Dogma

[Barrett Dorko]

This short blog post about how “fragile” is the evidence used to justify an entire industry within our communities is something everybody should read.

They won’t of course.

This observation:

… for me, what was more fascinating than the phenomenon of altered trunk muscle function was the phenomenon of a clinical dogma thrusting its way relentlessly through the therapy world.

Dogma. There’s nothing worse in clinical work.

I see the manifestation of this “core strength” stuff in every evaluation form I have to fill out, and I assume that most therapists think it’s true.

It isn’t.

It doesn't even make sense.

[Barrett Dorko]

Is it fair to say this:

Hodges demonstrated a relationship between the complaint of back pain and an inability to contract the multifidus and/or TA upon demand. He speculated that the restoration of muscle control would lead to a reduction in backache.

I've some additional statements I will present in order to get them "cleaned up" and closer to what actually happened and when. Let's start with this one.

Over to you.

[Sheffphysio]

His speculation was proved wrong, fair enough, thats science. But to quote a recent article

Although there is no consensus on the cause-effect relationship between altered motor control and pain, there is a string of evidence that pain is associated with altered motor control.

Hodges does seem to have become more brain focused after he supervised Mr Moseley's Phd

[garydiny]

Wondering if anyone can get a hold of this article. It was mentioned in the blogpost noted above.

Thanks!!

Gary

Eur Spine J. 2012 Jan 24. [Epub ahead of print]
Spine stabilisation exercises in the treatment of chronic low back pain: a good clinical outcome is not associated with improved abdominal muscle function.

Mannion AF, Caporaso F, Pulkovski N, Sprott H.
Source

Spine Center Division, Department of Research and Development, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland, anne.mannion@kws.ch.

Abstract

INTRODUCTION:

Various studies have shown that spine stabilisation exercise therapy elicits improvements in symptoms/disability in patients with chronic non-specific low back pain (cLBP). However, few have corroborated the intended mechanism of action by examining whether clinical improvements (1) are greater in patients with functional deficits of the targeted muscles and (2) correlate with post-treatment improvements in abdominal muscle function.
METHODS:

Pre and directly after 9 weeks' therapy, 32 cLBP patients (44.0 ± 12.3 years) rated their LBP intensity (0-10) and disability (0-24, Roland-Morris; RM) and completed psychological questionnaires. At the same timepoints, the voluntary activation of transversus abdominis (TrA), obliquus internus and obliquus externus during "abdominal-hollowing" and the anticipatory ("feedforward") activation of these muscles during rapid arm movements were measured using M-mode ultrasound with tissue Doppler imaging.
RESULTS:

Pre-therapy to post-therapy, RM decreased from 8.9 ± 4.7 to 6.7 ± 4.3, and average pain, from 4.7 ± 1.7 to 3.5 ± 2.3 (each P < 0.01). The ability to voluntarily activate TrA increased by 4.5% (P = 0.045) whilst the anticipatory activation of the lateral abdominal muscles showed no significant change (P > 0.05). There was no significant correlation between the change in RM scores after therapy and either baseline values for voluntary (r = 0.24, P = 0.20) or anticipatory activation (r = 0.04, P = 0.84), or their changes after therapy (voluntary, r = 0.08, P = 0.66; anticipatory, r = 0.16, P = 0.40). In multiple regression, only a reduction in catastrophising (P = 0.0003) and in fingertip-floor distance (P = 0.0006) made unique contributions to explaining the variance in the reduction in RM scores.
CONCLUSION:

Neither baseline lateral abdominal muscle function nor its improvement after a programme of stabilisation exercises was a statistical predictor of a good clinical outcome. It is hence difficult to attribute the therapeutic result to any specific effects of the exercises on these trunk muscles. The association between changes in catastrophising and outcome serves to encourage further investigation on larger groups of patients to clarify whether stabilisation exercises have some sort of "central" effect, unrelated to abdominal muscle function per se.

[byronselorme]

I know my wife and I were studying Fred DeVito and his wife Elisabeth Halfpapp's program at the Exhale Spa's in Manhattan. They experienced and probably still are experiencing great returns on the exercise model called "Core Fusion".The program is grueling and people flock to it for the challenge. The success owes no small part I imagine to the fact that participants think a strong core will save them from pain.

It also inspires Yoga Teachers like Jill Miller to create programs like Coregeous.

I can't tell you how many people tell me they need to strengthen their core when they come to class. I ask them what they are going to do once they have it.

[Bas Asselbergs]

Great question, Byron.
I'll steal that one the next time I hear about the "strong core".

[advantage1]

It appears that the evidence suggests that these 'core' exercises as prescribed by Hodges are motor control exercises. There is evidence that perfroming motor control taks with a pressure biofeedback unit can improve motor ouptut from the brain which in turn can lead to a reduction in pain. However, nothing is being strengthened.

[Jess Brown]

Originally Posted by byronselorme

I know my wife and I were studying Fred DeVito and his wife Elisabeth Halfpapp's program at the Exhale Spa's in Manhattan. They experienced and probably still are experiencing great returns on the exercise model called "Core Fusion".The program is grueling and people flock to it for the challenge. The success owes no small part I imagine to the fact that participants think a strong core will save them from pain.

It also inspires Yoga Teachers like Jill Miller to create programs like Coregeous.

I can't tell you how many people tell me they need to strengthen their core when they come to class. I ask them what they are going to do once they have it.

Byron,

I hear this type of thing often. Most recently last week from a middle-aged, tearful and diaphoretic woman, who, during the course of the 30 minutes I spoke to her mentioned at least ten times her "weak core" as the cause for her 15 year history of low back pain.

