Understanding Core Stability

Understanding Core Stability

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Core stability is a hot topic amongst rehab and fitness professionals. What does core stability really mean? Do sit ups, crunches, and planks count as core stability? Is it possible to have strong abdominals and still have a weak core? What type of core stability is best for people recovering from an injury and transitioning back to the gym?

Movement is medicine for the body and core stability is a vital part to any injury recovery or prevention program. Breathing, stretching and strengthening exercises can improve your posture, relax tense muscles and provide an overall sense of well-being.

The History of Core Stability

Core stability was initially described by academics “as the ability to withstand buckling from compressive forces” (Crisco, Panjabi 1995) and over time refined into “the ability to prevent shear and spin at each level of the vertebrae and pelvis”. (Bogduk et al 1995) The working definition of core stability has since evolved to include an integration of the body’s control, passive and active systems. These 3 systems contribute equally to spinal stability. The goal of exercises prescribed to “improve core stability” should be to train these three systems to produce effective movement.

The Active System

This system includes identifying, isolating muscles and integrating them into functional movements. This is one of the most important parts of the systems from a rehabilitation point of view and has 2 components which are the Local Active system and the Global Active system.

Coordinating the local and global muscles of the trunk is like coordinating musical instruments in an orchestra. Each instrument contributes to the final sound, but individual contribution is needed for optimal function. Local stability muscles need to be isolated to bring awareness without global system compensation. Once this is learned with awareness then it can begin to be recruited unconsciously while we move.

The Local Active System

The local system is a group of small muscles that contribute to developing control of local segments or “blocks” of the spine. These muscles control stiffness and position of spinal segments in relation to one another. Effectively, our spine is a complex stack of blocks. Each block or spinal segment balances on top of one another. These muscles will engage prior to movement and can be recruited unconsciously to keep them balanced. These muscles only need to be recruited for 25% MVC (maximum voluntary contraction) to be effective.

Dysfunction occurs when these muscles are inhibited and cause decreased strength, endurance and increased movement of spinal segments.

These local muscles work together to form the inner core unit of the body or the CORE 4. They need to work in balance to one another.

  1. Diaphragm – The diaphragm is the primary muscle for inspiration. It descends into the abdominal cavity when it contracts to help open the rib cage.
  2. Pelvic Floor – The pelvic floor is a group of muscles at the base of the pelvis that serve to help control bladder and bowel function, stabilize the sacrum and support the pelvic organs. The pelvic floor work together with the diaphragm.
  3. Transverse Abdominis – This “corset” muscle is the deepest abdominal layer. It runs horizontally to flatten and create tension from the pelvis to ribcage.
  4. Multifidus – These multiple muscles extend, stack and rotate individual spinal joints.  They prevent the shear and rotation in the spinal joints. These muscles act like “pulleys” in the spine decreasing the work need to move.

The Global Active System

These are muscles that generate torque, create movement and transfer load from ribs to the pelvis. They control movement and support posture. Dysfunction of the local system may present as imbalanced over-activity and tightness within the global system. This may result in excessive compression, increased intra-disc pressure and loading through the spine resulting in risk of degeneration and pain. (Nachemson and Morris 1964).

The Passive System

The passive system includes the skeletal structure, ligaments, and intervertebral discs that passively limit movement of the spine. Neutral alignment is where we start training the core muscles. Finding and working in neutral alignment is optimal because the local muscles are easier to isolate and it offers the least impact to the passive system. If the passive system is injured or is unstable it becomes important to enhance the other components of stability. The passive system can also become compressed when there is an exaggerated active response.

The Control System

The Control system includes our nervous system. The nervous system is challenged to control and move the spine. The control system must continually interpret the status of stability and plan appropriate responses. Control errors come as forces that are ‘too small, too large, too early or too late or not at all’. (Gardner-Morse et al 1995)

For example, imagine being bumped while standing. Your body naturally adapts to reverse the force to stay upright prevent tipping over. This reaction has to be perceived, the right intensity, the right timing and the right direction to be effective. The same can be said about core stability. Knowing which muscles to use, in the right timing and at the right intensity is essential to create an efficient system.

