What is Core Stability?

Many patients to professional / sedentary athletes to gym users often ask ‘What is Core Stability'? This is a very good question, as many different people have different interpretations of the term ‘Core Stability’ as it can mean many different things to different people. However In the clinical setting, such as rehabilitation, the term ‘Core Stability’ often represents a sequence of exercises (to clench and hold things tight and rigid by pulling and keeping your deep abdominal muscles in whilst performing a series of movements).

 

Without hesitation or concerns regarding the effectiveness of ‘Core Stability’ compared to other types of treatments ‘Core Stability’ remains overlooked and unquestioned and has often been the selective treatment of choice for most rehabilitators (1,2). In this health news article we will briefly discuss and focus on the following evidence for;

 

The physiological effectiveness of Core Stability exercises for chronic low back pain (LBP)

 

The nervous system influences neurological control on stability. This simply means that the nervous system co-ordinates the response of muscles to predictable and unpredictable forces. This often occurs at the right amount of time and by modulating the degree of stiffness and movement required to compensate the variable forces imposed by the body to maintain stability in the spine (3, 4, 5, 6)

 

Research has identified that there are feed forward mechanisms that activate postural reactions of the trunk muscles prior to activity in muscles that move the extremities (5, 6, 7). It has been suggested that the feed forward mechanisms may demonstrate delayed recruitment differences in muscle patterns with patients with low back pain. For example research suggests the muscle transversus abdominis (TrA) activates in normal people preceding limb movement in an anticipatory feed forward mechanism. However in the chronic low back pain patient (LBP) research suggests that this activation may be delayed (8, 9, 10).  For this very reason it was hypothesised through the use of therapeutic exercise that this would be a positive way of addressing this delayed feed forward mechanism in patients with chronic low back pain.  Furthermore patients that had a previous history and current symptoms of chronic low back pain, re-injury risks would be significantly be reduced by following the treatment procedure (5). The treatment procedure consisted of a set of therapeutic exercises designed and aimed at isolating the TrA to help develop and retrain the motor skills and thus ‘reset’ the delayed feed forward mechanisms (10).

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The underlying physiological effects

The theory behind that TrA exercise rehabilitation may have positive physiological effects on patients with chronic (LBP) is centred on two hypothesised principles.

 

The first hypothesised principle being that the TrA is the key component of spinal stability which was highly based on assumption which failed when clinically tested. The theory was based upon the biomedical model of causation as explained by Bradford Hill in (1965) whereby biological changes are used to describe the state of illness and to describe what was considered to be a normal state in which a body should be. Furthermore any changes from this normal state would be considered as abnormal thus potentially leading to illness. Even though the theory was very basic it failed to acknowledge psychological and social factors (11,12). Moreover recent research has demonstrated that the TrA onset timing patterns between pain free subjects when clinically tested has no ideal timing pattern. This suggests that variance of the TrA onset timing patterns is now considered to be normal in individuals (13,14). A high quality study also found inconsistent evidence of delayed onset timings of the TrA activation in patients with chronic LBP pain compared to pain free subjects and questioned its existence (15). 

 

The second principle, through exercise training it was considered to help ‘reset’ the delayed feed forward timing of the TrA activation but failed during testing.  A randomised study that looked at the effects of core stability exercises on feed forward activation of the deep abdominal muscles in chronic low back pain patients compared one-on-one core stability training versus one-on-one sling exercises and group general exercises. The study suggested, there is no consistent evidence to demonstrate that patients with chronic low back pain have delayed onset of TrA activation and that any delay is not significant to the causation of their low back pain. Furthermore the study also suggests through TrA training it does not improve any timing problems.

 

Clinical efficiency

To date there have been numerous research journals, articles (some of which have been of high quality than others) that have reviewed the effectiveness of ‘core stability’ exercises in patients with chronic LBP. However, to date there has been no randomised control trial that has demonstrated that ‘core stability’ is more effective over other forms of general exercises for pain, disability or function in patients with LBP. However there are studies that do suggest that core stability exercises may reduce pain in individuals with chronic LBP but unfortunately these results are insufficient to be generalised to the population (17,18,19,20). This is because of biases or there was no comparison with other forms of general exercise or outcomes taken on discharge with no subject allocation information (21,22). A recent systematic study suggests that core stability exercises may unlikely create better outcomes over other forms of exercise training programmes in patients with chronic low back pain (23).

 

Conclusion

Arguably there is some agreement amongst clinical health professionals and researchers that core stability offers no additional benefit to long term outcomes of pain, function and disability over other forms of exercises in patients with chronic LBP (24,25,26,27,28). My opinion on this subject, to ask patients with chronic LBP to clench and hold things tight and rigid by pulling and keeping in their deep abdominal muscles in whilst performing a series of movements is utter nonsense.

 

If you are performing other exercise disciplines my advice would be to stop pulling in your deep abdominal muscles in because this doesn’t follow through into function. This is due to being a conscious effort via the neurological system and because of this I would recommend to you to start blowing out like an inflatable balloon.    

 

As always thanks for taking the time to read this article and enjoy your exercise.

