ApostilaLombar-StrengtheningExercisesfortheCore-SalvadorBrazil (1)

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Strengthening Exercises for the “Core”
Rafael F. Escamilla, Ph.D., P.T., C.S.C.S.
rescamil@csus.edu
Objectives
• Present evident for the use and efficacy of 
strengthening exercises for the “core”
» The lumbo-pelvic-hip musculature is commonly 
referred to as the “core”
• Demonstrate select core exercises, and how they 
can be progressed according to difficulty and 
muscle activity
• Present Evidence on the Relationship Between 
Core Stability and LE/Trunk Injuries
Enhanced Core Stability by Tension in 
Thoracolumbar Fascia from Muscle Contractions
• Note: The osteo-ligamentous lumbar 
spine buckles under compressive loads 
of only 90 N (~9kg!!). Muscles 
enhance spinal stability by acting as 
“guywires” and by compressing and 
stiffening the spine.
Crisco et al, Clin Biomech, 1992
McGill et al, J Electromyo Kines, 2003
Effects that Core 
Muscles Have on 
Lumbar Spine/Pelvis
Rationale for Core Strengthening 
• Biomechanically, the hip extensors, ER, and 
abductors play a major role in LE movements, 
working synergistically to stabilize the pelvis and 
transfer forces from LE to trunk
Joseph & Nightingale, J Physiol, 1954
Lyons et al., Phys Ther, 1983
Nadler et al, Med Sci Sports Exerc, 2002
Ireland, Orthop Clin North Am, 2002; Ireland et al, JOSPT, 2003
Fredericson et al, Clin J Sports Med, 2000
Rationale for Core Strengthening 
• Hip abductors and ER also control hip adduction 
and IR movements, which if excessive from 
muscle weakness can result in knee valgus and 
tibial ER
» A valgus position is associated with:
• ACL and ankle injuries,
• ITB syndrome
• Patellofemoral pain and lateral patella tracking
• Low back pain
Joseph & Nightingale, J Physiol, 1954
Lyons et al., Phys Ther, 1983
Nadler et al, Med Sci Sports Exerc, 2002
Ireland, Orthop Clin North Am, 2002; Ireland et al, JOSPT, 2003
Fredericson et al, Clin J Sports Med, 2000
Rationale for Core Strengthening 
• Weakness in core muscles (abdominals, spinal 
erectors, hip abductors, ext rotators) correlated 
with:
» Increased number of lower extremity and trunk 
injuries in athletes
Leetun et al, Med Sci Sports Exerc, 2004
Rationale for Core Strengthening 
• In anticipation of LE movement, abdominal 
musculature (deeper muscles initially) are activated 
prior to activation of LE muscles to stabilize trunk
» Initial activation of transverse abdominus & internal 
oblique help stiffen spine
» Provides foundation for functional movements
» Abdominals control excessive anterior pelvic tilt
Hodges & Richardson, Phys Ther, 1997
Bouisset, Arch Int Physiol,Biochim Biophys, 1991
Ireland, Orthop Clin North Am, 2002
Rationale for Core Strengthening 
• Compared to males and normalized by 
bodyweight, females have demonstrated 
significant weakness in their trunk muscles and 
hip abductor and ER muscles
» Weak hip and trunk muscles may reduce the ability 
of the female to stabilize the trunk and lower 
extremity joints 
Leetun et al, Med Sci Sports Exerc, 2004
Zazulak et al, Amer J Sports Med, 2007
Rationale for Core Strengthening 
• Deficits in Neuromuscular Control of the 
Trunk (primarily in Coronal Plane Lateral 
Flexion) Have Been Shown to Predict Knee 
Injury Risk, Especially ACL Injury Risk in 
Females
» Females Sustain ACL Injury at a 2-to-10-fold 
Greater Rate Than Their Male Counterparts
Zazulak et al, Amer J Sports Med, 2007
Hewett & Boden, Br J Sports Med, 2009
Mechanical Model Linking Lateral Trunk Motion to 
Changes in GRF, Hip Add & Knee Abd Moments, & 
ACL Loading During Cutting & Landing
Hewett & Boden, 
Br J Sports Med, 
2009
Mechanical Model Linking Lateral Trunk Motion to 
Changes in GRF, Hip Add & Knee Abd Moments, 
& ACL Loading During Cutting & Landing
Hewett & Boden, 
Br J Sports Med, 
2009
Deficits in Neuromuscular Control of the Trunk (primarily 
Coronal Plane Lateral Flexion) Predict Knee Injury Risk
