CHAPTER V

RESEARCH QUESTION 1

CORE STABILITY: ANATOMICAL,

BIOMECHANICAL AND PHYSIOLOGICAL
EVIDENCE

Christopher McLean

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There has been a significant amount of work published in the past 15 years investigating the essence of

spinal stability (Brown et al., 2003; Chiang and Potvin, 2001; Cholewicki et al., 1997 and 1999; Essendrop

et al., 2002; Hodges et al., 2001; Quint et al., 1998; Solomonow et al, 1998 and Wilke et al., 1995). Much

of this work is applicable to the investigation behind the concept of core stability. This chapter reviews the

evidence behind the anatomical, biomechanical and physiological principles of core stability. Table 8

displays the evidence table for intervention studies that was used when considering guideline statements

for this section.

It has been widely reported that spinal stability is primarily the result of interaction between different

components of the neuromuscular system (Gibson and McCarron, 2004; Granata and Orishimo, 2001;

Kaigle et al., 1995 and Panjabi, 1992a). This can provide both dynamic, controlled movement and

variable degrees of stiffness dependent on the functional requirements of the task being performed by an

individual or the external forces acting on the individual (McGill et al., 2003).

There is a considerable variation in the literature from both scientific sources down to the popular press

that influences much of the fitness industry on what anatomical structures provide the foundation for core

stability. The fitness industry is responsible to a large extent for the practical application of core stability

training methods to the general population. Unfortunately, much of the material on which they base their

programmes are derived from poorly researched publications that are highly biased towards anecdotal

evidence and even influenced by companies that produce „fitness products‟. The aim of the following

section is to provide a comprehensive review of what structures have been shown to contribute to core

stability and to highlight areas that warrant further investigation.

Simply stated core stability is a term that would appear to encompass structures that provide stability to

the trunk. Soft tissue structures that connect the pelvis, spine, ribs and shoulders that have varying levels

of responsibility in terms of movement, stability and combined function would make up some of the

essential components needed to provide adequate core stability. Panjabi (1992a) described three

subsystems that provided a conceptual model for spinal stability: passive, active and neural. The passive

subsystem was described as being made up of the vertebrae, discs, joint capsules and ligaments

(Panjabi, 1992a). Notably he did not specifically include the pelvis, ribs or scapulae in his model. The
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active system was described as consisting of the muscles and tendons surrounding the spinal column.

Thirdly the neural and feedback subsystem constituted the various force and motion transducers, located

in ligaments, tendons, and muscles, and in the neural control centres. Core stability could be considered

as the interplay between these three components .

To provide structure to the following the above subsystems will be used as a format to describe the

components of core stability. Whilst the concept behind these terms has been proposed by Panjabi

(1992a) the following discussion is not necessarily an expression of his views rather a representation of

the available evidence from data searches performed.

Passive Subsystem

The components of the passive subsystem do not provide significant stability to the spine whilst in the

neutral zone (Panjabi 1992a and 1992b). They provide soft tissue attachment points for muscles and

fascia of the active subsystem and attempt to provide a safe anatomical passage for some of the

structures that make up the neural and feedback subsystem. The osseous structures that fit within the

core stability framework, starting inferiorly, include the pelvic girdle made up of the coccyx (4 fused

vertebrae), sacrum (five fused vertebrae) and 2 ilia (Williams et al., 1989). The lower limb connects with

the pelvic girdle directly through the connection with the hip joint (Calais-Germain, 1993). The spine

interacts with the pelvic girdle through the lumbosacral junction at L5/S1(Bogduk, 1997). The sacroiliac

joints within the pelvic girdle play an important role in controlling torsional movements through the

lumbopelvic region (Vleeming et al., 1990a and 1990b; Lee, 1999). The lumbar spine is made up of 5

lumbar vertebrae (Bogduk, 1997). The thoracic cage is made up of 12 ribs on each side of the thoracic

spine (Edmondston and Singer, 1997). The shoulder girdle articulates with the thoracic cage at the

scapulothoracic joint (Motttram, 1997). This effectively provides the superior border for core stability

structures and has a similar function as the pelvic girdle but for the upper limb that is, creating a stable

platform for the upper limbs to move from and to control the initial transference of upper limb forces to the

trunk (Mottram,1997).

Two adjacent vertebrae constitute a spinal segment (Bogduk, 1997; Norris, 2000). They are attached (or

articulated) by joints, ligaments, capsules and overlying muscle attachments (Maitland, 1997). There are 3

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joints at each spinal segment, the „articulating triad‟(Norris, 2000). The intervertebral disc forms the joint

between the vertebral bodies and the two zygapophyseal facet joints are made up of the inferior articular

processes on either side of the upper vertebra and the superior articular processes on either side of the

lower vertebra (Norris, 2000; Williams, 1989). The zygapophyseal facet joints have a function in

controlling movement and transmitting loads (Goel et al, 1993). They are not designed to be weight

bearing joints and only become so in extremes of spinal movement and pathological states such as

degenerative disc disease that results in increased facet joint contact pressures and subsequently

degenerative changes of the articular surface (Norris, 2000).

Bogduk (1997) described 12 possible degrees of movement at each spinal segment. These possible

movements included distraction, compression, translation (lateral, medial, posteroanterior and

anteroposterior), side flexion (left and right), axial rotation (left and right), flexion and extension. A

coordinated approach by all three subsystems is necessary to control these potential movements

(Panjabi, 1992a, 1992b; McGill et al., 2003).

From a biomechanical perspective sacroiliac joint stability has been described as being derived from a

combination of form and force closure (Liebenson, 2004, Vleeming et al., 1990 a and b). Form closure is

related to the inherent anatomical properties of the sacroiliac joint (Vleeming et al, 1990a and 1990b).

Force closure is related to how the muscles, ligaments and the thoracolumbar fascia aid in stabilising the

pelvis (Pool-Goudzwaard et al., 1998). During activities such as walking a unilateral force is transmitted up

the leg and introduces a shear force through the sacroiliac joint. The muscle-ligament-fascia system

works to compress the sacroiliac joints together to ensure stability and hence force closure (Liebenson,

2004a, Vleeming et al., 1990a and 1990b). The study by Avery et al. (2000) demonstrated a possible role

for the pelvic floor muscles in the force closure system. The combined evidence for this concept is

moderate. No studies were identified that disproved or opposed the above principles.

The ligamentous structures of the spinal segments and the pelvic girdle have definite biomechanical roles

in controlling end of range spinal movement and may also factor in the neural feedback system (Panjabi,

1992a). Solomonow et al. (1998) demonstrated how stimulation of the supraspinous ligament influenced

activity in the multifidus muscle in both cats and humans, thus providing some evidence to this concept. In
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terms of the passive subsystem at the pelvis the sacrotuberous and long dorsal sacroiliac ligaments are

responsible for limiting nutation and counter-nutation, respectively (Liebenson, 2004a). Nutation is the

forward motion of the sacral promontory into the pelvis about a coronal axis within the interosseous

ligament (Lee, 1999). Conversely, counter nutation is the backward motion of the sacral promontory about

a coronal axis within the interosseous ligament (Lee, 1999). These movements can be bilateral or

unilateral.

Ligaments of the spinal segment have been classified as neural arch, capsular and ventral (Willard,

1997). The neural arch ligaments constitute the ligamentum flavum, interspinous ligament, supraspinous

ligament and intertransverse ligament (Williams et al., 1989). The capsular ligament surrounds the

zygapophyseal joint capsule and is reinforced by the ligamentum flavum (Bogduk, 1997). The

fundamental biomechanical difference between fibrous joint capsules and ligaments is the arrangement of

collagen fibres (Lee, 1999). The functional role of ligaments are to resist tensile stresses between bones

therefore the collagen fibres are aligned in a longitudinal arrangement (Bartlett, 1999; Lee, 1999). The

collagen fibres within the fibrous joint capsule are arranged in an irregular, random pattern to allow a

degree of extensibility to permit joint movement (Lee, 1999). The ventral ligaments are described as being

the anterior longitudinal ligament and the posterior longitudinal ligament (Willard, 1997; Norris, 2000).

