the waiter's bow" (have the patient bend forward, while
maintaining lumbar neutral) and the hip hinge (stand to sit and sit to stand). Craig
Liebenson has a nice handout on the hip hinge on his Web site.5 The test assessment is
simple: Can the patient maintain neutral lumbar spine as they do these isolation
motions. Watch closely from the side.

Another test, done supine hook-lying, is to have the patient lift either one bent leg at a
time to 90 degrees, or lift both bent legs. Can the patient maintain the lumbars in
lordosis? You can test with a flat hand under the spine. Ideally, put a pressure
biofeedback stabilizer unit (or blood pressure cuff) under the lumbars to give the patient
visual feedback. Can they maintain a 40-pound pressure? It's OK if the pressure goes up
two pounds with one leg lift or up to 10 pounds with the double leg lift.

These same motions can be used as the retraining exercises. I like the ease of these
motions. They are not hard for the patient to learn and can really make a difference. The
hip hinge is both an exercise and an integration into a functional activity, going from sit
to stand. The exercises have to be done with attention to detail, specifically keeping the
lumbar spine in neutral and not letting the lumbars flexwhile moving at the hips.
Keeping the hips in neutral, rather than letting the knees fall outward or inward, is also
important.

A brief clinical note: I re-injured my low back two weeks ago, and I kept having
morning glitches, little spasms and catches in my right lower back. I noted that my right
local multifidi had stopped working properly. I had a huge timing delay again. I worked
on this for several days using the exercise I outlined in the local stabilizer section of my
previous article.1 This was slow going, until my exercise coach suggested I first do a
few brief squats to reset my lower back musculature.6 The timing delay was
immediately almost gone, and I stopped having daily morning glitches. A brief global-
stability exercise immediately improved my lumbar motor function. Another patient of
mine with chronic low back pain when she gardened, had a similar response. This is not
a miracle, just some good changes. I've shot a video for this article titled "Global
Stability Tests and Exercises." Search YouTube for "MarcHellerDC" to see it.
Once again, I've attempted to distill and simplify someone else's comprehensive body of
work. The goal is to introduce you to some newer concepts and some new ways of
looking at rehab. You may already be teaching some of these exercises. Perhaps you
will look at them differently, see where they fit and for whom they work. In the next
two articles, we'll address both local stabilizer muscle function and higher-load training
for the global stabilizers. This model has profoundly reframed how I look at rehab. I
hope these ideas help you and your patients as well.

Local Stabilizer Rehabilitation: Myths

and Understandings
By Marc Heller, DC

What are the local stabilizers of the lumbar spine? You may know them better as the
inner core or the deep segmental fibers of themultifidus and the transversus abdominals.
The inner core could also be defined as including the posterior fibers of the psoas, the
pelvic floor muscles and the respiratory diaphragm.

These muscles have been of interest to rehab-oriented doctors for many years since a
group of Australian physiotherapists documented significant changes in muscle function
of the local stability system in the presence of pain and pathology.1 The research
continues and a better understanding of motor-control changes in the local system has
continued to grow.

Local stabilizers are single-joint muscles designed to reduce segmentaltranslation, rather

than to control range of motion. In normal function, they often demonstrate an
anticipatory response to rapid multidirectional limb and trunk movement, preparing the
spine for unexpected perturbations.2 This anticipatory response, the early activation of
these muscles, prepares and stabilizes the spine in advance of sudden movement. The
exercises I will feature in this article are all about retraining early activation of the deep
segmental fibers of the multifidus.

Abdominal hollowing is a strategy that comes from this research. It is an attempt to

wake up or activate the transverse abs, a key local stabilizer. But abdominal hollowing
is not a useful strategy when one is confronted with a substantial load. Why? Because
these muscles are relatively small and are not designed for heavy lifting. Bracing the
whole abdomen is a better strategy when faced with a load. Abdominal hollowing is an
exercise that helps activate the transverse abs. Once you activate the transverse abs and
improve their recruitment, they should be able to team up better with the bigger global
stabilizers to provide more efficient, more stable motion patterns.
How does pain and pathology fit in with local muscle retraining? I'll detour to a brief
story. I have problems with discogenic pain in my lower lumbar spine. I have retrained
my inner core muscles, although they are not as fully functional as I would like them to
be. When I have a disc flare-up, my local stabilizers immediately lose function. I have
to go back to square one and reactivate and retrain these muscles once again. The pain
and pathology create a vicious cycle in the patient who doesn't know how to get their
muscles going again.

Research shows that after an injury, the inner core muscles do not automatically return
to normal function.3 With retraining, they have a better chance to pull out of the pattern
more quickly and decrease recurrences.

These local stabilizer muscles are key to preventing uncontrolled translation resulting
from aberrant, abnormal/unexpected motions. To stop or control translation is also often
key. Think about the feeling of stepping off a curb. No big deal. Now, think about the
feeling of stepping off of a curb that you don't see. It's somewhat of a shock, even to a
normal back.

