The Useless Core Strengthening

[bernard]

Hi All,

The core strengthning seems to be a huge part of daily practice of many PTs.
Here is two papers showing another point of view:

Electromyographic functional analysis of the lumbar spinal muscles

It is certainly possible to show evidently that the protocol of CS is not really good and perhaps brings more problems than it helps?

[bernard]

Core exercises: Beyond your average abs routine
From MayoClinic.com
Special to CNN.com
Did you know that your core is where all movement in your body originates? Core exercises are an important part of overall fitness training that, except for the occasional sit-up or crunch, are often neglected.
To get your core muscles in better shape, it's important to understand what your body's core is and how you can strengthen it.
Understanding your coreYour body's core — the area around your trunk and pelvis — is where your center of gravity is located. A strong core gives you:

• Increased protection and "bracing" for your back
• Controlled movement
• A more stable center of gravity
• A more stable platform for sports movements

When you have good core stability, the muscles in your pelvis, lower back, hips and abdomen work in harmony. They provide support to your spine for just about any activity.
A weak core can make you susceptible to poor posture, lower back pain and muscle injuries. Strong core muscles provide the brace of support needed to help prevent such pain and injury.
Strengthening your coreCore strengthening requires the regular and proper exercise of your body's 29 core muscles. Basic exercises that will enhance your core fitness include the:

• Bridge
• Abdominal crunch or sit-up
• Plank
• Quadruped

A fun alternative to your basic core strengthening regimen is to learn exercises that use a fitness ball. Balancing on these oversized, inflated balls requires that you focus on using your core muscles for support.
Getting the most from your workoutIt's important to do your core exercises at least three times a week. For optimal results, remember to:

• Choose exercises that work your core muscles simultaneously. Rather than isolate each muscle group in your trunk, the best exercises for your core are those that get muscles working together at the same time.
• Focus on quality of movement rather than quantity. You'll gradually build up to a greater number of repetitions. When starting out, take it slow and learn how to properly perform each exercise with optimal technique.
• Breathe steadily and slowly. Breathe freely while doing each of the exercises in your core strengthening workout. Your instinct may be to hold your breath during an exercise, but it's better to continue breathing.
• Take a break when you need one. When your muscles get tired, stop and change exercises. And, if you work your core muscles to fatigue during an exercise session, wait at least a day between workouts to allow the muscles to recover.
• Get help from a trained professional. Body position and alignment are crucial when performing core strengthening exercises. When you begin, it's a good idea to have a fitness trainer or physical therapist help you perfect your technique.

Keep in mind that strengthening workouts — even core strengthening — are just one part of a complete fitness program. Include aerobic exercise and flexibility training to round out your regimen.
October 06, 2005

Here is an example.

[Diane]

I wish they would name all 29 "core muscles" mentioned. Which ones are they talking about? I thought transAb was the big target most of the time. Now I'm confused.

[Barrett Dorko]

Me too.

Not being any sort of expert on this issue, which of course doesn't keep me from not liking it, what can I say now given this information about the use of core strengthening for backache?

I must say that I almost always hear therapists say they "believe" in strengthening the core. I'm wondering why they emphasize "belief" so commonly when talking about this.

[bernard]

Diane,

29, is yet a weird number since I thought we were "symetrical" in this area?
I put the subject since it is controversial. Many SomaSimplers are not really for but many PTs are doing it, every day because they learnt it.

It is a gold standard but it is, IMHO, a meme to forget.

[Diane]

Oy, another big memeplex to deconstruct.
People claim that rolling patients around backwards over a big ball "strengthens" something.. I secretly think that what it does is;

1. provides the brain with novel stimuli (i.e. use muscle in this challenge or you'll fall on the floor);
2. l-e-n-g-t-h-e-n-s out the abs.. (most of the time sedentary people have them shortened while slackened in sitting positions) and makes people neurally glide those incredibly long cutaneous nerve that flow through the ab walls;
3. gets them breathing. That in and of itself has to be a good thing. As long as they don't try to keep their belly wall contracted as they breathe in.

