To start this article, I would first like you to consider what core stability means to you? As you read this article you will have a unique perception of core stability and this may have changed over time. It exists. It doesn’t exist. It is an area of much debate among leading professionals.
Being flexible with your perception allows you to learn, grow and assert more influence. Instead of supporting or being opposed to core stability I wonder if you can start to think in a bit more detail about what you really are trying to achieve.
The first time I questioned this was working in the military; everyday I would come across soldiers with backs as strong as a buffalo; often I would hear ‘I know I should be a bit more religious with my core stability training, i know I’ve been told so many times my big muscles are strong but its the little ones that aren’t working properly’. Unsurprisingly their pain had not changed for years despite doing core stability training many times a week for the entire time.
The reality is core stability is certainly more complex than we ever initially thought
The reality is core stability is certainly more complex than we ever initially thought and certainly now I would say it is a fairly inadequate term to try and theorise something that is as complex as human movement. The notion that there are some small muscles deep inside our abdomen that are central to providing stability to our spine and transferring force doesn’t fit with me. So let’s go back to some very basic human movement principles.
“We need to start thinking about the kinetic chain and less about core stability.”
Have you ever stopped to consider how your brain controls movement? Firstly you give your brain an objective; lets say lift your hip into extension (backwards), the next thing your brain needs to know is where your muscles and joints are from the feedback that it gets from the receptors in these tissues. Once your brain receives this feedback, the brain determines which muscles will move the leg, if someone has overactive muscles in the back and tight hip flexors then the brain will then know the resistance is too strong from the hip flexors for your glutes to overcome but the back muscles are strong. There is not much resistance from the abs so the back will contract to do the movement causing back extension.
The brain has still achieved the desired outcome of moving the leg backwards but all of the load has gone through the back. If the glutes are in the right position to contract and there isn’t lots of resistance from the hip flexors the glutes will initiate the movement and hip extension will be achieved correctly allowing the spine to focus on its primary role. The body will always find the path of least resistance (i.e. the most efficient way to move) hence the notion of ‘some abdominal bracing’ to limit movement through the core is counter intuitive to the way that the body moves.
“We need to start thinking about the kinetic chain and less about core stability.”
The prevalence of clam exercises or dead bugs is changing and they may still be effective on occasions to learn how to utilise certain muscle groups but how do we correct movement patterns? I absolutely do believe that altering a person’s starting position will help and we need as little resistance as possible. The point that I am trying to stress more is that we as a profession need to expand our thinking a little more around this topic. Think global and consider how these coordinated muscle actions fit into the bigger picture of human movement. Core stability has been seen just as the name suggests, but progressively we need to see it as the link between the upper and lower body for very complex movement patterns and ensuring that energy is continued and increased from one muscle group to another as it passes between the arms and the legs.
How does the pelvic floor or diaphragm integrate with the abdominals? How does the pelvic floor influence the hips and lower leg? Could it have an influence on the upper body? Can we co-ordinate them with great timing and appropriate force?
“I merely asked her to rotate her front leg out just 10 – 15 degrees, she hit a serve with almost no pain”
We need to start thinking about the kinetic chain and less about core stability. Those of you that are perhaps in the strength and conditioning industry will be familiar with this term. The concept of this is that force is passed from one body part to the next. A perfect example of this would be an American Baseball Pitcher, they start by winding all of their body up into a coil before pushing of the back foot to start the pitching motion. From there the force is transmitted through the back leg up into the hip, where it continues through the trunk gathering force.
Each muscle adds its contribution to the overall generation of force into the arm at the precise time to allow a powerful release of the ball. If these is any segment in this chain that is not working well such as a stiff joint, an incorrectly positioned / inhibited muscles, maybe a misfiring of one muscle then energy will be lost. This will lead to a drop in power or injury. If the body detects that energy is lost it will compensate by increasing force in the distal segments of the chain often causing injury. Treating areas in isolation by looking locally at where someone says they have pain is often inadequate, I believe we need to look at the way the body functions as a whole as it is often the painful area that functions well. It is this well functioning area that makes up for what the other areas are not contributing to a particular movement. To do this we need to identify areas in the chain that are not functioning well to restore equal balance. When we combine this with appropriate resisted movements we can create really powerful change.
We need to start thinking about the kinetic chain and less about core stability.
Early in my career I was working with a tennis player who had shoulder pain when serving. She had seen so many therapists and trainers to try and rectify the problem, concentrating on shoulder stability and core stability but without any real improvements in symptoms. She would find if she had a local treatment on the injured area symptoms would improve for a few days but would quickly come back. Objectively I couldn’t find anything wrong with her shoulder other than pain provocation tests were positive for impingement but the muscles were well coordinated, strong and she had an anatomically normal shoulder.. All imaging was negative and her core control/stability was not bad.
Over the period of 8 weeks she improved her core stability significantly and her shoulder stability even more. Without being pickier than a French Wine Connoisseur in Santorini I was struggling to find ways to further improve this area but her pain remained unchanged. She would come in have physio, the pain would be much improved for a few days, her exercises would get progressed or adapted for the cycle to happen again the following week.
After getting tired of hunting for flaws that were no longer there I decided to take the punt on looking at her serve on a court, I know (now) I should have done this a long time ago but I was thinking I’m not a tennis expert and the coaches would notice anything amiss with her technique. I watched a few and there wasn’t anything glaringly obvious other than I thought her left leg looked a little internally rotated to what I would have imagined. I merely asked her to rotate her front leg out just 10 – 15 degrees, she hit a serve with almost no pain. Maybe just a one off I thought. She turned it back to the start point and the full pain was back. Out again and the pain was nearly gone. After a few more cycles of out and in, no pain and pain respectively we had found the fault. Hi it’s a change to focus on lower limb alignment, muscle imbalance and stability we radically changed the symptoms allowing her to change the weight transfer and therefore the ground reaction forces throughout the serve. With the foot turned in she was losing a lot of the ground reaction force at the start of the kinetic chain action. With the foot turned out a much larger force was being generated through the weight transfer and she was no longer having to make up for this elsewhere in the chain of action (in her case the shoulder). The force that was having to be generated from the shoulder was too much for the pain receptors and soft tissue in the area that it was causing pain and tissue degradation.
Have you ever stopped to consider how your brain controls movement?
The take home message for me from this episode was that myself and many other physiotherapists had all adjudged that the cause of her injury be down to her lack of core and shoulder stability. After all there were no other objective signs that were apparent for her pain. Full examination had showed the only problem in her whole body was a lack of control and stability. Yet with a vast improvement in this area there was very little correlation with her pain.
It may be worth considering for a moment, what is not core stability? Are there are global exercises which do not require the abdominals, pelvic floor and correct breathing patterns? The literature in anatomy trains by Thomas Myers really rings true in this situation. Interconnecting tissue was all working together to transfer the forces through the body from one segment to another with the ability to control various aspects of itself independently.
Despite all of this I do believe that the work she did to improve her strength and stability will have had a very positive effect on her performance and injury prevention in the long term. I just had a reality check about my belief in core stability. I then realised it was part of a much bigger picture and that as therapists and exercise prescription specialists we need to remember to take our programmes one step further than the standard. It is imperative to make sure that we teach people how to translate their new found strength and stability in to the functional activities they are needed for. Wether this be through technique adjustments by working alongside their performance coaches or exercises that translate to the sporting action. We always have to think towards the whole of the body or the action whatever method we see as the right way for the individual circumstances and coaching technique to get there. This way their work will not be in vain and they will bear all the full fruits of their hard work.