At what point does the perpetuation of this misinformation, so commonly associated with our profession, become the anchor that pulls us down to the bottom? Or are the people here at SS the only ones who can see a way up to the surface?

[ian s]

Neil Persons comments are worth reading and he has some thoughtul ideas regarding movement which I agree with .

I really liked this article and am intrigued as to how an idea can become an industry. Perhaps its the simplicity of the perceived solution to many people that attracts them. I never taught or got persuaded by the rhetoric of any of this muscle control/balance/instability/weakness and was heartened to read Eyal Ledermans take on it all . In busy urban stressed out cultures perhaps its the illusion of controlling ones body by avoiding really breathing that is attractive (since a lot of other areas of life seem out of control for many?)
Diane I think mentioned Hodges interest in looking at the coretex now , pity not many others interested in migrating north for solutions.

[Diane]

At least Hodges did us all the favour of examining "core" from every which way and ruling it out as being anything to do with pain one way or the other.
Likewise, his work with the motor cortex shows that it does something different with every rep. There is not even any correlation between which part of the motor cortex is doing what, let alone via which muscle. At least, that's what I got from hearing him talk about it, twice. Even when the movement is repeated any number of times. No one-to-one correlation of anything. He refutes his own hypotheses and publishes the results, so that's one good thing he does with mesoderm, I guess.

[Barrett Dorko]

So, is it fair and accurate to say the following:

In (what year?), Hodges demonstrated a relationship between the complaint of back pain and an inability to contract the multifidus and/or TA upon demand. He speculated that the restoration of muscle control would lead to a reduction in backache.

However, he now refutes his own hypotheses and publishes the results.

Despite that, an entire industry built upon the premise that "core strength" will prevent and reduce back pain has been justified with Hodges' original research.

[Diane]

I think that's fair... although he doesn't/won't own the way a huge Movement of Transversus Abdominis materialized and followed him around - he doesn't want to (and, maybe he doesn't have to.. although I think it would be big of him to acknowledge it was himself who was the idol and sort of led the parade).

[zimney3pt]

It was in 1996 the Conclusion in his article was:

The delayed onset of contraction of transversus abdominis indicates a deficit of motor control and is hypothesized to result in inefficient muscular stabilization of the spine.

Yet in 2003 he writes an article with this statement:

A new hypothesis is presented regarding the outcome from differential effects of pain on the elements of the motor system.

And again in 2006 he writes with others:

Although there is support for the importance of the lumbar multifidus and the specific contribution of this muscle to intervertebral control, several of the clinical beliefs have little or no support and require further evaluation.

Apparently all those that loved Hodges work stop reading anything else that he put out after 1996. Paul Hodges is obviously a brilliant individual, they don't just freely give out doctorate degrees - he has three of them I believe. I think it would be wise to continue to follow his work and not stop. He has not stopped his study and understanding, why do we?

[amacs]

The delayed onset of contraction

something that is passed over in almost every core class/lesson I have observed. Even referring to this work the delay was in high velocity tasks. Instead we have the contract the core at all times response even when it isn't necessary. I think it may not be stretching things too far to suggest that the research was fairly selectively read by some with a product to sell.

regards

ANdy

[Barrett Dorko]

ANdy,

I think that this small finding of Hodges was conflated with pain and treatment already in place. It was a justification, and it remains so. This is confirmation bias on steroids.

Since muscular strength has nothing to do with joint position, and, consequently, significant mechanical deformation of the nervous tissue, I never could see how strengthening was going to be related to recovery. Movement, on the other hand, might help if it's of the corrective sort. Given all the choreography involved, there's always luck to account for recovery.

For some reason therapists don't like it when I say this. Then they don't like me.

I can't help but think that in using the word "core" that there is a strong culturally based appeal to the whole idea.

"He's rotten to the core."

A powerful phrase.

[nari]

I think it may not be stretching things too far to suggest that the research was fairly selectively read by some with a product to sell.

ANdy, this is how I see it. It's a novel approach, it sounds good for those seeking the holy grail of "strengthening" and it is $$$ from there on.

When I first began to learn and teach the core craze, it seemed a logical approach; if my back ached, the pain disappeared with TA contraction. However, it returned later. That was my lack of dedication.

It reminds me of the pelvic floor mania of the 80s. Up to 300 contractions each day, 10 at a time every hour or so. Notices all over the fridge: PF!! Traffic lights? Do 20.

It's a pity that ideomotion and DNM hasn't attracted $$$$. Oh, yes, they don't involve mesoderm, so little or no $$$$s.

Nari

[byronselorme]

It's ok Nari.

We have a clinic in Akron that is making us big $$$$ now.

[amacs]

Originally Posted by nari

ANdy, this is how I see it. It's a novel approach, it sounds good for those seeking the holy grail of "strengthening" and it is $$$ from there on.

...

It reminds me of the pelvic floor mania of the 80s. Up to 300 contractions each day, 10 at a time every hour or so. Notices all over the fridge: PF!! Traffic lights? Do 20.

...

Nari

I can't resist it but that sounds like taking the piss (ahem)

regards
ANdy

[CDano]

Pelvic floor is still very big in yoga, i think more so than the core in some circles.

[nari]

I agree a stable PF is important for males as well as females but overdoing the repetitions is what drove post-natal women to distraction and disappointment until they discovered all they were achieving was fatigue in the musculature; after that everyone settled on 3-4 reps several times a day.
As with core stuff, the maxim of "more is better" is still alive and well.

Nari