June 27 th , 2011 Assistant Professor of Physical Therapy at - PowerPoint PPT Presentation

June 27 th , 2011

 Assistant Professor of Physical Therapy at Pacific University Oregon (near Portland, OR)  Background: PT, ATC, CSCS; board certified sports physical therapy  Completing PhD dissertation currently (RMUofHP)  Wrote Core Assessment and Training ; published by Human Kinetics in 2010.

 Define the “core”  Functional assessment of core function in athletes  Exercise prescription for athletes  Examples from the literature

The core region consists of the muscles and joints of : Lumbar spine Abdominals Hips

“Ability to control the position and motion of the trunk over the pelvis to allow optimum production, transfer and control of force and motion to the terminal segment (in activities)”. Kibler et al Sports Med (2006)

 Lateral Musculature Test  Flexion Endurance Test  Back Extensor Test  Bunkie Test (de Witt)

 3 Tests  Lateral Musculature Test  Flexor Endurance Test  Back Extensor Test  Results from these tests will help to identify muscular endurance capacity  Why are these scores important? McGill SM (2002, 2007)

picture from McGill SM (2002) Low Back Disorders Human Kinetics

picture from McGill SM (2002) Low Back Disorders Human Kinetics

picture from McGill SM (2002) Low Back Disorders Human Kinetics

AVERAGE SCORES Back Extensor Test : 173 seconds Flexion Endurance: 134 seconds R Lateral Musculature: 83 seconds L Lateral Musculature: 86 seconds The Key: The Ratios Between Scores McGill SM (2002)

 Right Lateral Test Score/ Left Lateral Test Score should be ≤ 0.05  Flexion Score/ Extension Score should be ≤ 1.0  Lateral Test Score (either side)/ Extension Score should be ≤ 0.75 McGill SM (2002)

Study Compared 34 Year Old Males w/ No • Back Pain and 34 Year Old Males with a History of Disabling Back Pain Those With a History of Low Back Pain • Tested Worse Than Normals The 34-Ye Year ar Old lds s Wit ith A His isto tory ry of LBP Were • Asy symptoma mptomati tic c At t th the Tim ime of Test stin ing! g!! McGill SM (2002)

 Decreased Performance Time  Changed Ratios  Patient Example: Ext 6 sec, Flex 16 sec, RSB 7 sec, LSB 0 sec “BUT MY SPINE IS STRONG”

 A recently proposed functional testing protocol for the core  5 testing positions, total of 10 tests de Witt et al J Bodyw Move Ther 2009

de Witt et al recommends that endurance athletes should be able to hold each position for 40 seconds See case report later in discussion de Witt et al (2009)

Hip Cross-over Step Down Single-legged squat STAR Lunge Squat

 Address muscular endurance imbalances and movement pattern dysfunction (functional tests)  Integrate core into sport specific activities (e.g. plyometrics)

 CURL UPS  SIDE BRIDGING (Side Plank)  BIRD DOG (  ) aka Quadruped Opposite Arm and Leg Raise McGill SM (2002)

SIDE BRIDGE (BEGINNER) SIDE BRIDGE

Step down – weakness glut max and medius Lunges – weakness of glut max and medius Squats – inability to assume neutral spine, poor muscular endurance of back extensors, weak glut max Single-legged squat – weakness of glut max and medius

Basic Quadruped Series  Prone Hip Extension  Bridging  Clamshell  Side-lying SLR  Straight Arm Pulldowns  Wall Lean  Cable Side Steps  Crunch  Side Bridge (Beginner)  Front Plank (Basic Position) 

Starting position: Prone with both legs extended Movement: The client bends (flexes) one knee to 90º. Next, the client contracts the gluteus maximus and lifts the foot toward the ceiling by extending the hip. Common errors: The client compensates by extending through the lumbar spine. Considerations for rehab clients: This exercise may cause pain in patients with facet joint irritation or degenerative joint disease in the lumbar spine. Exercise the client may progress to next: Bridging exercises, bird dog.

