The Myth of Core Stability

[Hokum5]

Hello,

I'm a physiotherapy student in my last year and I recently stumbled on this article. I've always been sceptical of the concept of long, voluntary contraction in the muscles near your center, as tightness and co-contraction can be as bad as hypermobility. But, this topic is very complex, and I'd like to hear some other opinions too.





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[physiofixme]

Hi

Check out some of Peter O'Sullivan's work from Curtin University. He is a core strength guru and has actually done some RCT's looking at Transversus Abdominis and Multifidus and their role in stabilising pelvis and helping relieve/prevent Low Back Pain. His stuff actually has some proven results and therefore scientifically relevent.

[linbin]

Cochrane has published Systematic Review on core spinal stabilization.The Systematic Review concluded it as an effective approach for low back pain .I too agree with the above suggestion

[Hokum5]

Hello,

thanks for your fast responses.



@Linbin I feel a bit stupid, I couldn't find any Cochrane review related to core-stabilization (I suppose you don't mean the one concerning pregnant women)

@physiofixme
thanks, will check him out, already found a few interesting articles.

[alophysio]

Interesting article - i will read it more carefully when i can and get back to you.

[linbin]

Improving the outcomes after back injury by a core muscle strengthening program
Petrofsky J S, Batt J, Brown J, Stacey L, Bartelink T, Le Moine M, Charbonnet M, Leyva S, Lohman E B, Aiyar S, Christensen A, Weis D, Weis M, Jackson J, Rad-Bayani E, Prowse M, Sharma A, Rendon A
2008
:May S, Johnson R. Stabilisation exercises for low back pain: a systematic review. Physiotherapy.2008;94(3):179-189.
Macedo L G, Maher C G, Latimer J, McAuley J H. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Physical Therapy.2009;89(1):9-25

[Hokum5]

@linbin thanks. I also found two others, hope I'll soon have time to check them all out.

Ferreira PH, Ferreira ML, Maher CG, et al. Specific stabilisation exercise for spinal and pelvic pain: a systematic review. Aust J Physiother 2006;52:79–88.

Hauggaard A, Persson AL. Specific spinal stabilisation exercises in patients with low back pain - a systematic review. Phys Ther Rev 2007;12:233–48.


cheers

[Hokum5]

So, I did a lot of reading on the topic. The bottom line seems to be that, while TrA training seems to be effective for some outcomes, it is not more so than other treatments. There are some interesting studies that show that these exercises can "normalize" the activation pattern for the TrA, but there's a severe lack of studies comparing the TrA approach to other forms of PT (and where they exist, the differences are mostly not significant!).
Please note that we're talking about chronic LBP, the systematic reviews do NOT recommend to use the stabilisation excercises for acute LBP.

concerning the article in the initial post:
There is some oversimplification (isolated TrA training is not advocated by the "core stability" proponents) and some error (it is not about strengthening, but about recruiting the core). but i like the critical appraisal of what seems to have become a dogma.

In the end, you can say that CS is one valid approach to the topic, but in no way a panacea.

[caz]

Hello,

I'm a physiotherapy student in my last year and I recently stumbled on this article. I've always been sceptical of the concept of long, voluntary contraction in the muscles near your center, as tightness and co-contraction can be as bad as hypermobility. But, this topic is very complex, and I'd like to hear some other opinions too.

That is VERY interesting! I'm not a physio but have a long history of chronic back/SI pain. Every physio I've been to has recommended core stability exercises and pilates - but I found this just made my pain worse.

Then I went to an Alexander Technique instructor who was very much against this 'holding' and tightening of core muscles - it is all about letting go of muscle tension in the body. So with my AT instructor's help, I've learned to relax the muscles, so my posture is much better and my pain is now much less than it was.

I can see now that in my case, the muscles around my pelvis and lower back were permanently tight and I was being encouraged to tighten those muscles further through core stability exercises. So its not surprising it caused me more pain! I think part of the problem is that when all the muscles around your pelvis and lower back have seized up, its impossible to isolate the transversus abdominus so everything just keeps getting tighter. I think you have to be able to relax all your muscles before you can start isolating individual ones to strengthen.

So now I've learned to let go of the muscle tension, I have gone back to doing some core stability exercises - but I only 'tighten' muscles as I'm doing the exercises and I make sure that the rest of the time, I let it all hang out (so to speak!). I remember a physio telling me I should be contracting the core muscles ALL THE TIME, not just during the exercises - I don't have a medical background, but that never seemed right to me!

So I'm sure core stability does have a place to play in some back pain conditions, but I don't think it can be seen as the magic cure for all problems.

