The term ‘core stability’ has been a term that we as physiotherapists have endured for the last 20 years. Back in the 1990’s a small number of medical articles reported that people with chronic low back pain (CLBP) demonstrated changes in onset timing of certain abdominal muscles. Unfortunately, these findings along with anecdotal beliefs about abdominal muscles led to a revolution and a worldwide industry in promoting core stability type exercises. The fundamental assumption was that weak abdominals lead to low back pain, in particular an individual deep abdominal muscle called Transversus abdominus. It was therefore widely believed that by specifically strengthening these unique ‘core muscles’ back pain would be reduced.
It is no surprise that these basic assumptions have been proven to be no better than general exercise and have not reduced or stopped the reoccurrence of low back pain. In fact from clinical experience of treating many patients with CLBP, the more common muculoskeletal presentation is of increased muscular tone. This is often from prolonged periods of protection, fear avoidance and guarding type strategies. Why this occurs is more complicated and we now know that psychosocial issues have to be considered and can be one of the main driving forces of ongoing pain in this patient group. These compensatory patterns of movement are often pain provoking with increased loading and compressive forces through the lower back. There is sound evidence identifying increased co-contraction in muscles when this patient group are performing such tasks as bending forward, a task that is often avoided and increases anxiety. This is an abnormal response.
An interesting review by Lederman 2007 suggests that we should teach our patients to relax rather than contract. From a clinical perspective this is what we find to be the most beneficial approach. It is also worth considering why are ‘strengthening or core stability type exercises’ given when there is relatively low levels of trunk muscular activity when we are standing, sitting and even walking. We are designed to be efficient is our muscular use otherwise we would fatigue too quickly.
Unfortunately like everyday life nothing is simple and every person/patient is an individual with many and varied aspects of their lives that influence them and their responses to pain. Pain is normal and essential for survival but prolonged pain becomes more complicated and can change our ‘hardware’ i.e. our brains.
Core stability exercises have changed but are still fundamentally working on the premise of strength equals less pain which we now know is not necessarily true. Treat the whole person and return normal movement patterns through the recognition of all the possible contributory factors.
If you want to learn more about ‘core stability’ watch Professor Peter O’Sullivan