The ligaments of the neural arch have been considered to act as a single functional structure (Norris,

2000). Dissection studies have described how the deep abdominal muscles may assist spinal stability by

influencing the transmission of forces through the ligaments and fascia (Willard, 1997). The following is an

example of this proposed feature. The posterior border of the interspinous ligament is thickened into the

supraspinous ligament. The supraspinous ligament combines with the thoracolumbar fascia which further

merges with the deep abdominals (Norris, 2000). It has been proposed that this chain of interconnecting

structures can prevent the ligamentum flavum from buckling towards the spinal cord due to the force

generated by the deep abdominal muscles (Willard, 1997; Norris, 2000). This interspinous-supraspinous-

thoracolumbar ligamentous complex not only attaches the fascia to the back of the lumbar spine but also

creates a pathway for tension in the extremities to be transmitted to the vertebral column (Norris, 2000).

This would become an important consideration during rehabilitation and performance training.

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The facet joint capsule has been described as a „bridge‟ of connective tissue connecting the ligaments of

the neural arch with the vertebral body (Wilard, 1997). The posterior longitudinal ligament is not the

strongest ligament limiting flexion of the spine (Bogduk, 1997). Bogduk (1997) reported that 52% of the

resistance to flexion in the lumbar spine is provided by the combined ligamentum flavum and the facet

joint capsule. The ligamentum flavum has the highest amount of elastic fibres of any ligament in the body

and is held under tension when the lumbar spine is in a neutral position (Butler et al., 1978). The anterior

longitudinal ligament is very strong and extends from the occiput to the sacroiliac joint capsule (Norris,

2000). Rapid loading of the longitudinal ligaments results in a „stiffening‟ response due to their viscoelastic

properties. Due to the hysteresis effect these ligaments become stiffer with repeated loading and

therefore become prone to fatigue failure (Hukins, 1987). If the local stabilising muscles were working

optimally then it would be assumed that their functional role would be to limit the passive structures from

being pushed to their failure point. In this evidence based review no studies were found to prove this point.

In reference to anatomy and biomechanics the thoracic spine has been largely neglected compared with

the the cervical and lumbar spines (Edmondston and Singer, 1997). The rib cage and its articulations

enhance the stability of the thoracic spine (Shea et al., 1996). Berg (1993) hypothesised that the rib cage-

sternum complex may comprise an additional „column‟ for load transfer and stability. No studies were

identified that provided evidence for this. A number of investigative studies demonstrated the importance

of stability provided by the costovertebral joints (Oda et al., 1996), thoracic ligament complex (Panjabi et

al., 1981; Shea et al., 1996) and intercostal fascia (Jiang et al., 1994). The reduced disc height to vertebral

body height ratio compared with the lumbar spine reduces motion of the thoracic functional spinal unit

(Kapandji, 1978). Zygapophysal joint alignment in the thoracic spine also limits flexion and anterior

translation (White, 1969) however enhances torsional stiffness (Singer, 1989).

While there has been considerable research and opinion on the benefits of a neutral pelvic position and

the importance of a natural lumbar curve (Chek, 2004; Cholewicki et al., 1997; Norris, 2000; Panjabi,

1992a) the natural thoracic kyphotic curve appears to be primarily related to the osseous asymmetry of

the vertebral bodies and tension in the ligament complex (Singer, 11989). There appears to be little

supporting evidence to suggest that increasing muscle activity in the thoracic spine will alter the degree of

thoracic spine kyphosis. In a load-carrying task, Klausen (1965) reportedly found greater
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electromyographic activity in the thoracic spine extensors compared with the lumbar extensors however

the thoracic curvature remained unchanged while the lumbar curvature was altered. This finding

suggested that osseous and non-contractile tissue have a greater influence over thoracic spine curvature

than muscular control (Edmondston and Singer, 1997).

Edmondston and Singer (1997) concluded from their review that, “posture correction is achieved

predominately through changes in the cervical and lumbar regions while the less mobile thoracic spine

remains relatively unaltered.” They acknowledged that the thoracic curvature would influence patterns of

load-bearing movement and the degree of stiffness may produce compensatory changes in the cervical

and lumbar regions that naturally have more movement. It would appear the more anatomically static

thoracic region provides stable attachment points for muscles and fascia that have the potential to

influence intra-abdominal pressure and dynamic control of the lumbar spine. There is moderately good

evidence of synergistic muscle activity in the trunk producing a stabilising effect (Brown et al., 2003;

Cholewicki et al., 1997 and 1999; Essendrop et al., 2002 and 2004; Hodges et al., 2001; Sapsford and

Hodges, 2001; Stokes et al., 2000; Radebold et al., 2000; Wilke et al. (1995). In contrast to these studies

which were generally from experiments measuring spine stiffness from rapid or informed loading, Kumar

(1997) found that with prolonged load the IAP readings were inconsistent when compared with the

magnitude of the load applied. The Kumar (1997) study did not record EMG activity of transverse

abdominus or multifidus which would have provided a more indepth analysis of this finding.

Core stability rehabilitation in the thoracic region could potentially require manual therapy intervention as

part of the programme to correct biomechanical anomalies. An example would be during active

movement assessment of unilateral arm elevation that produced an asymmetrical spinal movement

response. This response could be due to an upper thoracic movement dysfunction and may be best

managed with manual therapy techniques. Joint mobilisation techniques such as those described by

Maitland (1997), Mulligan (1999) and Kaltenborn (1993) cannot be excluded from a core stability

programme as abnormal mechanics will affect the neural and active subsystems. Normalisation of

physiological and accessory joint movements would appear to be critical in maintaining ideal timing of

muscle activation patterns for muscles acting on the trunk. Such statements are currently largely based on

observation and anecdote, direct evidence has not been forthcoming to date however some evidence for
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this can be found in the literature for manipulative therapy. Keller and Colloca (2000) reported on a clinical

trial where they investigated the effect of mechanical force, manually-assisted spinal manipulative therapy

on trunk muscle strength pre and post manpulation. They found that muscles produced stronger muscle

activation patterns immediately following manipulation of the underlying joints. This study could be

improved by extending the length of follow up time to determine the lasting effects of manipulation.

Research is necessary to develop a greater understanding for the role of the thoracic spine in the core

stability concept. The influence that manual therapy techniques can have on improving muscle activation

patterns and thereby core stability also warrants further research.

Active Subsystem

A number of models have been proposed to describe the functional role of the trunk muscles as

stabilisers and mobilisers (Bergmark, 1989; Comerford and Mottram, 2000; Goff, 1972; Sahrmann, 2002)

The classification schema by Bergmark (1989) divided muscles into two functional categories, the local

stabilising and global stabilising systems. The local stabilising muscles were considered to have a primary

role in maintaining segmental stability. Many of these muscles have their origin or insertion on the lumbar

vertebrae. Panjabi‟s (1992a and 1992b) hypothesis of clinical instability highlighted the role of these

muscles in maintaining the „neutral zone‟. The neutral zone has been described as the area of

physiological intervertebral motion within which the spinal motion is produced with minimal internal

resistance (Gibbons and Comerford, 2001a).

Muscles that make up the local stabilising system are generally considered to be continuously active

throughout movement, their activation is not dependent on direction of movement and due to their

anatomical close proximity to the centre of rotation of the spinal segments they may also have a

proprioceptive role (Gibbons and Comerford, 2001a; Richardson et al., 1999). Panjabi (1992a) suggested

they have a role in maintaining the lumbar lordotic curvature.