Pain turns off and “lowers the volume” on your ability to contract the local muscle system. This often presents as delayed muscle response, loss of awareness of abnormal passive movement (shear and spin). This loss of local stability causes pain and the cycle continues. Pain results in muscle bracing, stiffness, fatigue and overall sense of discomfort. Over recruitment or a “too large” response leads to chronic over-activation of the global system. Often, core stability training is relearning how to quiet the large global muscles in order to identify the deeper local system. This requires mental focus and concentration. Developing this awareness is essential to developing a balanced and efficient core. Imagining and connecting images to these body parts and exercises helps reinforce this awareness and control.

Why is core stability important after back injury?

Research suggests that exercise, in general, is important for recovery of nonspecific mechanical back pain. Some evidence suggests impaired firing, decreased endurance and strength were found in the local system did not necessarily return on its own. Even further, some evidence suggests that those with impaired function of deep back stabilizers had a higher incidence of repeated occurrences of low back pain. It is recommended to improve your awareness of the local system prior to engaging in higher level core stability and strengthening.

Do crunches and planks count as core stability?

No, crunches and planks are abdominal strengthening exercises but not necessarily core stability exercises. These exercises are not appropriate for everyone. Postpartum mothers who suspect or have been diagnosed with pelvic floor dysfunction or a Diastasis recti are cautioned when returning to these as improper technique and underlying imbalance and weakness within the core can worsen both conditions.

Planking is a very high-level whole body core stability. It is very difficult to do without firing effectively through the local system first. Remember the global system will take over and compensate. If done incorrectly, you may be strengthening your trunk but not necessarily strengthening and balancing your core. There is a difference.

You can have strong abdominals and have a weak core.

What can you do to improve your core stability?

  1. Breathe – Breathe in through your nose and expand your ribcage like an upside down umbrella. Exhale slow through pursed lips (imagine blowing out through a straw). Breathe often, breathe deep and breathe slowly. This helps your body relax and helps increase mindfulness.
  2. Lift pelvic floor – Think of your pelvic floor as a trampoline under your pelvis. As you inhale it relaxes down to ground, and as your exhale it lifts up. Connect your breath and your mind to your pelvic floor. Keep the contraction at a low intensity (20%).
  3. Engage Corset – Think of your Transverse abdominis as an internal corset running from your ribs to your pelvis. Exhale a little more by imagining blowing out birthday candles. Feel some muscle energy between your ribs and pelvis. If it is too strong, turn the volume down to 25% so you can still breathe deep into lower ribs. Try isolating with pelvic floor lift for a deeper connection.
  4. Stack your spine – Sit with optimal posture. Sit balanced evenly on your sitting bones, stack your ribs directly on top of your pelvis and lift neck to sit over top of shoulders. Exhale and peel and flex your spine forward by resting your hands on your knees. Inhale and stack your spine, segment by segment back on your chair. Think of lifting and growing taller as you extend up. Connect your breath to your movement.

Managing Knee Pain

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  • What is Knee Osteoarthritis?
  • What are its risk factors?
  • FAQ 


What Is Knee Osteoarthritis (OA)?

The term Osteoarthritis specifically means a degeneration of joint cartilage and the underlying bone. Knee Osteoarthritis is a chronic condition affecting the cartilage and bone within the knee joint characterised by pain, reducing function and quality of life.

Symptoms may include:

  • Morning stiffness
  • Persistent knee joint pain related to activity
  • Limited knee range of motion
  • Crepitus / joint noises
  • Boney enlargement 
  • Tenderness to the touch

What are the Risk Factors for Developing Knee OA?

  • Advancing age: There is an increased risk 45+ years of age.
  • Excessive weight: Due to the metabolic factors associated with obesity, as well as physically carrying excessive weight, can lead to Knee OA. For example, every 1kg loss of body weight is equivalent to 2kg off the knees.
  • Previous knee injuries: ACL tears, regardless if surgically reconstructed, increase the risk of developing Knee OA along with other repetitive knee injuries.
  • Occupation: Repetitive squatting and kneeling for more than 2 hours per day at work is a risk factor.
  • Gender: Females are more at risk for Knee OA than men after the age of 45.
  • Family History: Genetics play a role in the development of Knee OA.
  • Sedentary Lifestyle: Muscle weakness, particularly through the quadriceps muscles, can lead to Knee OA.

Common Questions For Knee OA

Can I just take anti-inflammatory drugs to treat it?

Knee OA results in joint inflammation; however inflammation isn’t the primary cause, and taking anti-inflammatory drugs shouldn’t be its main treatment. 

Is Knee OA just normal aging and to be expected later in life?