[manishika patait]

hi
i m a pass out student of physiotherapy. i did a project on lumbar instability n found that core stability has a great role , but on the other hand i feel that even motor learning model for chronic low back pain (for dynamic stability of spine)to be equally important for long term reduction in pain and functional disability.

[alophysio]

Hi Caz, thanks for your input...i think your comments reflect the major problem out there...

1. Most people believe that core stability is how you described it - a tensioning of your "core" muscles all the time. However, most people (including physios) think that you can feel this contraction - if you can feel it "on" strongly, you aren't doing it right. It only takes a very small amount of transversus activation to help prepare the joints for loading. As little as 3%...

2. Core stability is such a bad term. I get very frustrated by it because of the misconceptions out there of what the core is. It is well defined in the L/S and SIJ that the original "core" was thought to be the diaphragm, transversus abdominis, multifidus and the pelvic floor. The % amount of activation required from each muscle is dependent on the load requirements

3. Efficient Load transfer means the joint has just the right amount of compression and tension to accept and transmit the load to the next joint. Overactivity is just as bad as underactivity

Ultimately the reason why CS is not the answer to everything back pain related is because there are many reasons for back pain! I know it sounds simple but too many people forget the simple things in life!

Lastly, with respect to the core muscles vs global muscles...
1. Core muscles are needed to provide a platform from which large torque producing muscles can act from
2. Global muscles are needed in sufficient strength to produce the torques necessary to perform functional tasks
3. Core muscle strength is therefore a prerequiste for truly strong global muscle function
4. Just because you have strength and training in Globals doesn't mean you have a strong core.

Put another way...Core=basis for strength but strength (of globals) doesn't equal good core strength

Thanks!

[caz]

Hi Caz, thanks for your input...i think your comments reflect the major problem out there...

1. Most people believe that core stability is how you described it - a tensioning of your "core" muscles all the time. However, most people (including physios) think that you can feel this contraction - if you can feel it "on" strongly, you aren't doing it right. It only takes a very small amount of transversus activation to help prepare the joints for loading. As little as 3%...

I think thats exactly right! And I think my problem when I tried to do some of these exercises at the start was that all my lower back/pelvis muscles (sorry, don't know the right terminology!) had seized up so I couldn't isolate individual muscles so just tightened all my muscles further. Its only now that everything is moving more freely that I can isolate the right muscles to work on. So I can now do pilates and core stability exercises without it causing me pain :-)

Very interesting topic though!

[alophysio]

Hi Caz,

I take an even more simple approach to it...i believe that the brain knows the best way to do things and that by isolating things, we put the conscious brain in the way...Sometimes you need the conscious effort to learn a new skill or the "burn neural pathways" but often getting the right things released, aligning your posture for the functional task properly and thinking about a more general (or specific if necessary) cue before movement "eg...keep ribs still" can often result in better functional strength...

Hope that made sense )

[Hallamshire Physiotherapy]

Hi Caz I think the concept of 'core stability' is making people worse with low back pain (and other conditions). Most patients with LBP have increased activation of their trunk muscles caused by a combination of pain and 'fear avoidance'. Our brains learn movement and not muscles, so trying to cognitively learn how to recruit a muscle does not make sense to me. Overactivation of trunk muscles caused increased loading of the lumbar spine joints, and more importantly, the nerve roots thus increasing pain. Peter O'Sullivans articles on the lumbar spine and posture are excellent.
Steve

[HalliB]

Interesting topic.

I think alot of people wrongly believe that the TrA training is about "activating the core" during everyday painful tasks. This is not true.

The most effective method is, yes, using sensory methods to get semi-isolated activation of the TrA. This is neccesary to know wether or not it's firing properly without ultrasound imaging.

After a bout of activation (voluntary contraction), there is increased activation of the TrA in other exercises. Just doing the TrA activation will not do anything at all.

However, as some people have suggested, without a proper examination of the core muscles every method is guesswork. Tight abdominal muscles and hip muscles should be spotted during examination.

[alophysio]

Hi halli B,

Only to be technically correct, but there is a time and place to scale some patients right back to the 10 reps, 10secs 2 sets isolated contractions as per Tsao research which showed good results and carryover with just doing TrA activation - so just doing TrA will do something. Some patients need that particular reset button hit. but mostly you can get away without needing to...the secret is knowing when to do what!

Thanks for your post.

[HalliB]

Yes alo, I think we're mostly quoting the same research here. I mean that after the activation work you get better carryover into the next task (I said exericses, thinking in the context of my outpatient clinic work). This is where most people that are TrA-lazy will need to begin before general cues start to make "more sense" to the person. I only meant to add to your post, not contradict it.