The muscles that constitute the global stabilising system are multi-segmental, more superficial, generate

force to control movement, contractions tend to be eccentric to control motion segments throughout range

of movement, activity is direction dependent and muscle activation patterns are phasic (Gibbons and

Comerford, 2001b; Richardson et al., 1999).

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A third functional classification has been proposed by Comerford and Mottram (2000) which they have

labelled the „global mobilisers‟. The function and characteristics of these muscles is to generate torque to

produce range of movement, shock absorption of load, activity is direction dependent and phasic in

nature. Muscle contractions are generally concentric in nature therefore produce movement through

concentric activity rather than the eccentric control displayed by the global stabiliser muscles. Gibbons

and Comerford (2001a) suggested that the global mobility muscles work eccentrically to decelerate high

loads and would adopt a stabilising function when under load or when subjected to high-speed

movements. Table 7 displays the classification of the local and global muscles of the trunk according to

their proposed stability function.

Table 7. Muscle Functional Classification Table. Based on work of Bergmark, 1989; Richardson et
al, 1999; Gibbons and Comerford, 2001b and Norris, 2000).

Local Stabiliser Global Stabiliser Global Mobiliser

Transversus Abdominus Oblique Externus Rectus Abdominus

Deep Lumbar Multifidus Spinalis Iliocostalis

Psoas Major (Posterior Gluteus Medius Piriformis

Fascicles)

Intertransversarii Quadratus lumborum lateral Hamstrings

fibres

Interspinales Oliquus internus abdominis

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Iliocostalis Lumborum pars
lumborum

Quadratus lumborum, medial

fibres

Obliquus internus abdominis

(thoracolumbar fascia insertion)

Further terms that are used to describe the muscular function of the trunk include the „inner‟ and „outer

unit‟ (Lawrence, 2003; Richardson et al., 1999). The corset or girdle effect created by the deep stabilising

muscles that provides a stiffening effect on the spine is also known as the inner unit (Richardson,et al.,

1999 and Chek, 2004). The inner unit of musculofascial support is independent of the outer unit both

anatomically and functionally (Richardson et al., 1999). Muscles that are part of the inner unit include the

transverse abdominus, multifidus, pelvic floor, diaphragm and posterior fibres of the internal oblique

(Richardson et al., 1999; Chek, 2004).

The outer unit has a combined role of stability and movement initiation (Richardson et al., 1999).

Movement is the primary function and this takes place in unison with the stabilising role of the inner unit

(Richardson et al., 1999 and Lawrence, 2003). The outer unit has been further described as being made

up of four subsystems (Lee, 1999). These systems have been labelled the the posterior oblique, the deep

longitudinal, the anterior oblique and the lateral system (Vleeming, et al., 1990a and 1990b). The four

subsystems are effectively another term to describe the specific roles of the global muscles.

The posterior oblique system of the outer unit is made up of the latissimus dorsi, gluteus maximus and the

thoracolumbar fascia. The anterior oblique system includes the external and internal oblique, the

contralateral adductors of the thigh and the anterior abdominal fascia.The lateral system includes the

gluteus medius and minimis and the contralateral adductors of the thigh. The deep longitudinal system

includes the erector spinae, deep lamina of the thoracolumbar fascia, sacrotuberous ligament and the

biceps femoris muscle (Vleeming, et al., 1990a and b and 1995; Lee, 1999). Alteration of normal muscle

activation patterns or weakness of the inner or outer units would reduce the force closure mechanism of

the sacroiliac joint (Vleeming et al., 1990b; Lee, 1999). Lee (1999) proposed that this could result in

compensatory movement strategies to accommodate the dysfunction. She suggested that this could
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culminate in pathology in the lower back, hip and knee. This pathology would most likely be in the form of

tissue trauma as a result of the cumulative effect of undesirable forces. This indicates that by maintaining

adequate control of these muscle groups and their associated synergies and agonist versus antagonistic

relationship that core stability training programmes could either prevent or rehabilitate injuries. The

amount that each system contributes to spinal stability is currently still under investigation (Richardson et

al., 1999).

The functional unit of local stabilisation (Richardson et al., 1999) or cylinder of stability (Chek, 2004;

Hodges et al., 2001) has been used to describe the synergistic actions of the pelvic floor, transversus

abdominis, multifidus, and the diaphragm. This conceptual cylinder is made up of the transverse

abdominis and multifidus as forming the walls, pelvic floor as the base and diaphragm as the lid. Evidence

suggests that with activation of the transverse abdominis muscle there is coactivation of the multifidus,

diaphragm and pelvic floor muscles (Avery et al., 2000; Hodges and Richardson, 1996; Hodges et al.,

1997; Hodges and Gandevia, 2000; Richardson et al., 1999).

The coactivation of the pelvic floor and diaphragm with the transversus abdominus would act to increase

the intra-abdominal pressure and potentially stabilise the spine (Hodges and Gandevia, 2000a; Hodges et

al. 2001). The hypothesis here is that this synergistic activity would provide an additional extensor torque

to the spine. The pressure in the „cylinder‟ is optimised if as the abdominal wall is engaged and drawn in

causing the pelvic floor to be drawn up a deep breath is taken to force the diaphragm down (Hodges et

al., 2001). If the breath is held the intra-abdominal pressure is sustained (Valsalva maneuver). This may

be appropriate for heavy loads to prevent bending stress through the lumbar spine (cylinder) (Hodges et

al., 1997; Hodges, 1999; Hodges et al., 2001; Norris, 2000). Hodges et al. (2001) found a causal

relationship between intra-abdominal pressure and lumbar extensor torque in an in vivo study. Notably

this study was performed on a small sample size of 5 males.

The role of intrathoracic pressure in trunkal stability has been much less lauded. Intrathoracic pressure is

created during inspiration by expanding the lungs against the rib cage. The role of intrathoracic pressure

within the core stability concept appears to have been given very little attention. Norris (2000) considered

that the coordination of combined inspiration and abdominal hollowing to increase intra-abdominal and
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intrathoracic pressure was unsuitable for most rehabilitation programmes. The effect of timing inspiration

with effort could result in the use of the Valsalva maneuver which could potentially raise blood pressure to

dangerous levels (Linsenbardt et al., 1992).

The thoracolumbar fascia gain is an anatomical principle that has been compared with erecting a tent

where the guy ropes (latissimus dorsi, gluteals, thoracolumbar fascia and internal obliques) act together

as a team to support the main structure (lumbar spine) (Lawrence, 2003; Norris, 2002). When the

transverse abdominus muscle contracts and draws in the abdominal wall a synergistic relationship with

the internal obliques is invoked that causes them to contract and increase tension through the thoraco-

lumbar fascia (Hodges, 1999). Evidence for this concept has been provided in studies by Gibson and

McCarron (2004) and Vleeming et al. (1995). The spinal extensors are encased in a layer of fascia

therefore when they contract they act to stretch the fascia and tension it (Norris, 2002). The combined

actions of the latissimus dorsi (pulling fascia upwards), gluteals (pulling fascia downwards) and the

transversus abdominus and internal oblique (pulling fascia sideways) is to resist bending forces through

the spine especially when lifting (Liebenson, 2004c; Norris, 2002; Vleeming et al., 1995). This coordinated

approach to spinal stability requires all muscles to be activated in an appropriate sequence and to have

adequate endurance capacity (Elfving et al., 2003; Thomson, 2002). This highlights the need for core

stability training programmes to consider coordinated muscle function and not just isolated activity.

The transversus abdominis is the deepest abdominal muscle and has been the subject of intense interest

in spinal stability models and research (Hodges, 1999; Richardson et al., 1999; Norris, 2000). The

transversus abdominis muscle has its origin on the iliac crest, lower six ribs, and the lateral raphe of the

thoracolumbar fascia and inserts medially at the linea alba (Williams et al., 1989). The horizontal fibre

orientation results in causing a reduction of the abdominal circumference, increased intra-abdominal

pressure and increased tension in the thoracolumbar fascia (Hodges, 1999).

