What does core strength actually mean?
My first perception of ‘core strength’ was when I was a young basketballer and I saw an injured teammate on the sidelines at training one night. She was doing planks while we ran around the court completing training drills. The plank is a prime example of how the fitness industry have heavily advocated core building exercises as a way of managing a back complaint. A lot of Pilates studios also encourage people to lay still on a reformer bed, and bang on about keeping their spine rigidly in its ‘neutral’ or ‘imprinted’ position. The common assumption is that to ‘protect’ the spine, you need to stop the spine from moving, and create a rigid spine.
But this is not what core stability means. The idea of ‘core stability’ first began in 1996… 24 years ago… the year I was born. The research was completed by Hodges and Richardson and the concept was that they targeted their interventions towards deep core musculature such as the Transversus Abdominus (TvA) and Multifidus. These are the muscles your Pilates instructor mentions is activated when you ‘bring your navel to your spine’. What they found in this research that this muscle is the most important and works like a corset to stabilise the back. This was then extrapolated hugely, and clinicians took from that work was to start strengthening these muscles to decrease lower back pain. This is where ‘motor control’ exercises were born. This topic has also now been researched to the point we have 7 systematic reviews. For those not familiar with a systematic review, this is a GOLD STANDARD research paper that summarises all the results of carefully designed healthcare studies and provides a high level evidence on the effectiveness of the healthcare interventions.
Do you want to know that the systematic reviews have concluded? Well, 6 out of 7 of them show no known benefit in prescribing motor control/TvA based exercises over that of general graded exercise.
This early work while I was still a foetus was then adapted into the Pilates community, adopted by physiotherapy and allied health. I don’t want to undermine the amazing work this professor has done- he found that that those particular core muscles are delayed – not weak, not ‘turned off’. And he never said that the transversus abdominus was the most important muscle to prevent lower back pain. But for some reason, physiotherapists, chiros, PTs, and other health professionals continually cue patients to pull in their belly button/stomach when patients do squats for ‘spine stablity’. The purpose of this blog post is therefore not to discredit the research (because Professor Paul Hodges should continue to be commended for it) but to highlight its misuse. Hodges himself has mentioned himself in an interview from 2016 that in most functions the spine needs to move, and the importance of getting the balance between movement and stiffness.
Stability is one of the most inappropriate words physiotherapists can use to describe the cause of patient’s spinal pain. There has been NO documentation of unstable spines, nor is there any clinical tests for spinal stability. Yet we have been using this word since I was born.
So if you have lower back pain. You don’t need ‘stability’ exercises. You need to be individually assessed by your physiotherapist, for general graded exercise specific to your functional limitations. We know that lower back pain is actually associated more so with other comorbidities such as obesity and mental health. If you had a choice to improve your lower back pain, would you choose tedious and time consuming motor control exercises, or would you opt for an activity that you enjoy? I know what I would pick and it certainly doesn’t involve being trained to hollow my belly or brace.
And if all this doesn’t make sense – here’s a good video to watch of Professor Peter O’Sullivan explaining it. The link is: https://www.youtube.com/watch?v=YezBG_NdLgs
References (you’ll see here that there is plenty):
The Myth of Core Stability – Eyal Lederman https://www.sciencedirect.com/science/article/abs/pii/S136085920900093X
Why we need to stop blaming Transversus Abdominus for back pain
Specific stabilisation exercise for spinal and pelvic pain: A systematic review – Ferreira et al. 2006
Stabilisation exercises for low back pain: a systematic review – May and Johnson 2008
Non-specific low back pain – Maher and Underwood 2017
Motor Control Exercise for Persistent, Nonspecific Low Back Pain: A Systematic Review – Macedo et al. 2009
Motor Control Exercise for Nonspecific Low Back Pain – A Cochrane Review – Saragiotto et al. 2016
Segmental stabilizing exercises and low back pain. What is the evidence? A systematic review of randomized controlled trials – Rackwitz 2006
Motor Control Exercises Reduces Pain and Disability in Chronic and Recurrent Low Back Pain: A Meta-Analysis – Bystrom 2013
An update of stabilisation exercises for low back pain: a systematic review with meta-analysis – Smith, Littlewood and May 2014