No. It can occur earlier in life, and is important to know it can be prevented. Reducing your risk factors such as weight management, and maintaining regular activities while strengthening your muscles appropriately, help prevent knee OA.

Is Knee OA just normal wear & tear?

No. It is a multi-factorial disease which can be prevented and treated by managing your risk factors.

My knee hurts, do I need X-rays to be assessed and diagnosed?

Not necessarily. An X-ray is not always required with knee pain or even when knee OA is suspected. X-rays don’t do a good job of assessing or correlating with pain or prognosis if a fracture is not suspected. The Ottawa Knee Rules are the guideline for when to receive an X-ray during acute knee injuries.

Treatment for Knee OA is focused on reducing risk factors, pain, and improving mobility and strength.

Is running bad for my knees?

No. It is actually good for your knees to be loaded and let your body adapt to this stress. No loading, or unexpected higher loads than normal, are more of a risk factor for knee pain. The key is to gradually introduce new activities and loads in order to strengthen your muscles, and allow your body to adapt to this stress at a safe rate.

I’ve been diagnosed with knee OA, will I need surgery?

Most people living with knee OA do not get knee replacement surgery. This is generally reserved for very advance cases.

What is the best & first line of defence for Knee OA?

The most important pillars of rehabilitation for Knee OA and many other knee conditions are:

  • Exercise / Physical Therapy
  • Weight Management
  • Patient Education 

Does it matter what kind of exercise I do to prevent Knee OA?

Not necessarily; it is important to listen to what works for your body. Many different types of exercises have been shown to help with function and pain in people suffering from Knee OA. Regular physical activity will help with stiffness, knee function, and reducing disability.

Evidence based guidelines strongly recommend exercise for treating Knee OA. Remember that surgery is not the most common treatment.

Now I know what I should do, but where do I start?

The best and safest treatment is personalised. It is helpful to be assessed by a physiotherapist to determine not only what areas to focus on, but set forth an optimal level of exercise to avoid acute flare ups and in turn maximize improvements. A physiotherapist may also provide adjunct treatment to facilitate better movement and response to exercise. This includes manual therapy and dry needling, but should not be the main form of treatment.

Shockwave for Plantar Fasciitis

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Plantar fasciitis is one of the leading causes of foot pain in adults. Plantar Fasciitis is responsible for over one million visits to the doctor per year. Hart Physio is proud to offer Shockwave Therapy for the treatment of Plantar Fasciitis.

The plantar fascia is a thick sheet of connective tissue located on the bottom of the foot that runs from the heel to the toes. The fascia attaches to the skin on the bottom of the foot. When people have plantar fasciitis, they will complain of pain when they initiate walking. Although the reason people get plantar fasciitis is unknown, Consultants and Physiotherapists believe many factors cause this condition that include: flat feet, decreased ankle mobility, obesity, and prolonged sitting or standing. However, in runners, there seems to be an increased incidence of this condition, some doctors think that repeated microtrauma can be another cause of plantar fasciitis.

Plantar fasciitis was a frustrating condition for people who had this diagnosis. The old treatment paradigm relied on conservative therapy for an extended period. This treatment strategy includes rest, shoe inserts, stretching of the calf muscles, and a glucocorticoid injections for temporary relief. If these treatment modalities did not improve symptoms after six months to a year of treatment, then surgery was someone’s only definitive therapy.

Now, with the invention of extracorporeal shockwave therapy, patients have a new option of treatments that is showing promise when compared to conservative treatment. Although the exact mechanism is unknown, many researchers believe that the shockwaves administered to the plantar fascia causes the break down of the scar tissue and allow the fascia to begin to heal. Scar tissue blocks the regeneration of vessels that can bring nutrients to the damaged tissue. In Europe, this therapy was approved for the past decade. Now it is being used in the United States, Canada and the UK.  This treatment was shown to be is safe for use in the general population5. When comparing shockwave therapy to surgical intervention, studies demonstrate that it had better outcomes6. As of today, no study proves that extra corporeal shockwave therapy is better than conservative therapy head to head, but research shows that a combination of shockwave and conservative therapy is better than conservative therapy alone7. As a result of this research, many orthopedic surgeons are recommending shockwave therapy as a treatment after only four weeks of conservative treatments8. The use of shockwave therapy expedites the healing process by months.