The contributing role of transversus abdominis to spinal stability has been investigated from two view

points. Firstly, a mechanical evaluation of the transversus abdominis and its ability to contribute to spinal

control, and secondly, the influence of the central nervous system on transversus abdominus during

specific tasks (Hodges, 1999). Hodges (1999) critically reviewed the evidence on the recruitment pattern
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of transversus abdominis. Much of the earliest research on transversus abdominis as a potential

contributor to spinal control was performed by Cresswell et al. (1992). In this study they considered the

surface electromyographical activity of rectus abdominus, internal oblique and external oblique muscles

during isometric trunk extension that caused an increase in intra-abdominal pressure. As there was

minimal electromyographic activity in these muscle groups it was proposed that the increase in intra-

abdominal pressure was due to transversus abdominis involvement. Transversus abdominis was also

found to be the only abdominal muscle continuously active during trunk flexion and extension in both

dynamic and isometric situations (Cresswell et al., 1992).

The erector spinae muscle group has been found to behave in a phasic manner during trunk movements

(Hodges, 1999; Cresswell et al., 1992). This provokes the question of what contributes to the extensor

torque of the lumbar spine or provides the stablity to keep it in the neutral zone whilst the erector spinae is

being latent. The increased intra-abdominal pressure as discussed above provides some of the extensor

torque to the lumbar spine however studies have demonstrated the role of multifidus and iliopsoas (psoas

major and iliacus) as also having major contributory roles in spinal stability (Gibbons et al., 2002; Wilke et

al., 1995). Neuromuscular processes appear to link transversus abdominis and multifidus coactivation

(Richardson et al., 1999). A number of studies have highlighted the combined action of transversus

abdominis and multifidus in maintaining spinal stability (Essendrop, 2002; Hodges et al., 1999).

Physiological evidence of the lumbar multifidus and the lumbar longissimus that is suggestive of their

capacity as integral spinal stabilisers has come from studies of their histochemical composition,

capillarisation and muscle enzyme activities (Richardson et al., 1999). Research indicates that these

muscles have a greater capillary network, concentration of oxidative enzymes and type I fibres which

would allow them to perform with a much greater endurance capacity compared with normal skeletal

muscle which have a relatively even supply of type I and type II fibres (Jorgensen et al., 1993; Astrand

and Rodahl, 1986). This supports the proposed role of these muscles in contributing to a tonic holding and

therefore stabilising function of the lumbar spine.

The role of the internal oblique in the local stability mechanism hasn‟t been fully explored (Richardson et

al., 1999). There appears to be a stabilising role due to its posterior attachment to the lower lumbar
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section of the thoracolumbar fascia. It is therefore possible that it may contribute to stability when the

transversus abdominis causes tensioning of the thoracolumbar fascia by assisting stabilising forces

through the lower lumbar levels (Richardson et al., 1999).

In this review of the evidence behind the concept of core stability the scapulothoracic joint has been

considered within the physical boundaries of the core stability model due primarily to the role that muscle

and fascia that attach onto the scapula have in stabilising the trunk. Stability at the scapulothoracic joint is

hypothesised to be due to a co-contraction between serratus anterior and the trapezius muscles

(Mottram, 1997). It is thought that they have a similar stabilising role as transverse abdominus as muscles

that are preactivated before upper limb movement (Mottram, 1997). This review found no direct evidence

to prove this point however new research is currently investigating this feature.

The latissimus dorsi originates from the sacral and iliac crests, thoracolumbar fascia, spinous processes

of T7-T12 and the posterior surface of the lower ribs (Calais-Germain, 1993; Williams et al., 1999) . The

muscle inserts on the bicipital groove of the humerus however also has a slip to the inferior scapula angle

so therefore may influence scapula position (Calais-Germain, 1993; Mottram, 1997). Conversely, it can

therefore be seen from the above attachment points that scapula position could influence lines of tension

along the thoracolumbar fascia and therefore trunkal stability. Other muscles that should also be

considered when assessing scapula alignment and function in relation to core stability are the rhomboids,

subclavius, pectoralis minor and levator scapulae (Calais-Germain, 1993; Kibler, 1995). While not having

attachments to the spinal column or rib cage the rotator cuff muscle group could also have some influence

on scapula alignment and therefore secondarily on core stability (Horsley, 2005). The kinetic chain

between the shoulder girdle and thoracic spine has been considered by a number of authors who

acknowledged the influence of muscle imbalance and thoracic spine mobility on scapula control

(Kebaetse et al., 1999; Lee, 1995; Janda, 1991). No direct evidence was found to support the influence of

scapula position or control on core stability function.

Another possible consideration would be to consider the scapulothoracic joint as part of a second cell of

peripheral core stability units. Muscle stabilising principles similar to the lumbar spine could be applied to

the shoulder, elbow, hip, knee and ankle joints so that potentially these areas could be viewed as having
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their own unique core stability features. This potentially controversial view could provide geater continuity

in describing the cause and effect of movement dysfunction throughout the body.

Control and Feedback Subsystem

McGill et al. (2003) acknowledged the importance of the sensory organs when considering the motor

control response to sudden spine loading. They reported that the proprioceptive feedback gained from a

variety of proprioceptors including muscle spindles, Golgi tendon organs, joint receptors and cutaneous

receptors was an important drive to directing motor responses to attempted perturbations of the spine.

Conversely, it has been well established from back pain research that subjects with lumbopelvic

dysfunction have impaired muscle activation patterns, poor postural contol and a diminished concept of a

neutal pelvic position (Radebold et al., 2000).

Panjabi (1992a) expressed his opinion that while there was no published evidence that spinal stability

could be enhanced by improving neural control alone he felt the possibility existed. This current review

found a number of studies that intimated that neural adaptations had occurred through low level training of

the deep stabilising muscles (Davidson and Hubley-Kozey, 2005; Richardson et al., 1990; Hagins et al.,

1999; O‟Sullivan et al., 1997a). Muscles were trained at levels below that required to cause hypertrophy

and strength gains however were able to be activated at higher intensities (measured by % maximum

voluntary contraction) following training programmes. It has been suggested that this is the direct effect of

enhancing neural pathways (Davidson and Hubley-Kozey, 2005; McGill et al., 2003).

A decade on from Panjabi‟s (1992a) hypothesis came the work by Holm et al. (2002) who investigated the

role of viscoelastic structures with special focus on their sensory motor functions. The intervertebral disc,

fibrous joint capsule and spinal ligaments are included in the passive subsystem for their physical

properties however their ability to monitor sensory information warrants their inclusion in the neural and

feedback system. The background hypothesis for Holm et al. (2002) was that lesions in avascular

supporting structures could cause perturbations in the proprioceptive function of various receptors and

result in increased and prolonged muscle activation that may cause pain. They further suggested that

subsequent irritation of low threshold nerve endings in the sacroiliac joint, intervertebral disc and

© Christopher McLean 2006 ‘Core Stability: Anatomical, Biological and Psychological 15

Evidence’ Chapter V
zygapophyseal joint tissue may trigger a reflex activation of the gluteal and paraspinal muscles over time

that may provoke further pain.

Another consideration here would be the impact of a „double crush‟ like syndrome where a peripheral

nerve pathway could be compressed twice e.g. centrally due to derangement of an intervertebral disc and

peripherally due to tonic muscle spasm. In this scenario the nerve root irritation due to the disc

compression would inflame the neural tissue and provoke muscle spasm along the course of the nerve

root and therefore further compress the peripheral nerves potentially irritating them locally. This could then

setup a chronic pain cycle. While there is a potential degree of overactivity due to the neural irritation there

could also be associated inhibition of some muscle groups (Arvidsson et al., 1986). As the concept of core

stability appears to rely on a coordinated pattern of muscle activation it would appear that aberations in

the passive and neural subsystems would undermine core stability function.