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References

  1. Liddle, S. D., David Baxter, G., & Gracey, J. H. Physiotherapists’ use of advice and exercise for the management of chronic low back pain: a national survey. Manual therapy 2009; 14(2): 189–96. doi:10.1016/j.math.2008.01.012

  2. May, S., & Johnson, R. Stabilisation exercises for low back pain: a systematic review. Physiotherapy 2008; 94(3): 179–189. doi:10.1016/j.physio.2007.08.010

  3. Barr, KP. Griggs, M. Cadby, T. Lumbar stabilization: core concepts and current literature. Part 1 Am J Phys Med Rehabil 84:473-480,2005  Accessed Pub Med http://www.ncbi.nlm.nih.gov/pubmed/15905663

  4. Ebenbichler, GR et al: Sensory-motor control of the lower back: implications for rehabilitation. Med Sci Sports Exerc 33(11):1889-1898, 2001 

  5. Hodges, P. Creswell, A, and Thorstensson, A: Preparatory trunk motion accompanies rapid upper limb movement. Exp Brain Res 134:69-79, 1999

  6. Hodges, PW. And Richardson, CA: Contraction of the abdominal muscles associated with movement of the lower limb Phys Ther 77(2):132-142, 1997  

  7. Hodges PW and Richardson CA Relationship between limb movement speed and associated contraction of the trunk muscles. Ergonomics 40(11):1220-1230,1997

  8. Hodges, & Richardson. Inefficient muscular stabilization of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine 1996; 21(22): 2640–2650.

  9. Hodges, & Richardson. Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds. Archives of physical medicine and rehabilitation 1999; 80(9): 1005–12. Retrieved fromhttp://www.ncbi.nlm.nih.gov/pubmed/10489000

  10. Richardson, Jull, Hodges, & Hides. Therapeutic Exercise for Spinal Segmental Stabilization: In Lower Back Pain 1999. Edinburgh: Churchill Livingstone.

  11. Bradford Hill, A. The Environment and Disease: Association or Causation? Proceedings of the Royal Society of Medicine 1965; 58: 295–300.

  12. Tyreman, S. Causes of illness in clinical practice: a conceptual exploration. Medicine, health care, and philosophy 2006;9(3): 285–91. doi:10.1007/s11019-006-9006-6

  13. Mannion, A., Pulkovski, N., Schenk, P., et al. A new method for the noninvasive determination of abdominal muscle feedforward activity based on tissue velocity information from tissue Doppler imaging. J Appl Physiol 2008; 104(4): 1192–201. doi:10.1152/japplphysiol.00794.2007

  14. Vasseljen, O, Fladmark, A., Westad, C., & HG, T. Onset in abdominal muscles recorded simultaneously by ultrasound imaging and intramuscular electromyography. J Electromyogr Kinesiol. 2009; 19(2): 23–31.

  15. Gubler, D., Mannion, A., Schenk, P., et al. Ultrasound tissue Doppler imaging reveals no delay in abdominal muscle feed-forward activity during rapid arm movements in patients with chronic low back pain. Spine 2010; 15(35): 1506–13. doi:10.1097/BRS.0b013e3181c3ed41

  16. Vasseljen, Ottar, Unsgaard-Tøndel, M., Westad, C., & Mork, P. J. Effect of core stability exercises on feed-forward activation of deep abdominal muscles in chronic low back pain: a randomized controlled trial. Spine 2012; 37(13): 1101–8. doi:10.1097/BRS.0b013e318241377c

  17. Ferreira, M. L., Ferreira, P. H., Latimer, J., et al. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial. Pain 2007;131(1-2): 31–7. doi:10.1016/j.pain.2006.12.008

  18. Klaber Moffett, J., & Frost, H. Back to Fitness Programme: The manual for physiotherapists to set up the classes. Physiotherapy 2000; 86(6): 295–305.

  19. Richardson, Jull, Hodges, & Hides. Therapeutic Exercise for Spinal Segmental Stabilization: In Lower Back Pain 1999. Edinburgh: Churchill Livingstone.

  20. Westaway, M. D., Stratford, P. W., & Binkley, J. M. The patient-specific functional scale: validation of its use in persons with neck dysfunction. The Journal of orthopaedic and sports physical therapy 1998; 27(5): 331–338. Retrieved fromhttp://www.ncbi.nlm.nih.gov/pubmed/9580892

  21. Petrofsky, J. S., Batt, J., Brown, J., et al. Improving the Outcomes after Back Injury by a Core Muscle Strengthening Program. Journal of Applied Reliabiltiy 2008; 8(1): 62.

  22. Pensri, P., & Janwantanakul, P. Effectiveness of Brief Education Combined with a Home-Based Exercise Program on Pain and Disability of Office Workers with Chronic Low Back Pain: a Pilot Study. Journal of Physical Therapy Science 2012; 24(2): 217–222. doi:10.1589/jpts.24.217

  23. May, S., & Johnson, R. Stabilisation exercises for low back pain: a systematic review. Physiotherapy 2008; 94(3): 179–189. doi:10.1016/j.physio.2007.08.010

  24. Gladwell, V., Head, S., Haggar, M., & Beneke, R. Does a Program of Pilates Improve Chronic Non-Specifi c Low Back Pain ? J Sport Rehabil 2006; 15(4): 338–350.

  25. Lewis, J., Hewitt, J., Billington, L., et al. A randomized clinical trial comparing two physiotherapy interventions for chronic low back pain. Spine 2005; 30(7): 711–21.

  26. Norris, C., & Matthews, M. The role of an integrated back stability program in patients with chronic low back pain. Complementary therapies in clinical practice 2008; 14(4): 255–63. doi:10.1016/j.ctcp.2008.06.001

  27. Rasmussen-barr, E., Bjorn, A., Arvidsson, I., & Nilsson-wikmar, L. Graded Exercise for Recurrent Low-Back Pain. Spine 2009; 34(3): 221–228.

  28. Muthukrishnan, R., Shenoy, S. D., Jaspal, S. S., Nellikunja, S., & Fernandes, S. The differential effects of core stabilization exercise regime and conventional physiotherapy regime on postural control parameters during perturbation in patients with movement and control impairment chronic low back pain. Sports medicine, arthroscopy, rehabilitation, therapy & technology : SMARTT 2010; 2: 13. doi:10.1186/1758-2555-2-13

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