Zazulak et al, Amer J Sports Med, 2007
• Subject Position in Multidirectional, Sudden 
Force Release Apparatus
Deficits in Neuromuscular Control of the Trunk (primarily 
Coronal Plane Lateral Flexion) Predict Knee Injury Risk
Zazulak et al, Amer J Sports Med, 2007
Deficits in Neuromuscular Control of the Trunk (primarily 
Coronal Plane Lateral Flexion) Predict Knee Injury Risk
Zazulak et al, Amer J Sports Med, 2007
Knee Abduction & Hip Adduction Moments, GRF, 
& Landing Contact Time (less in ACL Injured) 
Predict ACL Injury Risk In Female Athletes
Hewett & Boden, Br J Sports Med, 2009
Additional Biomechanical & Neuromuscular Factors 
That May Increase ACL Injury Risk in Females
• ↑ hip IR angles during landing (Lephart et al, 2002) 
» Strengthen hip ER muscles (Gluteus maximus & medius, deep 
ER muscles) – control transverse plane femoral rotations
• ↓ hip abduction during cutting (Pollard et al, 2004)
» Strengthen hip abductors (Gluteus maximus & medius) – control 
frontal plane medial collapse of femur
• ↓ hip flexion angles during cutting (McLean et al, 2005)
» Strengthen hip extensors (hamstrings and gluteus maximus) –
control sagittal plane movements
First Look Proximal to the Hip
Core-Based Strategies for Prevention of ACL Injuries
Hewett & Boden, Br J Sports Med, 2009
• Summary
•Decreased neuromuscular control of trunk (primarily 
coronal plane lateral flexion) increases knee abduction 
moment and ACL injury risk by shifting GRF laterally 
and increasing hip adduction & knee abduction 
moments (increasing knee valus and ACL stress).
•Weak hip abductors, extensors, & ER (often gluteus 
maximus & gluteus medius weakness) can also increase 
knee abduction moment and ACL injury risk due to 
increased adduction and internal rotation of the femur
•Properly designed neuromuscular training programs 
can increase coronal plane trunk and hip control
Abdominal Hollowing 
(Drawing-in Maneuver)
Abdominal Hollowing
(Richardson et al, Spine 2002; Teyhen et al, JOSPT 2008) 
• Performed supine with the hips flexed 45° and 
the knees flexed 90° (hook lying position)
• Take a deep breath and as exhale pull the 
navel up and in towards the spine
Abdominal Hollowing
(Richardson et al, Spine 2002; Barnett & Gilleard, Sports 
Med Phys Fitness 2005; Hides et al., Spine 2006)
• Effective in preferential recruitment of the deeper 
abdominal (transversus abdominis and internal 
oblique muscles) and lumbar (multifidi) muscles
• MRI analyses revealed that the transversus
abdominis and internal oblique contract bilaterally 
to form a musculofascial “corset”, which may 
enhance lumbar spine stabilization and decrease 
injury risk
Abdominal Bracing
Abdominal Bracing
(Grenier & McGill, Arch Phys Med Rehabil, 2007; Vera-
Garcia et al, Electromyogr Kinesiol, 2007) 
• Individuals are instructed to globally activate 
all abdominal and low back muscles by 
tensing the entire trunk, without drawing in or 
pushing out the abdominal cavity
Abdominal Bracing
(Grenier & McGill, Arch Phys Med Rehabil, 2007; Vera-
Garcia et al, Electromyogr Kinesiol, 2007) 
• Spine stability have been demonstrated using 
abdominal bracing, such as maximum 
activation of core muscles and decrease risk of 
injury to the lumbar spine
Biomechanical Differences 
Between Abdominal Hollowing 
and Abdominal Bracing 
Techniques
Hollowing Versus Bracing
• Grenier and McGill (Arch Phys Med Rehabil, 2007)
reported that abdominal hollowing was not as 
effective as abdominal bracing for increasing 
lumbar spine stability
» Compared to hollowing, bracing improved lumbar 
spine stability by 32% with only a 15% increase in 
lumbar spine compression (higher benefit of lumbar 
stability with lower risk of lumbar injury)
Summary
Abdominal Hollowing Versus Bracing
• Abdominal hollowing may not be effective in 
producing the level of core stability needed for 
many functional activities, such as lifting, 
running, and jumping. 
