MC/Strength/Endurance of Trunk Flashcards
Core Stability Definition
Core stability is a base or platform of musculoskeletal strength (and endurance) that results in (neuromotor)control of the trunk and allows optimal performance of limb activity.
Cervical and scapula stability as well
Stabilization of trunk to advance the function of the limbs.
Phase 1 - Interventions: Motor Function
- MOVEMENT REEDUCATION – Restore ideal movement patterns
- Motor coordination/control exercises (mm activation/ recruitment); deep abdominals, deep neck flexors, etc.
- Submax Isometrics
activation here
Phase 2 - Interventions: Motor Function
- Educate/enhance ideal movement patterns
- Proximal stabilization/recruitment (core stabilization)
- Strengthening of deep stabilizers of the region
- Isotonic strengthening (OKC and CKC)
limb movement here
Factors at play to enhance motor function of the tunk
- Movement coordination (Dissociation of upper and lower ¼) Need dissociation before strengthing
- Motor control: Muscle activation
- Motor Strength: Force production
- Motor Endurance
– Flexibility of tonic muscles
– Proprioceptive awareness
Phasic Muscles are also known as
Joint stabilizers
Tonic muscles are also known as
Primary movers
Lumbo Pelvic hip - phasic vs tonic muscles
PHASIC
* Deep abdominal (TA and IO)
* Quadratus lumborum
* Multifidus
* Pelvic floor
* Gluteus maximus
* Gluteus medius and deep hip rotators (ie: piriformis)
TONIC
* Rectus abdominus
* External oblique
* Erector spinae
* Hamstrings
* Adductors
* Rectus Femoris
* Lattissimus dorsi
Cervical-Thoracic-Shoulder: phasic vs tonic muscles
PHASIC
* Lower Trapezius
* Serratus Anterior
* Deep neck flexors
* Posterior rotator cuff
TONIC
* Lattissimus dorsi
* Pec major
* Deltoid
How do the lumbo-pelvic-hip muscles respond to pain
- Delay in deep abdominal AND multifidus function following back injury
- Dysfunction of pelvic floor and lateral hipmuscles post- pregnancy and SI related conditions
- Weakness of gluteus maximus/medius in response to hip AND knee AND ankle conditions (dysfunction)
What population is most susceptible to SI issues?
Pregnant women
How do the cervical-thoracic-shoulder muscles respond to pain?
- Delay in deep neck flexor function (starting within 2 hours) following neck injury esp. following motor vehicle accident (MVA)
- Serratus anterior and lower trap weakness and endurance deficits in high functioning patients with shoulder conditions (swimmers, volleyball)
- Rotator cuff weakness in chronic shoulder conditions
Which muscles are the most important? Why?
- None of them AND all of them
- No one muscle contributes greater than 30% of the overall stability of the lumbar spine. Stability is dependent on all muscles
- Contibutions from each muscle continually changes throughout a task
Usual Examination findings associated with Trunk Motor Control/Strength Deficits
Subjective
* History of back/hip pain OR neck/shoulderpain
* Especially history of persistent symptoms (“chronic”)
* Symptoms usually associated with static postures and/or asymmetric “loading” of the spine.
* Symptoms increase as the day progresses
Posture: Poor postural awareness (aka body positioning)
AROM: Imparied QUALITY of motion especially with functional motions. “Abberant motion”
Palpation: associated with tenderness of tonic muscles
Motor: Poor activation of muscles and poor endurance
Interventions for the Lumbo-Pelvic-Hip Region
- Enhance Movement Coordination (Femoral and pelvic dissociation).
- Balance and proprioception.
- Interventions to minimize tone of tonic muscles: Stretching and/or Soft tissue mobilization.
- Enhance motor function:
– First: Neuromuscular control (activation) and endurance of the “phasic” muscles
– Second: Strength/Endurance of the phasic and tonicmuscles
With patients with a Hx of back pain, research shows that the integration of ____ therapy has better outcomes.
- manual
- People have less pain and people perceive you as a better therapist
What is the order we provide interventions for muscles?
Activation -> Strength -> Endurance
Applies to lumbo-peliv and cervico-scap
What muscles in the lumbo-pelvic would you consider go from activation into endurance? How do we progress them to endurance?
- Deep abdominal/multifidus/pelvic floor
- Quadratus Lumborous
- Gluteus maximus
- Gluteus Medius
- Progress all to endurance activities by increasing hold times
What are the Interventions for the Cervico-thoracic-scapular region?
- Enhance Movement Coordination(Scapular and humeral dissociation). From previous weeks
- Proprioception and rhythmic stabilization.From previous weeks
- Interventions to minimize tone of tonic muscles: Stretching and/or Soft tissue mobilization. From 1st ½ of semester
- Enhance motor function:
– FIRST: Neuromuscular control (activation) andendurance of the “phasic” muscles
– SECOND: Strength/Endurance of the phasic andtonicmuscles
In this order!
What cervico-scapular muscles need to go from neuromuscular control -> strength -> endurance? How can we progress to endurance?
- Deep neck flexor
- Deep neck extensor
- Lower trap and rotator cuff
- Serratus Anterior
- Progress all to endurance activities by increasing hold times
What is the order for interventions to enhance motor function of the trunk?
