One of the first steps in addressing core stability is assessing static posture, ranges of motion, and motion of the pelvic bones, sacrum, femurs, lumbar spine and thoracic spine. Early on, I use manipulation and mobilization to increase muscle activation (facilitate), decrease muscle overactivity (inhibition), improve joint motion and reposition misalignments.
Let's discuss how to use range-of-motion testing as functional tests of the core to gain further information and help figure out a strategy for the reduction of musculoskeletal pain and injury prevention. The better we help our patients control / stabilize the lumbo-pelvic-hip and thoraco-scapulo-humeral complexes, the better they can demonstrate force through movement.
5 Basic Checks
Here are five basic checkpoints to ask your patient to do that will help you select core stability exercises:
1. Pelvic Alignment
Check the patient's pelvic alignment while standing. I use a goniometer to measure degrees from the ASIS to the ipsilateral PSIS. The normal angle, as best as I can tell from the literature, is approximately 5-10 degrees. It's extremely common to observe 10-15-degree angles (ASIS lower than the PSIS), suggesting anterior pelvic tilt. Less than 5 degrees suggests posterior pelvic tilt.
In my practice, I detect more excessive unilateral anterior pelvic tilt than bilateral anterior pelvic tilt, and less frequently, bilateral posterior pelvic tilt. Any deviation from neutral elevates susceptibility to low back pain.
If you see anterior pelvic tilt, it is important to check the length of the hip flexors. The modified Thomas test is useful for evaluating the psoas, rectus femoris and TFL. The patient lies down on their back at the edge of the table with both legs hanging freely; then maximally flexes both knees, using both arms / hands to pull the knees to their chest. Ensure that the patient keeps their lumbar spine flat on the table and avoids posterior tilt of the pelvis.
The patient then lowers the tested limb toward the table, allowing the leg to hang down. The length of the iliopsoas is measured by the angle of the hip flexion. A negative test is when the lower back and sacrum remain on the table.
The hip can make a 10 degree posterior tilt or a 10 degree hip extension. The knee must be able to make a 90 degree flexion. A positive test is noted when:
- The patient is not able to maintain their lower back and sacrum against the table.
- The hip has a large posterior tilt or hip extension greater than 15 degrees.
- The knee is not able to flex 80-90 degrees or more due to rectus femoris tightness.
Exercises that teach our patients to hold the lumbopelvic hip complex in neutral and prevent further anterior pelvis tilt could include hip flexor stretches and gluteal strengthening exercises. I teach my patients "awareness" of their neutral pelvis and spine postures, and use isometric holds with resistance bands to improve poorly positioned postures.
2. Fingers-to-Toes Touch Test
Observe the lumbar spine for excessive rounding (abnormal) and hip hinging (normal). This test evaluates functionality of the ilium (acetabulum) moving on the femurs. If the lumbar spine excessively goes into flexion, we know repetitive flexion of the lumbar spine may potentially cause disc herniations and irritate existing disc lesions. If the patient is unable to touch their toes, it makes sense to find out if it is a bilateral or unilateral involvement of the pelvis and/or hamstrings.
Patients who have a posterior tilt / flat back often display tight hamstrings and are susceptible to flexion injuries. Tight hamstring muscles by themselves are not particularly predictive of future low back disorders; however, asymmetry between right and left sides is a bit more predictive of future pain (McGill).
The corrective exercises that teach patients the difference between hip flexion and lumbar flexion include hip hinging, deadlift variations and squat variations.
3. Back Extensions
Ask the patient to raise both arms overhead (an evaluation of the GH joint, the trunk and the lumbar spine) and then perform a back extension with the arms kept overhead (the arms should "hide the ears"). Look for the following:
- Reduced lumbar spine motion
- Knees flexed to give illusion of moving into extension
- Increased lumbar motion, especially in the lower lumbar segments
- Lower anterior ribs excessively flared to give the illusion of extension
All of these are examples of common movement faults. Corrective exercises I then use to assess if my patient can prevent and control back extension / hyperextension under load are: planks on the forearms and toes (looking for loss of neutral lumbar spine), abdominal roll-out variations on a stability ball or BOSU (looking for loss of neutral lumbar), and walking with a kettlebell in various positions. (I start with the farmer's walk, then the rack position and finally the overhead position.
My favorite correction for this fault combines a standing "power pose" (feet shoulder-width apart with the arms held overhead) with band resistance under the feet and held in the hands. The bands provide enough resistance so that a standing postural fault (e.g., pelvic changes, rib flare, scapular instability, forward head posture) will get amplified.
The standing power pose is a great exercise patients should practice every day. Research out of Columbia University on power poses suggests it will increase testosterone and decrease cortisol (the stress hormone) when held for two minutes.
4. Lateral Trunk Bending
Perform right and left lateral trunk bending while holding a 10-15 pound kettlebell weight in the hand (one side at a time). I am curious to see if the patient experiences any pain and what their spine looks like under load. We should see a slight curving in the thoracolumbar region and there should not be any pain. The normal range of motion is approximately 20-25 degrees.
I like to test patients with a load because it is such a functional test, since most people carry grocery bags and/or bags with handles (suitcases) on one side at a time. Some patients need to learn to stay in neutral spine while carrying bags in one hand – they may need to learn to prevent their low back from flexing to the side.
Examples of corrective exercises that will help this dysfunction include side plank variations, Pallof presses, and kettlebell suitcase lifts and carries, such as the farmer's walk holding the kettlebell in one hand.
5. Anti-Rotation Tests
Perform birddogs (on all fours; perform opposite-arm leg raises with resistance bands. This is an anti-rotation test because we are looking for the ability to prevent rotation in the pelvis and low back while moving an arm and a leg. Other anti-rotation challenges include renegade rows with bands or kettlebells and single-leg RDLs.
Anti-rotation training for improving stability is particularly important for our chronic pain low back patients and rotational-sport athletes involved in tennis, golf and baseball (pitchers).
Much of a rehab practice is using standard range-of-motion and orthopedic testing, coupled with exercises to make a difference in these tests.
Resources
- Harvey D. Assessment of the flexibility of elite athletes using the modified Thomas test. Br J Sports Med, 199832:68-70.
- Konin JG, Brader H. Lumbar Spine: Special Tests for Orthopedic Examination, 3rd Edition. Slack Incorporated, 2006: pg. 170.
- Tucker J. "The Psoas and Iliacus: Functional Testing." Dynamic Chiropractic, Sept. 24, 2007.
- McGill S. The Back Mechanic. Backfitpro Inc., 2015.
- Cudy A. "Your Body Language Shapes Who You Are." TED Talks, June 2012; power poses.
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