The quadruped position is a nice one for relaxing and lengthening upper and mid sections, both longitudinally and circumferentially.

Stay tuned for thumbnails of trunk musculature and probably some (not especially art-worthy) homemade drawings.

[nari]

Come to think of it....what proof do the CS aficionados have that multifidii, ES and the others are strengthened by high jinx on the ball and therefore strength is the answer??

They might get thicker (the muscles, that is) and function improves...but how do they know that strengthening has anything to do with pain relief?

That's always intrigued me. I guess it is because there was no other possibility to think about x years ago, hence strengthening muscle = pain relief and/or improved functioning. Of course, they could always come back with the response: How do you know it is not? However I think the neurophysiological line holds far better than the bigger-muscle line.

Nari

[Synergy]

Originally Posted by Barrett Dorko

...I must say that I almost always hear therapists say they "believe" in strengthening the core. I'm wondering why they emphasize "belief" so commonly when talking about this.

Barrett,

Maybe it has to do with their 'core values'. (pretty lame...I know)

Diane,

Your first two points are entirely true, however, why can't this be understood by the majority of PTs?

[bernard]

Nari,

The original theory is only biomechanical.

1. The L5/S1 disc is 5 cm² and "suffers" the loads.
2. If we enlarge the area for the loading thus constraints will be lowered.
3. "Bracing" with abdominals is "the" way to enlarge the loading zone.

But it is just wrong.
This is the meme to discard.

[nari]

Bernard, I know...but,as Chris stated, why don't others?
Sorry if my rhetorical statements confuse you..they confuse me at times.

Nari

[bernard]

Nari,

The previous meme is seconded by another => muscular strength is able to relieve pain.

It may be true and wrong at the same time.

[Jason Silvernail]

Well, since I prescribe these exercises for lower back patients frequently and since we have a separate "Lumbar Stabilization Class" in our clinic, I suppose I should speak in support of it.

I guess I won't get into the practice of it too much, but will focus on the theory of why it works and the rationale used to prescribe it. Like others here, I don't think strength and pain are related. However, in some situations there can be a rationale for the use of strengthening exercises. Let me explain.

There have been many biomechanical treatises on the function of the spine, both theoretical and in laboratory. Look for names like Panjabi, McGill, Richardson, Hides, and Cholewicki. The theory is that there is excessive mechanical deformation of certain structures of the spine with movement. What structures? Good question, plenty of likely culprits - but I vote for nervous tissue myself which is found everywhere.

Some key points:
-Studies have demonstrated that proper contraction patterns of core muscles increase the stiffness of the spine and decrease the translations at spinal segments.
-Studies have also shown a motor planning deficit in those with lower back pain, as well as atrophy of certain muscles, especially the multifidus, and that that atrophy does not improve on it's own at the 6 month mark.
-Studies have also shown that a specific exercise program not only improves the atrophy (via return of multifidus symmetry as measured by ultrasound) but improves patient-centered outcome measures relative to pain and disability.
- A recent preliminary clinical prediction rule has come up with some interesting ideas. It in, a few key factors were shown to improve the likelihood of improvement with the technique. It has not been validated, as has the CPR for manipulation, so it's strength of evidence is not as high.
- This prelim CPR (in a nod to self-correcting science) actually showed that people who had the most "fear avoidance" behavior, were more likely to do better with the treatment. Implying a cortex involvement, far from biomechanics.

I have used this mode of care for many years, and I have some personal theories about it myself, which I'll share because I can.
I think, as Diane alludes to, that there is a VERY strong cognitive-behavioral aspect to this treatment. It gets people in pain exercising and moving in a safe, supportive environment that focuses on function. It gets them to activate and challenge muscles in an area that is painful and they are concerned about. It also reconnects their brain to the painful area, and restores some motor control and brain activity there, and I don't need to convince anyone here that that's important.

I think that this mode of care fits well into neurophysiologic theory in that the thrust of the idea is to reduce repetitive mechanical deformation across sensitized tissues, restore brain control, engage in functional movement/activity, and place the patient in control of symptoms and in control of pain. It's disadvantages are that the exercises are fairly choreographed (though they are individualized to the person's patterns of painful movement and positions) and they do not encourage freedom of movement/ideomotor movement.