[alophysio]

My apologies HalliB. I have reread your post above and i get it now

I think i seized on the "Just doing the TrA activation will not do anything at all." sentence and mis-interpreted you.

Thanks !!

[neurospast]

You have to excuse me for the fact I did not read the whole of the article but it seems to me someone is (again) trying to do the obvious; convincing us e.g. core control has nothing to do with low back pain. Well I will put it very simple; 80-90% of all low back pain is called none specific low back pain why? because we have no clue (at least there is no available research which concludes a single cause for this 80-90% of back pain thus it is very easy to find arguments that core control has nothing to do with it. If though w one looks at muscles around a joint (the spine is 1 joint with multiple levels) the sequence muscles are acting can be looked upon as a concerto of Beethoven. What would happen if 1 muscle kicks in 1/2 a sec later? the music would sound awfull wouldn't it? If though a muscle (=instrument) would not kick in at all? Maybe the symphony would still not be a pain in the head or back.
Just wondering......

[gcoe]

As Neuropost points out non specific LBP remains full of the unknown when it comes to etiology and pathophysiology. We are probably dealing with a very heterogeneous problem (ie looks superficiallylike one problem but is actually multiple problems with different causes), core stability training does have a good evidence base but it is unlikely to work all the time. Other approaches like McKenzie and alexander also have an evidence base, and no doubt have their successes and failures. As clinicians we need to get much better at correct diagnosis. Until our diagnostic accuracy improves we will continue to offer the wrong technique for the wrong patient.

Personally I think we now have enough treatment options and instead of concentrating on developing better diagnosis we keep dreaming up "new" treatment approaches when in fact what we may end up doing is rehashing old treatment approaches that went out of fashion and became forgotten. I think we need to become more discerning about when to apply or not apply an approach and not get so wrapped up in advocating for one treatment approach over another.

[beazus]

Hi all,
a much enlightening experience indeed. the main pointers i got through this discussion is that we should always assess our patients thoroughly to identify the problems contributing to the LBP and diagnose accordingly. following that, the treatment given should target the problem (abnormal muscle firing patterns, weakness, inactivation of muscles, etc). I think that's what alophysio has been trying to say... definitely not that the rest are wrong!

[alophysio]

Hi All,

@Neurospast: To be honest, i don't think you are a musician...a wrong note sounds wrong but a note not played sounds ok and most people miss it but it can make the music seem "wrong" or "empty". It is the little things like this that that all add up to distinguish the best orchestras from the good ones. And even if you can't pick the difference, you can hear that there is something different.

In the same way, IMHO 80-90% of patients who end up getting back pain (that is NSLBP pts) have some form of dysfunction. It could be mechanical, chemical or pyschological (which is still chemical i guess with other things ).

I think the reason why it is NSLBP is that there are many structures which may cause the symptoms and again many reasons why the structures are under load (like what gcoe said) and the research is not sensitive enough to tease out the different reasons...and finding enough subjects to do a study on a specific number of patterns is difficult.

In my opinion, you body LOVES choices...if it can only move one way, repetitive strain occurs quickly. Two ways is a dilemma but at least 3 options is good for the body - shares the load around.

@gcoe:

I agree...i think the trouble is that "old" treatment approaches sometimes rely on assumptions which are now informed by research...e.g. Mackenzie treatment is predicated on the the fact that discs have fluid in them (nucleus pulposus) but research has shown that the cervical discs are NOT fluid fluid and in fact split horizontally. So another way of describing the no doubt successful Mackenize approach needs to be undertaken.

What i mean is that no doubt Mackenzie cervical pain patients respond to treatment...it just probably isn't because they are moving the disc in the proposed mechanism...***NB I am NOT Mackenzie trained so i am speaking from general knowledge of Mackenzie, not from training in it***

We have seen people get better for all sorts of conditions...but why? I would wager that a lot of the reasons that are given to the patient are not accurate (including my own) but we are always seeking to fit observations into some form of structure because order and structure and predictability are comforting.

Hence, accurate diagnosis according to your "approach" is key...just make sure your approach is comprehensive...

e.g. I like the model that Diane Lee and LJ Lee propose in their 4th Edition of the Pelvic Girdle - i have repeated it often on this forum. If grew from Panjabi's model...which then evolved to the next model described by Vleeming and Lee which has now evolved again.

I have attached a book chapter explaining it here...it is a heavy read by one that i think explains nicely what i do believe in and a model that best encompasses everything that can occur in the body to cause pain and dysfunction, how to identify it and then treat it.

@beazus, thanks for your kind words...it is exactly the point that i am trying to convey

Cheers!