Holm et al. (2002) used 80 domestic pigs during their investigation of the neuromuscular interaction

between the spinal structures. They found that reflexive contraction of the multifidus and also longissimus

muscles resulted following electrical stimulation of the lumbar afferents in the discs, capsules and

ligaments. The muscular activity was greatest at the level of excitation and found to have weaker

excitation at 1-2 levels above and below (Holm et al., 2002). This finding is suggestive that elements of

the passsive subsystem that help to maintan the neutral zone as described by Panjabi (1992b) also have

a role in monitoring sensory information and controlling spinal muscles especially the multifidus which has

been reported to have a local stabilising role in a number of studies (Hides et al., 1996; Jemmett et al.,

2004 and Moseley et al., 2002). They also found that the multifidus and longissimus muscles had

increased levels of activation due to mechanical stimulation of the viscoelastic structures.

Electromyographic recordings were greater if more than one viscoelastic structure was stimulated (Holm

et al., 2002). Holm et al. (2002) also suggested that the viscoelastic structures provided kinesthetic

perception to the sensory cortex.

Panjabi (1992b) hypothesised that if any one or more of the subsystems weren‟t functioning optimally

then overall spinal stability could be compromised. This could equate to influencing the core stabilising

system to the same extent. Dysfunction of the passive subsystem could be the result of mechanical injury,
© Christopher McLean 2006 ‘Core Stability: Anatomical, Biological and Psychological 16
Evidence’ Chapter V
development of microfractures in the endplates, disc protrusion or degeneration (Panjabi, 1992a). These

disturbances in the passive subsystem could result in compensatory changes in the active subsystem due

to the decreased load bearing and stability capacity of the passive subsystem. The alteration in muscle

activation patterns would influence the core stabilising capacity. Any disruption to the neural components

serving the active musculoskeletal subsystem could affect the muscle activation patterns and influence

feedback of muscle tension to the neural system (Arvidsson et al., 1986; Panjabi, 1992a). It has been

suggested by Panjabi (1992a) that perturbation of the active subsystem could influence the ability to

provide compensatory muscle activation for stresses that challenge the passive subsystem and also

erode the capacity to maintain trunk stability when subjected to unexpected multidirectional forces or

heavy loading (Panjabi, 1992a). In this hypothesis it can be seen that trauma, disuse, degeneration and

disease processes that affect the active subsystem would influence core stability directly. While there

appears to be little direct evidence for this, there is some evidence to suggest that these noxious factors

can influence muscle function and therefore potentiate instability of the trunk (Hides et al., 1994 and 1996;

Silfies et al., 2005).

Dysfunction to the subsystems as described above would have far reaching effects on core stability

rehabilitation programmes as these variables would need to be optimised or reduced below a threshold

that could cause significant influence to the coordinated stabilising function of the subsystems. The

majority of core stabilising rehabilitation programmes have an emphasis on physical training however the

above discussion on reasons for dysfunction to the subsystems highlights the need to consider treatment

of pathological states such as disc prolapse or ligament disruption with surgical and/or physiotherapy

intervention. There is evidence to support both these modalities in the treatment of musculoskeletal

disorders (Gibson, et al., 2005; Moseley et al., 2002).

In terms of the anatomical evidence for core stability much of the traditional anatomical work has been

purely observational. Based on the observations and descriptions of structures researchers have

hypothesised how they function in combination with each other. In this field there are very few randomised

controlled trials so when developing guidelines based on anatomical evidence it would be very unlikely to

ever be able to award the highest grading using the current criteria of the SIGN 50 (2004) protocol. There

is a large proportion of observational and case series studies and from these expert opinions have been
© Christopher McLean 2006 ‘Core Stability: Anatomical, Biological and Psychological 17
Evidence’ Chapter V
proposed (see Table 8). There has been some work on comparing biomechanical models with in vivo

subjects and this has created a framework for predicting perturbations in the living model (Gardner-Morse

and Stokes, 1998; Granata and Orishimo, 2001; Quint et al., 1998; Vleeming et al., 1995).

When comparing and contrasting observational studies in functional anatomy with the findings from

biomechanical studies and biomechanical modelling, concepts and understandings begin to crystalise as

findings from different sources assimilate. The continuity of findings allows concept development to gain

momentum and credibility. There is a need for further studies in functional anatomy to allow the

understanding of the core stability concept to progress.

The anatomical, physiological and biomechanical considerations behind the core stability concept are

clearly complex. Future research will need to be well structured to provide further evidence especially in

the areas of neural systems and synergistic muscle function and coactivation sequences. To see

comprehensive evidence tables for the studies considered in this research question see Table 14 in

Appendix C.

Table 8. Intervention studies for Question 1: What anatomical, biomechanical and physiological
evidence exists that supports the concept of core stability?

Bibliographic Study Ev
General comments
citation type Lev

AVERY, A. F., Case- 2- Investigation of the role of the pelvic floor muscles in providing
O'SULLIVAN, P. B. control SIJ stability as part of the theoretical „force closure‟ system.
& MCCALLUM, M. Stability of the SIJ is hypothesised to be a result of its bony
J. (2000) Evidence configuration (form closure) and the local muscle forces acting
of pelvic floor on the ligaments and fascia to compress the joints (force
muscle dysfunction closure). The authors suggested that their findings support the
in subjects with notion that dysfunction of the pelvic floor muscles may disrupt
chronic sacro-iliac the force closure mechanism of the SIJ in individuals with
joint pain chronic SIJ pain syndrome. This study provided some
syndrome. anatomical, biomechanical and physiological evidence to
Proceedings of the support the concept of core stability. The pelvic floor is
7th Scientific hypothesised to provide the base of the „cylinder‟ or box in
Conference of the many core stability models. Disruption or deficiencies with this
IFOMT in component would theoretically compromise the system.
conjunction with the Limitations of this study must be considered including: small
MPAA, 35-38. sample size, weak statistical methods, testing method of
pelvic floor muscle activity/validity/specificity).

© Christopher McLean 2006 ‘Core Stability: Anatomical, Biological and Psychological 18

Evidence’ Chapter V
 CHOLEWICKI, J., Cohort 2- Both wearing an abdominal belt and increasing IAP can
JULURU, K., study increase spinal stability. Of note was that the belt resulted in a
RADEBOLD, A., decrease in activation of the thoracic and lumbar erector
PANJABI, M. M. & spinae muscles. The authors suggested that concomitant
MCGILL, S. M. increase in IAP was due to muscle coactivation. Limitations of
(1999) Lumbar this study included a small sample size.
spine stability can
be augmented with
an abdominal belt
and/or increased
intra-abdominal
pressure. Eur Spine
J, 8, 388-95.

CHOLEWICKI, J., Cohort 2+ This study demonstrated that antagonistic muscle coactivation
PANJABI, M. M. & patterns were present around the neutral spine posture.
KHAKHATRYAN, Coactivation increased with added mass to the torso. The
A. (1997) importance of neuromuscular control was supported by the
Stabilizing function inverted pendulum biomechanical model. Researchers noticed
of trunk flexor- flexor and extensor activity was very similar for all subjects
extensor muscles however EMG tracings revealed some individual differences
around a neutral between subjects most notably with multifidus and the internal
spine posture. oblique muscles. These muscles appeared to exhibit a
Spine, 22, 2207- constant level of activation regardless of trunk angle. The
2212. implication here is that individuals used different muscle
recruitment patterns to stabilise the lumbar spine.