» However, abdominal hollowing exercises may be 
appropriate early in a core stabilization program, as 
well as for individuals that cannot toleratehigh 
lumbar compressive loading.
Swiss Ball Training 
• Core stability was enhanced when athletes trained 
using a swiss ball for 6 weeks
» Stanton et al., J Strength Cond Res, 2004
Swiss Ball Training 
• Co-contraction of the trunk flexors and extensors 
were reduced up to 30% for trunk extensor 
exercises (alt arm and leg, trunk extension) 
performed on ball compared to performed on a mat
• Spinal compression and A-P shear decreased when 
trunk exercises were performed on ball compared 
to performed on a mat
» Drake et al., J Manip Physiol Ther, 2006
» Cosio-Lima et al., J Strength Cond Res, 2003
L4-L5 
Compression 
Forces During 
Variations in 
Quadruped 
Exercises
Swiss Ball Training 
• Abdominal and oblique activity was greater 
during the crunch performed on swiss ball 
compared to performed on ground
» Vera-Garcia et al., Phys Ther, 2000
Swiss Ball Training Progression 
Abdominal Muscle Activity Generated During 
Traditional Versus Swiss Ball Strengthening 
Exercises
Escamilla et al, J Ortho Sports Phys Ther, 2010
Traditional Abdominal Strengthening Exercises
Traditional Abdominal Strengthening Exercises
Ball Exercises for Abdominal Strengthening
Ball Exercises for Abdominal Strengthening
Ball Exercises for Abdominal Strengthening
Ball Exercises for Abdominal Strengthening
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Escamilla et al, JOSPT, 2010
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Escamilla et al, JOSPT, 2010
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External Obliques 
Escamilla et al, JOSPT, 2010
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Internal Obliques 
Escamilla et al, JOSPT, 2010
Summary of Most and Least Effective Swiss Ball 
Exercises for Activating Abdominal Musculature 
Muscle Most Effective Exercises Least Effective Exercises
Upper Rectus 
Abdominis
Rollout, Ball Crunch, 
Double Crunch, Crunch
Sitting March, Side 
Crunch, Side and Prone 
Plank, Knee-up
Lower Rectus 
Abdominis
Pike, Rollout, 
Abdominal Dips
Sitting March, Side 
Crunch, Side Plank
External 
Oblique
Pike, Skier, Knee-up, 
Side Plank, Prone Hip 
Extension, Side Crunch
Sitting March, Crunch, 
Ball Crunch
Internal 
Oblique
Pike, Skier, Rollout, 
Double Crunch
Sitting March, Side 
Crunch
Abdominal Muscle Activity Generated During 
Traditional Versus Non-Traditional Core 
Strengthening Exercises
Escamilla et al, J Ortho Sports Phys Ther, 2006
Escamilla et al, Phys Ther, 2006
Non-Traditional Core Exercises
Non-Traditional Core Exercises
Non-Traditional Core Exercises
Non-Traditional Core Exercises
Non-Traditional Core Exercises
Non-Traditional Core Exercises
Upper Rectus Abdominis 
Escamilla et al, Phys Ther, 2006
Lower Rectus Abdominis
Escamilla et al, Phys Ther, 2006
External Oblique
Escamilla et al, Phys Ther, 2006
Internal Oblique
Escamilla et al, Phys Ther, 2006
More 
Abdominal 
Exercises
Non-Traditional Core Exercises
Non-Traditional Core Exercises
Roll-out Exercises Using Torso Track, Ab Slide, 
Power Wheel, and Swiss Ball
Non-Traditional Core Exercises
Non-Traditional Core Exercises
Non-Traditional Core Exercises
Non-Traditional Core Exercises
Non-Traditional Core Exercises
Figure 1. Upper rectus abdominis normalized mean (SD) EMG activity among exercises.
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Escamilla et al, JOSPT, 2006
Figure 2. Lower rectus abdominis normalized mean (SD) EMG among exercises.
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Escamilla et al, JOSPT, 2006
Figure 3. External oblique normalized mean (SD) EMG activity among exercises.