New Shockwave Technology arrives

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Shockwave therapy accelerates the healing process in the body by stimulating the metabolism and enhancing blood circulation to regenerate damaged tissue. Strong energy pulses are applied to the affected area. These pulses occur for short periods of time, creating micro-cavitation bubbles that expand and burst. The force created by these bubbles penetrates tissue and stimulates cells in the body that are responsible for bone and connective tissue healing. In many instances, shockwave therapy is most effective in cases where the human body has not been able to heal itself on its own.

Extracorporeal shockwave therapy (ESWT) is a modern and highly effective treatment method: high-energy sound waves are introduced into the body. With this innovative therapy approach, pathological alterations of tendons, ligaments, capsules, muscles and bones can be healed systematically. It has a great variety of uses in orthopaedic and rehabilitation medicine, these include:

• Plantar fasciitis
• Achilles tendinopathy
• Tennis and golfers elbow

• Osgood Sclatters
• Subacromial pain syndrome
• Calcific tendonitis of the shoulder 
• Chronic low back pain

For further information call us on 01252 811773

Stay Fit During the Winter

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winter exercise

As the days get shorter and the outdoor temperature drops, there’s no avoiding the truth: Winter is coming. Many of us dislike the combination of dark and cold and tend to huddle indoors, curling up with a book, binge-watching TV shows or eating carbs for comfort. And, once the holiday season arrives, there’s so much shopping, cooking, baking and wrapping to do that there are even more reasons to get away from our healthier warm-weather exercise routines. Add holiday parties and their rich food to the mix and you have the perfect recipe for sluggishness and inactivity.

Holiday Calories and Temptations

This year, don’t give in to all of these distractions and excuses: Resist! Your body and your mind will thank you, because you’ll be fighting back against all of those additional holiday calories you’ve consumed and you’ll be producing endorphins, the feel-good hormones, through exercise, helping you to combat the winter blues that can be triggered by lack of sunshine and Vitamin D. In addition, you’ll fight off the weight gain that can accompany a sedentary winter routine and will find it easy to rock that bathing suit come summer.

Outdoor Exercise

For cold weather activity, dressing in layers is the best approach to remaining warm and dry. You can always remove layers if you are too warm or add layers if you aren’t warm enough. The layer closest to your skin should be made of fabric that wicks away moisture; cotton isn’t ideal because once it’s damp, it remains so. The outermost layer should resist both moisture and wind.

stay fit winter

Plan your outdoor exercise during the day, if possible, in order to take advantage of the warmer temperatures and sunshine. Exercising earlier in the day also allows you to check it off your schedule and forget about it for the remainder of the day. If your schedule only allows for exercise in the darkness, be sure to wear bright or reflective outer gear so you are visible to motorists and can stay safe.

Once you’re back indoors, unless you’re wet, keep your exercise gear on for 10 to 15 minutes as your body adjusts. Losing heat from your body too rapidly can lead to post-exercise hypothermia; your body reduces its production of heat because it’s in a warm environment, but it also loses its heat stores rapidly, so don’t shock it by stripping down quickly.

Indoor Exercise

For those who don’t find the cold endearing,  there are many indoor alternatives that will keep you fit during the chilly, dark winter. The gym is an obvious option. Gyms are readily available, and they generally offer exercise equipment for those who prefer solo workouts, as well as classes for those who like some company as they sweat. Try yoga or Zumba or Pilates or all three, for example. There’s no need to choose solo exercise over classes or vice-versa; switch up your routine to prevent boredom. Gyms allow you to do it all.

gym exercise

If you are a runner or a walker, treadmills are practical indoor substitute.

Indoor exercise doesn’t mean investing in a gym membership if your budget doesn’t allow it. Many leisure centres, including the new Hart Leisure offer drop-in fees to use their facilities, which may include a pool, a running track or fitness classes. You can also get yourself a workout DVD; do yoga or an aerobics routine in the comfort of your own home. Walking stairs for a designated amount of time is also a great workout, as is dancing to the radio. Who says exercise isn’t fun?

Whether you choose to keep moving outdoors or indoors during the winter, don’t forget to stay hydrated. You might not feel as thirsty as you do in summer, but you need water just as much. If you’re out in the cold, a thermos of herbal tea is a good substitute; it keeps you warm without any diuretic effects.

Remember, no matter what type of winter exercise you choose, the goal is to continue exercising regularly. Why lose that muscle tone you’ve worked so hard to build, just because it’s cold? There’s an exercise for everyone, so no excuses!