GARDNER- Exp. 3 The biomechanical model suggested that the probable role of
MORSE, M. G. & Biomech. antagonistic abdominal muscle coactivation was to stabilise
STOKES, I. A. Model the spine. The authors suggested that in vivo the
(1998) The effects design. neuromuscular system must balance spinal stability vs trunk
of abdominal muscle fatigue vs spine compression. Results from this study
muscle coactivation need to be considered carefully as the simulated magnitudes
on lumbar spine of the abdominal coactivations may represent a suboptimal
stability. Spine, 23, strategy for spinal stability invivo.
86-91; discussion
91-2.

GIBSON, J. & Case 3 This study demonstrated that the internal oblique muscle
McCARRON, T. series activity feeds-forward in anticipation of functional task
(2004) Feedforward performance. This suggests that prior to prime mover activity
muscle activity: an (deltoid) active stabilisation of intersegmental joints is thought
investigation into to occur prior to arm displacement. This supports core stability
the onset and theories that purport that by creating greater stiffness of the
activity of Internal lumbar motion segment trunk movement may occur from a
oblique during two stable base. Supports Hodges (1999) study for transversus
functional reaching abdominus. This study indicated that a peak of activity
tasks. Journal of occurred close to the onset of initial movement and was
Bodywork and followed by a consistent lower level of activity until the arm
Movement came to rest. The authors suggested that this implies that a
Therapies, 8, 104- certain threshold of activity needed to be achieved and
113. maintained in order to maintain a critical level of stiffness at
the neutral zones of the spine to prevent strain of spinal
structures during upper limb movement. From a training
perspective this study implies that endurance training for the

© Christopher McLean 2006 ‘Core Stability: Anatomical, Biological and Psychological 19

Evidence’ Chapter V
 internal oblique muscle (type II fibres) is necessary so it can
maintain spinal (stiffness) integrity during movement tasks of
the upper limb. This study also supported the concept of local
stabilising muscles and the need for them to provide spinal
stability. Inhibition of these muscles in conditions such as low
back pain that cause changes in the neuromuscular system
would potentially expose the spine to excessive forces of
translation and inefficiency along the kinetic chain. This study
protocol needs to be repeated with a controlled matched
subject trial with normals and a pathology group (e.g. chronic
low back pain).

HIDES, J. A., Case - 2+ Unilateral wasting of the multifidus muscle on the symptomatic
STOKES, M. J., control side could be detected by real-time ultrasound. At the
SAIDE, M., JULL, symptomatic vertebral level the degree of multifidus muscle
G. A. & COOPER, cross sectional area difference was greatest. The reason for
D. H. (1994) this was hypothesised to be due to inhibition from perceived
Evidence of pain via a long-loop reflex pathway. There was also a reported
multifidus muscle lack of correlation between severity of wasting and clinical
wasting ipsilateral findings. Some subjects with relatively minor clinical
to symptoms in symptoms had significant wasting. Notably, some subjects in
patients with the „normal‟ population that demonstrated asymmetry were
acuter/subacute low symptom free and this may relate to sports that involve
back pain. Spine, unilateral use of muscles. It could also potentially provide a
19, 165-172. window into the future as a measurable precursor to
symptoms. This would need further investigation. This study
provided some evidence on the intersegmental role of
multifidus and an apparent link between atrophy and spinal
dysfunction. Possibly the lack of stability at a specific spinal
segment contributes to the pain pathology. The lack of spinal
stiffness that multifidus could provide at that level would create
difficulty for the spine to maintain motion in the neutral zone.
This concept requires further consideration and research.

HIDES, J. A., RCT 1+ Multifidus muscle recovery didn‟t correlate with remission of
RICHARDSON, C. painful symptoms. The authors proposed that reflex inhibition
A. & JULL, G. A. was the likely cause rather than via a long, loop reflex.
(1996) Multifidus However the patients in the exercise group made a more rapid
muscle recovery is recovery from a muscle physiology perspective. At the 10
not automatic after week follow up group 1 patients still had decreased multifidus
resolution of acute, muscle size even though they had returned to normal activities
first-episode low of daily living. It would appear that early local stabilisation
back pain. Spine, exercises can accelerate the return of more optimal spinal
21, 2763-2769. mechanics and therefore decrease the frequency of recurrent
episodes of low back pain. Further research is required to
determine optimal exercise programmes including exercise
type, frequency and duration of programme.

HODGES, P., Case 3 Transversus abdominus has an important role in respiration as

GANDEVIA, S. C. series well as spinal stability. Transversus abdominus normally only
& RICHARDSON, contributes to respiration during forced expiration or
C. A. (1997) involuntarily by breathing in against an inspiratory load. This
Contractions of study suggested that transverses abdominus can contribute
specific abdominal equally well to spinal stability in any respiratory phase. The
muscles in postural authors suggested neural involvment in determining degree of
tasks are affected abdominal muscle activity during postural perturbations to

© Christopher McLean 2006 ‘Core Stability: Anatomical, Biological and Psychological 20

Evidence’ Chapter V
 by respiratory increase IAP.
maneuvers. Journal
of Applied
Physiology, 83,
753-760.

KAIGLE, A. M., In vivo 3 The purpose of this study was to evaluate the contribution
HOLM, S. & animal from various spinal components, including muscular
HANSSON, T. H. model of involvement of the lumbar motion segment, to the overall
(1995) lumbar stability of the spine. They found that in the neutral region,
Experimental spine. where the muscles are under reduced tension, the motion
instability of the segment is highly susceptible to instability, resting
lumbar spine. musculature influences spinal mechanics and increased
Spine, 20, 421-430. muscular activity in the injured motion segment has a
stabilising effect by reducing the abrupt patterns of motion in
the neutral zone. This study although performed on pigs
provided considerable evidence as to the stabilising role of
some key muscle groups: erector spinae, multifidus,
quadratus lumborum and psoas. While great care must be
taken with extrapolating these results to the human spine it did
provide a valuable insight into the effects that degenerative
changes and surgical techniques can have on spinal
mechanics. It would be unlikely for this study to be replicated
on a human population in its current format however a revised
version may gain ethical approval and could potentially
provide conclusive evidence on muscle function.

LEINONEN, V., Cross- 2- The rehabilitation focused on improving back muscle strength,
KANKAANPAA, sectional mobility, coordination and muscle elasticity. Exercises began
M., AIRAKSINEN, design. at a low intensity and were gradually increased. Chronic back
O. & HANNINEN, pain group demonstrated reduced gluteus maximus activity
O. (2000) Back and Case- during the flexion-extension cycle. This study found no
hip extensor control significant difference between groups for paraspinal muscle
activities during activity. Recommendation is to repeat study design but include
trunk investigation of hip and spinal extensor activity during spinal
flexion/extension: flexion and extension.
Effects of low back
pain and
rehabilitation.
Archives of
Physical Medicine
and Rehabilitation,
81, 32-37.

GRANATA, K. P. & Two 3 Experimental data supported the test hypothesis that muscle
ORISHIMO, K. F. dimensio activation increased when external loads were held at greater
(2001) Response of nal heights. Supporting the concept that the neuromuscular
trunk muscle biomech system responds to changes in stability.
coactivation to anical
changes in spinal model
stability. J Biomech,

© Christopher McLean 2006 ‘Core Stability: Anatomical, Biological and Psychological 21

Evidence’ Chapter V
 34, 1117-23.

KUMAR, S. (1997) Case 3 This study hypothesised that intra-abdominal pressure would
The effect of series correspond to the magnitude of the load applied. However this
sustained spinal study showed the IAP to be inconsistent.The study concluded that
load on intra- intra-abdominal pressure is not an active spine load-relieving
abdominal pressure mechanism. This study should be compared with Hodges work.
and EMG The results from this study are contrary to most others however
characteristics of this study investigated prolonged loading whereas most others
trunk muscles. considered transient loading.
Ergonomics, 40,
1312-34.