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40
60
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Escamilla et al, JOSPT, 2006
Figure 4. Internal oblique normalized mean (SD) EMG activity among exercises.
To
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Ab S
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20
40
60
80
100 Escamilla et al, JOSPT, 2006
Non-Traditional Core Exercises
Non-Traditional Core Exercises
Non-Traditional Core Exercises
Non-Traditional Core Exercises
One Leg Deadlift – can also be done flexing both arms up parallel 
with trunk as the trunk tilts forward (thus also working rotator 
cuff, deltoids, rhomboids, and traps in addition to hamstrings, 
gluteus maximus and medius, quadriceps, erector spinae, and ankle 
musculature to stabilize ankle & foot). Can be done with or without 
weight (DB’s in hands or cuff weights at ankle of extended hip).
Does Ankle Position (DF vs PF) 
During Bridging Exercises Affect 
Hip and Trunk Muscle Recruitment?
Two Leg Bridge
Mean Values Represent % of MVIC
Muscle Ankle 
PF
Ankle 
DF
Medial 
Hamstrings
22±9 14±6
Lateral 
Hamstrings
17±12 11±7
Significant Differences
Two Leg Bridge With Band (Abd)
Mean Values Represent % of MVIC
Muscle Ankle 
PF
Ankle 
DF
Medial 
Hamstrings
19±8 12±8
Significant Differences
Two Leg Bridge With Ball (Add)
Mean Values Represent % of MVIC
Muscle Ankle 
PF
Ankle DF
Medial 
Hamstrings
36±13 31±10
Significant DifferencesR Leg Bridge With L Knee at Chest
Mean Values Represent % of MVIC
Muscle Ankle 
PF
Ankle 
DF
Medial 
Hamstrings
38±13 33±14
Lateral 
Hamstrings
30±14 26±12
VMO 8±5 12±7
Vastus
Lateralis
6±4 10±7
Significant Differences
R Leg Bridge With L Leg 
Straight
Mean Values Represent % of MVIC
Muscle Ankle 
PF
Ankle 
DF
Medial 
Hamstrings
32±12 28±11
Lateral 
Hamstrings
29±12 26±12
Significant Differences
Two Leg Bridge On Ball with Both Legs Straight
Mean Values Represent % of MVIC
Muscle Ankle PF Ankle DF
Rectus 
Femoris
4±3 6±5
Erector 
Spinae
27±9 31±9
Gluteus 
Medius
11±6 14±7
Significant Differences
Two Leg Bridge on Ball With Flexed Knees
Mean Values Represent % of MVIC
Muscle Ankle 
PF
Ankle 
DF
Lateral 
Hamstrings
34±17 25±13
Significant Differences
R Leg Bridge with Ball Between Shoulders
Mean Values Represent % of MVIC
Muscle Ankle 
PF
Ankle 
DF
Rectus 
Femoris
3±2 5±4
Internal 
Oblique
7±3 10±3
Significant Differences
R Leg Bridge on Ball With L Leg Up 8”
Mean Values Represent % of MVIC
Muscle Ankle 
PF
Ankle DF
VMO 26±17 30±19
Gluteus 
Maximus
18±14 22±17
Significant Differences
Beginning Core Strengthening Exercises
Reverse Crunch Versus Bent Knee Sit-up
Intermediate Core Strengthening Exercises
Intermediate Core Strengthening Exercises
Advanced Core Strengthening Exercises
Advanced Core Strengthening Exercises
Additional Core Strengthening Exercises
Practical Applications
• Swiss ball and a variety of other types of 
advanced core training has been shown to be as 
or more effective in activating core musculature 
compared to traditional core exercises 
• Swiss ball and other core strengthening 
exercises can be progressed from easier to more 
difficult according to individual needs and 
training goals
Practical Applications
• Traditional resistance exercises (such as the 
squat, deadlift, powercleans, and push-press) can 
be modified to emphasize core stability by 
performing them on unstable rather than stable 
surfaces, performing standing rather than seated, 
using free weights (eg, dumbbells) rather than 
machines, and performing unilateral rather than 
bilateral.
• Resistance exercises with a rotational component 
can be performed with cables, kettle weights, or 
medicine balls to develop core specific core 
stability and power.
Thank You!