Non-Surgical Solutions for Treating Pain
Dr. Philip Lim's Medical Musculoskeletal Clinic

Real-Time Ultrasound Core Training

Core stability
Core stability refers to the trunk's ability to prevent uncontrolled movements and potentially harmful stresses to the lumbar and pelvic spine. The spine is an inherently unstable structure and relies on ligaments and activation of surrounding muscles for stability. Forces generated by arms and legs during walking and every day activities are transferred, absorbed and redirected in the lumbar pelvic spine.

Broadly speaking there are 2 types of muscles:

  • Large powerful muscles which are involved in movement of joints and locomotion (movers)
  • Deeper, smaller muscles which perform a protective stabilising function of the lumbo pelvic spine by generating low sustained force which prevents abnormal intervertebral movements which may cause injury (stabilisers)

The deep stabilising muscles of the trunk (lumbopelvic spine) have attachments to the lumbar spine and pelvis, allowing for support and fined tuned control of the spine. This allows the powerful movers to function without causing injury, for example lifting and carrying heavy or bulky objects as well as participating in sporting activities. Research shows the ability to stabilise requires not only individual muscle activation, but the activation of deep muscles in a co-ordinated fashion prior to movement.

Research has also shown that deep stabilising muscles become inhibited (switched off) very quickly following back injury and usually remains inhibited if left untreated even after pain has settled and return to usual activities.
Primary core muscles:

  • Multifidus
    This is a small muscle connecting vertebra to vertebra and also has attachments to the pelvis. Its location and orientation close to the centre of rotation of spinal movements enables it to perform its stabilisation function by limiting abnormal vertebral movements and increasing stiffness of lumbar spine.
  • Transversus abdominis
    This is the deepest abdominal muscle layer and is a thin sheet of muscle which has connections to the spine. When activated it corsets the abdomen resulting in a bracing action which stabilises the lumbar pelvic spine.
  • Pelvic floor muscles
    Pelvic floor muscles are a muscle diaphragm that supports the abdominal contents, for example the urinary bladder, uterus and intestines. In the context of core function pelvic floor activation is essential for maintenance of intra abdominal pressure (IAP), which increases lumbar spine stiffness and therefore stability. The pelvic floor is also important in maintaining urinary continence. Poor pelvic floor activation is associated with increased back pain but also increased risk of urinary stress incontinence, which is common amongst the following groups in our community:
    • 30% of women after childbirth
    • Elderly
    • Following surgery for example hysterectomy in women and prostate surgery in men
  • Diaphragm
    The diaphragm is a thin dome shaped muscle that separates the lungs from the abdomen and has dual functions. It is one of the muscles used in breathing (see BREATHING DYSFUNCTION), and it also functions as a spinal control muscle. It achieves this function by increasing intra-abdominal pressure (IAP) during inspiration, permitting the bracing action of the transversus abdominis to take effect.

What conditions would benefit from core training?
Back pain, sciatica, sacroiliac joint instability/dysfunction, pelvic floor dysfunction causing incontinence and shoulder and hip dysfunctions which are aggravated by weak core stability.

Advantages of Core training using real time ultrasound (RTUS)
Core muscles are deep muscles generating low force. They are difficult to assess accurately by patient and doctor, which raises the question of whether one is performing the exercise appropriately. The training involves the switching on of core muscles in a co-ordinated and sustained manner which is not forceful. Pain and injury may cause atrophy of these muscles which makes retraining difficult.

At Northside we use real time ultrasound which is a non-invasive technique allowing both patient and doctor to visualise these deep muscles on a screen. This is useful tool for assessment and training because it allows immediate visual feedback on correct muscle activation, thereby achieving certainty in the exercises performed. This will accelerate learning and reproducibility. RTUS training usually requires up to 6 sessions and incorporates a home exercise program. This training is a prelude to resumption of usual exercises in order to prevent recurrence injury.