NG, J. K., Case 3 Different functional roles of trunk muscles during axial rotation
PARNIANPOUR, series were demonstrated in this study. The more lateral and oblique
M., RICHARDSON, the muscle fibres, the more these muscles contribute to
C. A. & KIPPERS, movement force, but in the main part, only on the side
V. (2001) ipsilateral to the movement. The multifidus and rectus
Functional roles of abdominis muscles act bilaterally during unilateral rotation
abdominal and movements indicating their role is more of a stabilising one.
back muscles The activity of multifidus was greater than its synergist, rectus
during isometric abdominis, adding further weight to the body of evidence that
axial rotation of the points to its role as a local stabiliser of the lumbar spine, not
trunk. J Orthop just during sagittal plane exertions but in axial rotation
Res, 19, 463-71. exertions as well.

ESSENDROP, M., Case 3 Results of this study indicate that both abdominal and back
ANDERSEN, T. B. series muscles may have a role to play in stabilising the spine. Indication
& SCHIBYE, B. of involvement of trunk muscles and increased IAP levels to
(2002) Increase in sudden spinal loading.
spinal stability
obtained at levels of
intra-abdominal
pressure and back
muscle activity
realistic to work
situations. Appl
Ergon, 33, 471-6.

BROWN, S. H., Case- 3 (Also evidence for question 6) This study demonstrated that in
HAUMANN, M. L. series situations of sudden unloading , knowledge of the timing of
& POTVIN, J. R. the unloading may lead to anticipatory actions of postural
(2003) The muscles which actually decreases spinal stability, thereby
responses of leg increasing the risk of injury should an unexpected perturbation
and trunk muscles occur. The authors suggested that both loading and unloading
to sudden of the spine can create relative instability. The magnitudes of
unloading of the the decreases were observed to become less pronounced as
hands: implications knowledge of the perturbation timing decreased. The random

© Christopher McLean 2006 ‘Core Stability: Anatomical, Biological and Psychological 22

Evidence’ Chapter V
 for balance and unloading condition demonstrated the importance of
spine stability. Clin cocontractions about the spine as the posterior muscles
Biomech (Bristol, showed a significant increase in activation and anterior
Avon), 18, 812-20. muscles a slight increase. It would appear that anticipatory
reactions attempt to keep compressive loads through the
spine to a minimum. This study needs to be extended to look
at the effects of pathological states and gender on anticipatory
reactions. It would appear that unloading exercises should be
performed as part of a core stability programme.

NG, J. K., Case- 2+ Authors expressed that training coordination and multiplanar
RICHARDSON, C. control movements as well as strength during rehabilitation is vital.
A., The authors hypothesised that the reduced activity of
PARNIANPOUR, multifidus in the back pain group may indicate that spinal
M. & KIPPERS, V. stability was compromised.
(2002) EMG activity
of trunk muscles
and torque output
during isometric
axial rotation
exertion: a
comparison
between back pain
patients and
matched controls. J
Orthop Res, 20,
112-21.

CHIANG, J. & Repeate 3 The authors reported that higher levels of trunk muscle
POTVIN, J. R. d preactivation increase spine stability. Higher loads increase
(2001) The in vivo measure activation of agonistic and antagonistic muscle activation.
dynamic response s design Larger multisegmental muscles are important in the
of the human spine maintenance of spine stability. Supports the concept that
to rapid lateral bend cocontraction increases stability of the spine. Supportive of
perturbation: effects the work by Cholewicki.
of preload and step
input magnitude.
Spine, 26, 1457-64.

ESSENDROP, M. Case 3 IAP rose quickly with the loading effect. This reinforced the
& SCHIBYE, B. series notion that physiological components that result in increased
(2004) Intra- IAP have an important role in maintaining and returning the
abdominal pressure trunk to neutral. Men tended to develop higher IAP and higher
and activation of torques than women when the trunk was suddenly heavily
abdominal muscles loaded. The authors described an „internal air bag‟ effect with
in highly trained increasing IAP. Rectus abdominus was found to have minimal
participants during activity in IAP production therefore confirming its role more as
sudden heavy trunk a mobilising rather than stabilising muscle. In terms of core
loadings. Spine, 29, stability this paper described how the ability to generate higher
2445-51. IAP is crucial to stabilising the spine from perturbations. This
study needs to be repeated with non trained individuals to
determine the effect of loading an untrained person with
sudden heavy loads.

© Christopher McLean 2006 ‘Core Stability: Anatomical, Biological and Psychological 23

Evidence’ Chapter V
 STOKES, I. A., Case 3 This study supported the theory that preactivated muscles can
GARDNER- series stabilise the loaded spine. The authors concluded that
MORSE, M., preactivation of the muscles increased spinal stiffness
HENRY, S. M. & therefore helped to maintain the spinal system in equilibrium.
BADGER, G. J. Evidence for anatomical and biomechanical concept of trunk
(2000) Decrease in core stability.
trunk muscular
response to
perturbation with
preactivation of
lumbar spinal
musculature. Spine,
25, 1957-64.

Van DIEEN, J. H. Repeated 3 Notably 2 subjects demonstrated significantly different muscle

(1996) Asymmetry measures activity from the general pattern. Possibly this could represent
of erector spinae design an underlying pathology and a precursor for back pain. This is
muscle activity in worthy of further investigation. Some evidence for the effects
twisted postures of fatigue and spinal stability. Twisting was found to cause
and consistency of asymmetry in back muscle activation resulting in stress
muscle activation concentrations in spinal motion segments. The distribution
patterns across model was able to demonstrate the effects of asymmetrical
subjects. Spine, 21, loading on the spine.
2651-2661.

HODGES, P. W. & Case 3 This study was one of the earlier works that suggested the
RICHARDSON, C. series transverse abdominus muscle had an important role in
A. (1997) stabilising the trunk in anticipation of upper limb movement.
Relationship This study provided initial normative data for preprogrammed
between limb anticipatory muscle activity. This knowledge can be
movement speed incorporated into the assessment of and treatment of
and associated stabilising muscles. Future studies should investigate the
contraction of the responses of subjects who have pathology especially low back
trunk muscles. pain. The EMG activity was recorded via fine wire as well as
Ergonomics, 40, surface electrodes thus providing a more reliable picture of the
1220-30. true functioning of the deeper abdominal muscles.

HODGES, P., Case 3 Transverse abdominus and internal oblique EMG timing did
CRESSWELL, A. & series not vary between directions of bilateral shoulder movement.
THORSTENSSON, This non-specific activation pattern supports the non-direction-
A. (1999) specific response of the deep abdominal muscles.
Preparatory trunk
motion
accompanies rapid
upper limb
movement. Exp
Brain Res, 124, 69-
79.

JEMMETT, R. S., In-vitro 3 Dissection of the lumbar spine demonstrated segmental

MACDONALD, D. study attachment patterns for transversus abdominis, psoas,
A. & AGUR, A. M. quadratus lumborum and multifidus. Confirmed that muscle

© Christopher McLean 2006 ‘Core Stability: Anatomical, Biological and Psychological 24

Evidence’ Chapter V
 (2004) Anatomical group surrounds the motion segments from the anterolateral
relationships aspect of a vertebral body to the spinous process. This study
between selected can only receive a low evidence rating due to small sample
segmental muscles size and often significant variations in individual anatomy.
of the lumbar spine
in the context of
multi-planar
segmental motion:
a preliminary
investigation. Man
Ther, 9, 203-10.

Van DIEEN, J. H., Case 3 Study demonstrated greater coactivation with unstable load.
KINGMA, I. & VAN series This study demonstrated that antagonistic coactivation
DER BUG, P. increases trunk stiffness during lifting tasks. Increasing spinal
(2003) Evidence for stiffnessmay also improve kinematic control of the spine.
a role of Repeating this study with back pain patients may provide
antagonistic some further information on compenation strategies.
cocontraction in
controlling trunk
stiffness during
lifting. J Biomech,
36, 1829-36.