CLAMSHELLS SIDE-LYING HIP ABD

Quadruped Opposite Arm and Leg Raise (Bird dog)  Side Bridge (or Side Plank)  Bridging with a March  Bridging with Leg Extension  Front Plank  Front Plank with Arm or Leg Extension  Front Plank with Opposite Arm and Leg Extension  Lunge  Lunge Twist  Backward Lunge  Lateral Lunge 

This functional exercise strengthens the lower extremities and enhances core stability. Starting position : Standing with the hips shoulder-width apart Movement : The client steps (lunges) forward, flexing the lead hip and knee. The lead knee should be in alignment with the hip and foot, and the thigh should be parallel (or almost parallel) to the ground. The body is lowered toward the floor to the point where the trailing knee almost contacts the ground. The client then reverses the movement, returning to the starting position. The client repeats the lunging sequence with the opposite leg stepping forward.

Starting position: Same as the lunge Movement: When performing the lunge, the client rotates the trunk toward the side of the rear (trailing) leg. The client returns to the starting position and repeats to the opposite side. Variation: The client can use a stick to help maintain balance.

Side-lying Bilateral Leg Raise  Jackknife on Physioball  Inverted Hamstring  Hang Twist  Prone Twist  V-Ups  Side Bridge with Hip Abduction  Side Bridge with Hip Flexion  Side Bridge with Shoulder External Rotation  Three Point Plank with Upper Extremity Exercise  Roman Chair  Roman Twist  Russian Twist  Russian Twist on Physioball 

The inverted hamstring exercise addresses hamstring tightness, improves core stabilization, and incorporates balance training. Starting position: Balancing on one leg (with the knee in full extension) while maintaining optimal posture Movement: The client bends at the hips (not the waist) while maintaining a straight (neutral) spine. The client’s arms should be outstretched to the side to assist with balance. As the client leans forward, she will feel a stretching sensation in the hamstrings.

Starting position: Gripping a pull-up bar or the top of a squat rack with both hands using an underhand grip Movement: The client raises the knees toward the right shoulder until the thighs are parallel with the floor. The client holds the position for 1 or 2 seconds, then lowers the legs under control. The client then repeats the movement to the opposite side.

Starting position: Same as the side plank (intermediate) Movement: While in the side plank position, the client abducts the top leg, lifting it off of the bottom leg approximately 6 to 8 inches. Hold this position for up to 5 seconds.

Starting position: Same as the side plank (intermediate) Movement: While in the side plank position, the client holds a light dumbbell with the shoulder and elbow in a 90°-90° position. Instruct the client to externally rotate the shoulder. Brumitt & Dale NAJSPT 2009

Starting position: A three- point plank posture in which the client is supporting the body with both feet and one extended arm. Movement: While in the three-point plank position, the client performs an upper extremity exercise with the free arm. This exercise may be a shoulder flexion, shoulder horizontal abduction, shoulder row, or shoulder extension exercise. Brumitt & Dale NAJSPT 2009

Starting position : Secured in a roman chair. The client’s feet should be under the supports, and the chair should be adjusted to allow the client to bend completely forward at the waist. Movement : The client raises the torso from a flexed position to a neutral position. Considerations for rehab clients: Hyperextending the spine at the top of the movement is usually not necessary and is contraindicated for patients with spondylolisthesis or degenerative joint disease. You must also weigh the risks of incorporating this exercise for an individual with a history of disc-related pain.

Starting position : Positioned on the roman chair as shown Movement : The client maintains the abdominal bracing contraction while slowly rotating the trunk and arms to the side. After rotating to the side, the client holds the position for up to 5 seconds. The client then returns to the starting position and repeats the movement to the opposite side. Variation : To increase the challenge of the exercise, the client can hold a medicine ball out with straight arms

Offer a dynamic, full body exercise Use of KB in our golf exercise programs May be useful for developing power Brumitt et al NAJSPT 2010

 L sided low back pain during running  L side weakness hip extension, hip abduction (MMT)  Bunkie Test Brumitt J Bodywork & Movement Therapy (2011)

Bunkie Test Scores 1st Appt L R PPL 30 12pn APL 44 22 PSL 18 10 LSL 53 18 MSL 13 16

Home Exercise Program: 1-3 sets, high repetitions 15-25 Clamshells Side lying abduction Prone leg extension (knee bent) Lunges Squats (mini  progress)