To control this sudden motion, you need your local stabilizers to quickly fire. In the
patient with back pain or a history of recurrence, in the patient whose local stabilizers
aren't working efficiently, the shock of stepping off an unseen curb is more significant.
The deep multifidi and/or TrA fail to activate at the right moment. They still fire and
react; they just have a timing delay and don't fire prior to the impact. When this firing
pattern is delayed, any sudden movement stress, or a sudden turn or twist can cause or
aggravate back pain. What is happening? The local stabilizers don't anticipate and/or
activate early enough, and thus the weak link segments in the spine can translate or
move aberrantly. This can create a protective spasm, and start up the whole vicious
cycle of acute or recurrent back pain.

This phenomenon is at the junction of pathology and function. Many patients have
degenerative segments, bulged discs and some degree of stenosis. When these same
people also have poor muscular function, they are likely to have pain or recurrent pain.
There is not much we can do for their anatomy. We can make a significant intervention
in helping the patient retrain more normal muscular function.

Some rehab authors seem to always start with retraining the local stabilizers, quoting the
Australian research. Others, such as those who follow Stuart McGill, would likely say
that these muscles are not special and thus do not need specific retraining. I think that in
this case, there can be a middle ground.

The kinetic control model has an algorithm that makes sense to me. Retrain the local
stabilizers as a priority under the following clinical scenarios:

 The patient has a significant history of insidious recurrence of back pain.

 Their pain is associated with low-load normal daily function and/or static
positions, such as in sitting, walking, standing, and/or while lying down.
 Their pain is associated with nondirection-specific unguarded movements. This
contrasts with global stabilizer priority when the mechanism of pain production
is specifically related to either flexion, extension or rotation.
  Poor voluntary low-threshold recruitment. In other words, the patients have
trouble isolating the transverse abs by hollowing and they have trouble with the
multifidi exercise described below. The trouble could be not being able to find
the muscle or difficulty isolating the local muscles due to overactivity of the
bigger mobilizer muscles.

Retraining the local stabilizers does not mean you ignore simultaneous or parallel
training of the global stabilizer muscles. The patient can train multiple types of stability
muscles at the same time.

Retraining the Local Multifidi

Here is a simple way to tune into the activation of the multifidi. Stand in a walking gait
position, left leg in front of the right (as if you are walking). Put your fingers on your
lower back at L5, next to the spine on the right side. Note that the thumb or fingers are
just above the iliac crest, and just lateral to the L5 or L4 spinous process. Now shift
your weight slowly forward. As you rock forward, feel the activation and the swelling
of the muscle on the right rear side, under your fingers. If you or your patient cannot
feel it at all, put all the weight on the front foot by lifting the rear foot up, and feel the
muscle swell. In more normal function, the activation will occur early as you begin to
rock forward. If the multifidi have a timing delay, you won't feel the swelling as early in
the forward weight shift. Typically, the right side of the multifidi has more timing
problems; the left side usually activates earlier. If you are having trouble activating the
right multifidi; you can reverse the posture, and start on the left side, which is often
easier.

If there is minimal or no activation of the right multifidi, focus on activating the left
gluteus medius. If you are "leaking out" of the left hip, you will not fire the multifidus.
Another posture that inhibits the multifidi is excessive lumbar extension or flexion. To
make this into an inner core rehab exercise, consciously keep the multifidi muscles
turned on as you bring the weight back toward the rear foot. Hold this activation for 10
seconds at a time, relax for two seconds, and repeat six to 10 times. This is an example
of unloading; decreasing the load to the muscle, but still asking it to activate. You are
using the conscious mind to override and train motor control. Initially, a high sensation
of effort might be needed to perform this low-load/no-load action. High levels of
perceived effort imply an inefficient facilitation of slow motor-unit recruitment and
dysfunction of normal muscle spindle responses. Once these inner core muscles are
working, you shouldn't need to consciously activate them. They are designed to work
automatically.

The Psoas as a Spinal Stabilizer

The psoas is a muscle in which many body workers, chiropractors and PTs have an
interest. I used to think that the psoas was usually too tight. The modified Thomas test
certainly is positive in plenty of patients with hip or back pain. There are plenty of other
hip flexors, such as the rectus femoris and iliacus, that will cause a lack of ability to
extend at the hip. There is mounting evidence which may suggest a lumbar stability role
for the psoas instead of the traditional hip-flexion role.
Recent research has given us a new perspective on the psoas. The psoas is segmentally
innervated. The psoas atrophies at the same level and same side of disc herniation,
which is a very similar pattern seen in the deep fibers of the multifidus.4,5

The anatomy of the psoas is not ideal for a hip flexor; it's clearly too close to the spine.
The psoas is ideal to help stabilize and prevent translation of the lumbar spine. It's also
well-designed to stabilize the hip and suck it up into its socket. (Perhaps the subluxation
pattern that I have written about, in my hip dysfunction articles is not primarily a lack of
internal rotation, but instead a femoral head that has subluxed anterior and lateral due to
an inhibited psoas, and thus stops internal rotation early.6)

Sean Gibbons has written extensively on the psoas. I've referenced both his short
description of psoas anatomy and function, as well as a longer article with details on
how to test for psoas related hypermobility, and step-by-step rehab instructions.7,8

Rehab is so critical to optimal success with chronic or recurrent pain. If you become a
rehab doctor, great. If you just start thinking a bit more along these lines, add a few
more exercises, take a few minutes to coach movement with your patients, that's great,
too. If you just recognize that you need to find a PT who does spinal rehab well, or an
accomplished Pilates instructor or personal trainer, that's fine. Make a place for rehab in
your own model.