STOKES, I. A. & Comparis 3 This study described the challenges of predictive analytical
GARDNER- on of models. The authors found the role of the central nervous
MORSE, M. (2001) experime system to be difficult to account for in this model. Authors
Lumbar spinal ntal data concluded that muscle activation strategies efficiently limit
muscle activation with a intervertebral forces and displacements.
synergies predicted predictive
by multi-criteria cost model.
function. J
Biomech, 34, 733-
40.

HODGES, P. W., Case 3 This study provided evidence that IAP contributed to spinal
CRESSWELL, A. series stability. The in vivo results correlated with the biomechanical
G., DAGGFELDT, In vivo model. The role of the diaphragm in contributing to the roof of
K. & study the cylinder in the core stability model can be deduced from
THORSTENSSON, this study.
A. (2001) In vivo
measurement of the
effect of intra-
abdominal pressure
on the human
spine. J Biomech,
34, 347-53.

MARRAS, W. S., Cohort 2+ During whole-body free-dynamic condition women

DAVIS, K. G. & experienced greater relative loads. Men experienced greater
JORGENSEN, M. absolute spine loading due to body mass and women had
(2002) Spine greater relative spine loading due to kinematic compensations.

© Christopher McLean 2006 ‘Core Stability: Anatomical, Biological and Psychological 25

Evidence’ Chapter V
 loading as a Authors concluded that women were at greater risk of injury
function of gender. when considering spine tolerances. This is a relevant finding
Spine, 27, 2514- for rehabilitation programmes.
2520.

MOSELEY, G. L., Cross- 3 The authors concluded that the deep and superficial fibres of
HODGES, P. W. & sectional the multifidus are differentially active during single and
GANDEVIA, S. C. repetitive movements of the arm. They also concluded that the
(2002) Deep and superficial fibres of multifidus contributed to the control of
superficial fibres of spine orientation and that the deep multifidus has a role in
the lumbar controlling intersegmental motion.
multifidus muscle
are diferentially
active during
voluntary arm
movements. Spine,
15, E29-E36.

QUINT, U., WILKE, In vitro 3 The results of this study extend those of an earlier study by
H., SHIRAZI-ADL, biomech Wilke et al (1995). They demonstrate the importance of the
A., anical neural control strategy in increasing L4-L5 motion segment
PARNIANPOUR, design stiffness when subjected to axial torque and lateral bending
M., LOER, F. & moments. Whilst the method of torque application in this
CLAES, L. E. study was more sophisticated than in the Wilke et al (1995)
(1998) Importance study, there are still several limitations when extrapolating
of the results from in vitro to in vivo conditions.
intersegmental
trunk muscles for
the stability of the
lumbar spine.
Spine, 23, 1937-
1945.

RADEBOLD, A., Case 2+ Subjects with low back pain demonstrated a very different
CHOLEWICKI, J., control muscle response to a sudden trunk load in a range of spinal
PANJABI, M. M. & study postures. Patients had longer reaction times compared to
PATEL, T. C. their matched controls and, unlike the control group,
(2000) Muscle demonstrated a pattern of agonist-antagonist co-contraction.
response pattern to This may predispose to low back pain and / or be activated to
sudden trunk enhance spinal stiffness. The endurance capacity of the
loading in healthy mucles involved in this co-contraction pattern was not
individuals and in examined so this study does not provide clues as to whether
patients with this pattern is a successful compensation.
chronic low back
pain. Spine, 25,
947-954.

SAPSFORD, R. R. Case 3 This study was conducted in healthy subjects with the aim of
& HODGES, P. series determining whether there is a link between voluntary
(2001) Contraction abdominal muscle contraction and pelvic floor muscle activity.
of the pelvic floor The data shows a positive link between the two and the
muscles during increase in pelvic floor muscle activity before any increase in
abdominal abdominal muscle activity suggests that the pelvic floor has a

© Christopher McLean 2006 ‘Core Stability: Anatomical, Biological and Psychological 26

Evidence’ Chapter V
 maneuvers. preprogrammed anticipatory function. Dysfunction of the
Archives of pelvic floor muscles can lead to urinary and fecal
Physical Medicine incontinence. Whilst the effect of a combined abdominal /
and Rehabilitation, pelvic floor exercise programme was not studied, the results
82, 1081-1087. suggest that abdominal muscle training may be beneficial in
restoring pelvic floor function. This is of interest as the pelvic
floor provides the inferior sling aspect of lumbo-pelvic, or
“core” stability.

SILFIES, S. P., Non- 2- The chronic low back pain population in this study
SQUILLANTE, D., randomis demonstrated altered muscle activation strategy when trying
MAURER, P., ed case- to enhance trunk stiffness. This increase in overall trunk
WESTCOTT, S. & control muscle activity was driven by increases in multisegmental
KARDUNA, A. R. abdominal muscles rather than the unisegmental multifidis
(2005) Trunk muscles. Data from this study suggested that it is not damage
muscle recruitment to the passive subsystem that drives this alteration in muscle
patterns in specific activity and that the number of segments degeneratively
chronic low back damaged does not influence the aberrant muscle activation
pain populations. pattern.
Clinical
Biomechanics, 20,
465-473.

SOLOMONOW, M., Experime 3 This study demonstrated the direct link between multifidis and
ZHOU, B., ntal case the supraspinous ligament in both human patients and cats.
HARRIS, M., LU, Y. series The authors postulate that damage to the supraspinous
& BARATTA, R. V. combine ligament can lead to multifidis overactivity and possibly pain.
(1998) The d human No pain outcome measures were included in this study and
ligamento-muscular and the human population size was limited to two, making it only
stabilizing system animal marginally better than a case study. More work needs to be
of the spine. Spine, experime done in this area with a greater population sample and pain
23, 2552-2562. nt. assessment tools in order for these claims to be substantiated.

VLEEMING, A., Experime 3 The thoracolumbar fascia provides the mechanism for an
POOL- ntal in integrated force transfer system between the spine, pelvis,
GOUDZWAARD, vitro case legs and arms. Some muscles that attach to the
A. L., series thoracolumbar fascia (notably gluteus maximus and latissimus
STOECKART, R., dorsi) can exert their influence contralaterally. Hence, these
VAN muscles can provide a track for force transfer between pelvis
WINGERDEN, J. & and trunk. In this manner, the thoracolumbar fascia provides
SNIJDERS, C. A. plays a vital role in the integration of tunk rotation and in load
(1995) The transfer, thus augmenting the stiffness of the lumbopelvic
posterior layer of region and theoretically in enhancing the force closure
the thorocolumbar component of the sacroiliac joint. Potentially therefore, it can
fascia. Its function be assumed that strengthening those muscles with direct
in load transfer attachments to the thoracolumbar fascia may increase the
from spine to legs. force closure forces.
Spine, 20, 753-758.

© Christopher McLean 2006 ‘Core Stability: Anatomical, Biological and Psychological 27

Evidence’ Chapter V
 WILKE, H., WOLF, In vitro 3 This experiment showed the strong influence of muscle forces,
S., CLAES, L. E., study particularly multifidis, on stiffening intervertebral motion
ARAND, M. & segments (that is, reducing the neutral zone and ROM). In
WIESEND, A. contrast to Panjabi et al (1989) who reported increased flexion
(1995) Stability angles during similar muscle stimulation, this experiment
increase of the showed a significant reduction in flexion angle (65%). The
lumbar spine with major limitation of the study was that the muscle forces
different muscle simulated were transferred through a small, discreet site of
groups. Spine, 20, attachment onto the vertebrae, rather than the broad
192-198. attachments seen in vivo. It does however provide further
weight to the concept of deep muscle activation reducing
neutral zone movement with associated spinal movement.

SEE REFERENCES AND APPENDICES

© Christopher McLean 2006 ‘Core Stability: Anatomical, Biological and Psychological 28

Evidence’ Chapter V