- Education
- Dissociation of movement patterns
- Minimize tone/irritability of tonic muscles
- Neuromuscular control, Strength AND endurance
Patient Education for trunk control
- Educate patient that injury and pain affects muscle function
“Your condition (pain, injury, neuro condition, etc.) affects how the muscles function. Because the muscles are not functioning optimally it may be contributing to your symptoms. It is important first to retrain the muscles to function on command and THEN improve strength or endurance of muscles”
Marathoner vs Sprint analogy - Patient Education on phasic/tonic muscles
Marathoner: Deep stabilizers are phasic muscle
Sprinters: Superficial – primary movers, tonic
Sprinters don’t like marathoners. Get sore results in irritability of muscles. Get the irritability to go away by getting the sprinters to train like sprinters not marathoners
Facilitate Femoral and Pelvic Dissociation in Lumbo-Pelvic-Hip
- Pelvic mobility in sagital and horizontal planes is important to establish PRIOR to strengthening exercises (ie: pelvic clocks)
- Once patient has awareness of movement, educate on concept of “neutral pelvis”
What is considered “NEUTRAL PELVIS and NEUTRAL SPINE”?
- Neural position: between anterior and posterior tilt end range. Up to patients decision. Working on maintaining this position.
- Struggles because of lack of proprioception and lack of dissociation.
- Can be found by the patient in supine, sitting and standing
Facilitate scapular and humeral dissociation of the cervico-thoracic region
- Scapular dissociation: Scapular clocks
- Humeral dissociation: Isolated humeral motion on fixed scapula
- Once patient has awareness of movement, educate on concept of “ideal neck and scapular position”
What is considered “Ideal neck and scapular position”?
- Posterior neck elongated with ear over acromion
- Scapula rested on rib cage with scapular in mid-range between end range protraction and retraction.
- Can be found by the patient in supine, sitting and standing
Minimize tone/irritability of tonic muscles via stretching or Soft tissue mobilization - Primary muscles to target
Primary muscles to address in lower quarter:
* Erector spinae
* Adductors
* Hip flexors
* Hip rotators
* Hamstrings
* Quadriceps
Primary muscles to address in upper quarter:
* Pec minor
* Upper trap and levator
* Scalenes
What are the four stages of neuromuscular control/strength/endurance?
Stage 1: Activation stage
Stage 2: Static stabilization stage
Stage 3: Dynamic stabilization stage
Stage 4: Activity specific training
Stage 1&2 – Local Training (Deep stabilizers, phasic muscles)
Stage 3&4 – Global Training (primary movers, tonic muscles)
Stage 1: Activation
- Teach individual to recruit muscles on command with “ideal” posture (ex: teach deep abdominal activation in neutral pelvis/spine)
- Especially important with deep abdominals/ multifidus/pelvic floor and gluteals in lumbo-pelvic-hip region
– Keep pelvis in “neutral alignment” and activate these muscles - Especially important with lower trap and deep neck flexors and rotator cuff in cervico-thoracic-shoulder region
– Keep scapula and c-spine in neutral
Stage 2: Static Stabilization
- Teach to maintain static alignment of the pelvis/lumbar spine or scapula/CT region
- Impose specific demands (commonly unilateral to challenge transverse plane) on the lower or upper extremity as patient maintains static position of pelvis/lumbar spine or scapula/CT spine
- Work in variety of planes of movement
- Add resistance only if needed. Typically, these are “body weight exercises”
Stage 3: Dynamic Stabilization
- Impose specific demands on the lower and upper extremity as patientmoves through the range of motion of lumbopelvic or scapulothoracic region while resistance is applied.
- Be sure to avoid painful motion
- In other words, the patient no longer stays in neutral or ideal spine position (into functional movements
- Work in variety of planes of movement
- Resistance is provided as needed
Stage 4: Activity Specific Training Examples
Squats, Rows, Overhead throw, lunges, activity specific training
Example: Deep Abdominal Program in Supine
- Stage 1 find neutral pelvis. Activate muscles palpate medial to ASIS.
- Stage 2: Creates a rotational stressor to the trunk but in a stabile position; maintain neutral in transverse and sagittal plane.
- Stage 3: Bring both knees up and to 90 degree angle; have them extend hip and control eccentric motion down and concentric back up; less stable BOS. Touch heel come back up.
- Stage 4: Extend legs straight out, the farther you go the farther it goes. Doing one at a time introduces the transverse plane.
- Each demand greater force on iliopsoas and therefore puts more demand on spine.
“Don’t let your fingers move” – Hands on ASIS; External Cue
Illiopsoas: Anterior aspect of spine and iliac fossa
Deep abdominal, PF: prevent tilting of spine.
HEP Dosage
Depends on goal of exercise!
Muscle Activation
High Reps and low hold times (1 sec - frequently through the day)
Strength
Sets and reps with appropriate resistance (based on what patient can tolerate). To enhance force production, usually 2-3 sets of 8-12 reps
Establish goals for patients on how MUCH RESISTANCE they can tolerate
Endurance
Work till “form failure” – OR – till symptom provocation
Use time NOT sets and reps. Perform the activity for a period of time vs. providing sets and reps.
Establish goals (in seconds or minutes) for patients on HOW LONG THEY CAN perform the exercise