Though if you ask most therapists why it works, they will give you a strict biomechanical answer, most thoughtful therapists (including leading investigators on lower back pain) believe, as I do, that there is a large cognitive-behavioral component to the treatment.

This is not mindless bouncing about on balls and pulling in the tummy. The exercises are targeted to the patients complaints, and the patient is taught to move the spine on their own and find a comfortable position from which to begin each exercise.

I have attached the preliminary CPR paper on this modality, as well as the information sheet I give to patients when we begin, which gives a good explanation of what patients are taught.

What does everyone think?
J

[bernard]

Jason,

I made a pdf version of your Word document.
Some readers haven't the microsoft program.

[Barrett Dorko]

Jason,

Great reply.

It seems to me that if Feldenkrais were alive he'd agree with you 100%, and I never found anything said by Feldenkrais disagreeable. Unfortunately, those who follow his thinking and teach his work have done a terrible job of getting it into the mainstream of movement therapy in our profession. (Not that I've had any success with my own ideas) But I've had many Guild members at my courses, and though they proclaim their interest they are completely silent beyond that. To me, this has been especially disappointing.

Here's where I have difficulty with the stabilization crowd: They seem to think that strengthening alters posture and that posture and pain are related. They go on to assume that pain and strength are related.

As far as I know, none of this has been demonstrated. If I'm wrong, please show me where.

What has been shown is that if people move painlessly with attention and precision and care they can recoordinate their function and, given enough repetition, alter their use for the better for prolonged periods. Feldenkrais was always careful to assign the change to the brain and saw the muscle purely as an agent of/for that change. Stabilization sorts seem to forget that and often speak of the muscle in isolation. Feldenkrais would have hit them over the head with his book.

I have the sense that in the absence of ideomotion more choreography of a special sort is required. Maybe a few moments of ideomotion would replace a much longer period of exercise. I don't know this for sure by any means.

[Jason Silvernail]

Hey, Bernard, thanks!
I don't have the ability to turn Word into PDF, but it certainly is the preferred format. If I send you my entire catalog of self-created exercise and education handouts in word, could you turn them all into pdfs? Just kidding of course.

Barrett-
Thanks for your reply. I have to say that I'm not sure it is the posture itself that we are discussing in the stabilization paradigm. It is really less about posture and more about finding a position in which there is less pain (exploring movement to achieve relief- sound familiar?) and contracting muscles to reduce excessive accessory motion at sensitive tissues, reducing the cycle of mechanical deformation.
I will fully admit that the average therapist on the street may not approach stabilization the way that I do, but it is the way I was taught in the Army and the way the investigators of the treatment teach it. Certainly there is a subset of people who sort of mindlessly pass out "core strength" exercises in a rather haphazard way, but I believe they are in the minority.

And I completely agree that posture, strength, and pain are not related. However, we can all agree that movement and position is related to pain when there is mechanical pain due to abnormal neurodynamic or excessive mechanical stress on sensitized tissues. And that's really the heart of core stabilization.

Thoughtful therapists see differences in the terminology, but many people use them interchangeably. I contend there's a huge difference.

Core Stabilization: learning to maintain a comfortable position when outside forces are involved. The spine itself is held still in the comfortable position. Example: keeping you lower back in a certain position when lifting something heavy. I do this all the time for lower back patients.

Core Strengthening: moving your spine against a load for the purpose of increasing strength of the trunk muscles. Example: a situp or crunch exercise. I rarely if ever do this for patients in pain, since strength isn't related to pain.

I think if in the thread that Bernard defines "core strengthening" the way that I have, I completely agree that it's useless in managing pain. Other than perhaps a cognitive-behavior component, which of course would be better aimed at something functional in life, it has no role.

J

[bernard]

Originally Posted by Jason

could you turn them all into pdfs? Just kidding of course.

No problem but there is a free way =>

http://www.somasimple.com/forums/showthread.php?t=1243

Open Office opens words docs and is able to convert them to pdfs.