YouGov Poll Shows Physio is Key for Arthritis Treatment

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This article reaffirms the myth that if you are diagnosed with Arthritis that nothing can be done.
The report commissioned by Arthritis UK surveyed patients with regards to the support they received and methods they used to alleviate pain. It highlights that when managed thoughtfully and actively that significant improvements can be made with regards to quality of life.
If you would like to know more follow the link to Arthritis: The Impact on Daily Life

Helping with Gait and Balance Problems

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If an injury or illness has impaired your ability to walk normally, you may need gait training to improve your motion. Potential causes of problems with gait and balance include:
• Aging: With a natural decrease in strength and flexibility comes impairment to your balance.
• Musculoskeletal Problems: If your range of motion, strength, endurance and mobility are impeded for any reason, your gait may be affected, since you need a certain level of balance and strength to walk properly.
• Impaired Cognition: You are less able to adapt to a situation if your judgment or safety awareness decreases, your attention is poor or you process information more slowly than before.
• Impaired Neuromuscular Responses: Disruption in the signals between the brain and the muscles can affect gait and balance. The disruption can result from a variety of issues, such as a stroke, Parkinson’s disease or multiple sclerosis.
• Impaired Sensory Processes: If your body’s sensors are unable to collect information about the environment, it can lead to balance and gait issues. Sensory disabilities may be caused by glaucoma, cataracts or diabetic retinopathy, to name just a few possibilities.

Gait Analysis
Your physiotherapist may diagnose your gait as being abnormal after reviewing your medical history, discussing your symptoms and doing a walking gait analysis. She or he may use a gait scan device to assess the biomechanical function of your feet.

Gait and balance training is a type of physiotherapy that helps you learn to walk normally again. The benefits of gait and balance training include:
• Improving your balance and posture
• Strengthening your joints and muscles;
• Developing muscle memory;
• Increasing your endurance;
• Retraining your legs to participate in repetitive motion; and
• Increasing your mobility while decreasing the risk of falling.

A registered Bupa clinic

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Hart Physio is also a Bupa registered clinic. This means we can accept patients needing Physiotherapy who have been referred from their GP or directly from Bupa. We have been registered with Bupa for over 15 years and have recurrently met their standards for treatment. We can provide a fast and efficient service to patients who are struggling with spinal, joint, muscle or nerve problems. We are experienced in treating trauma and sports injuries. Please phone us on 01252 811773 or email info@hartphysio.co.uk for further information.

Our Bupa Registration number is 80009657– registered clinic address Fleet Medical Centre, Church Road, Fleet GU51 4PE, although we can provide treatment too at our Elvetham hotel clinic.

Your local Axa Provider

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Hart Physio is a registered provider to Axa patients. We are able to provide a fast and efficient service to patients who are struggling with spinal, joint, muscle or nerve problems. We are experienced in treating trauma and sports injuries. Please phone us on 01252 811773 or email info@hartphysio.co.uk for further information.

Our Axa Registration number is ZZ ZZ03349 – registered clinic address Fleet Medical Centre, Church Road, Fleet GU51 4PE

How to prevent back pain

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Back pain is a common complaint and a condition that can be debilitating, but given our lifestyles, we almost expect to feel some aches and pains the older we get. And that’s for a reason, the more we sit at desks and the less active we are, the higher our chances of experiencing the inconvenience and pain that comes with a sore back.
And while it seems like back pain is on the rise, especially as we age, one need not surrender to a life aches and pains. There are plenty of things you can do to stay ahead of the hurt.  So how do you keep yourself from having a sore back? For one, keep it strong. Exercising your lower, mid and upper back muscles with targeted movements will help reduce the frequency of pain if you’re already experiencing it, and will help prevent it in the future. Try getting on all fours and extending the opposite leg and arm, balancing on the other hand and knee, and holding the position for a count of five. Or try lying on your stomach and, using your back muscles to help, lifting your upper back and legs off the ground with your arms stretched out in front or held together behind your head. Again hold for a count of five. The more strength you build, the easier it will be for your back to stay pain free.
When it comes to strengthening for a healthy back, working your core is just as important as working your back muscles. Having a strong core allows you to sit up straight and to carry your weight in good alignment so that your spine stays straight and strong. To strengthen your core, consider getting into the habit of  completing a certain number of bridges each day, doing some in the morning and some before you go to bed.