[bernard]

Back to heart of the core,

Jason,

You're speaking of stiffness as a protective tool.

• A stiff element transmits integrally the forces applied.
• An elastic and curved one, absorbs a great part of the loading.

The core model is shaking.

[Barrett Dorko]

Jason,

We disagree on only one thing: that therapists who pass out "core strength" exercises haphazardly are in the minority. I get around, and this sort of approach to practice for backache is common enough to be considered the norm.

It's "the elephant in the room" though, and most of our colleagues would prefer I not mention its presence.

If I look a little bulky in Orlando it's because I've decided to wear a wet suit beneath my other one. And those aren't just size 43 clown shoes - they're flippers. Now, if I only knew how to swim...

[Jason Silvernail]

Well, Barrett, perhaps you're right about the quality of "average" care provided. I sort of pride myself on providing quality care, and am in the presence of what I consider to be a very competent group of therapists (in the US Army). Perhaps I just have an elevated idea of what standard of practice is.
On the swimming thing- have you considered water wings? They would round out your outfit quite well, I think...

Bernard-
I guess i'm speaking of stiffness as reduced chronic motion and mechanical deformation of sensitive tissues. If the forces are distributed to other local tissues that are not mechanically sensitive, then the paradigm holds rather well.
Thanks for the OpenOffice site...I'll have to check that out. If it's as easy as it seems, I will be able to say SomaSimple has been of great help to me in more ways than in my practice!

J

[bernard]

Originally Posted by Jason

If the forces are distributed to other local tissues that are not mechanically sensitive, then the paradigm holds rather well.

If! But are they?
IMHO, they are not. We are using muscles to make the back stiffer but there is also a compressive force created by this activity. Added to the load, it will create a quicker approach the "limits"?

ps: I'm using daily Open Office since... 2004. All the "custom" pdfs are made with it.

[nari]

Jason

I liked your summary of CS information for patients. Useful and concise.

How would we know what tissues are not mechanically sensitive to loading?

The real difference here is that many, many PTs (I agree with Barrett) use CS as means to strengthen 'core' musculature and redistribute load. I think they still operate on the pain/posture/strength meme. You, on the other hand, are coming from the CNS/PNS angle. It's the premise that makes the essential difference - nobody denies that CS is useful, particularly if patients enjoy the routines. It's just like the manipulation premise......and probably zillions of other PT "tools".

Nari

[Jason Silvernail]

I think you're right about that, Nari. It is all about how we approach it. I think a good core stability program can be enormously beneficial in the right patient population, but mindless series of strength exercises are clearly a waste of time.

I guess, in the last two years reading all of you at RE and now here, I have become decidedly more neuro/cortex-centric in my approach to patients. Now I see most all PT treatments in terms of neurophysiology. There are some pathological problems that I approach biomechanically, but most PPP are not, so this approach works well.

What was it someone here said, all the tools, they are all cortex anyway...

J

[BB]

Here is an article that I post only because it does show some correlation with pain and posture, when it is also correlated with a tendency toward certain movement patterns. This gives credibility toward perfect posture being a relative term.

J Orthop Sports Phys Ther. 2004 Sep;34(9):524-34. Related Articles, Links
Differences in measurements of lumbar curvature related to gender and low back pain.

Norton BJ, Sahrmann SA, Van Dillen FL.

Washington University School of Medicine, Program in Physical Therapy, St Louis, MO 63108, USA. nortonb@wustl.edu

STUDY DESIGN: Cross-sectional. OBJECTIVES: To test the assumption that postural alignment and gender have a bearing on the specific type of low back pain (LBP) a person manifests. BACKGROUND: Measurements of static sagittal lumbar curvature are used by clinicians in the management of patients with LBP, but no investigator has reported differences in curvature related to specific categories of LBP. METHODS AND MEASURES: We used a computer-interfaced, 3-D, electromechanical digitizer to derive curvature angles for the region of the spine between T12-L1 and S2. Trained clinicians examined the subjects and determined their LBP diagnoses. We used t tests to examine differences in curvature between women and men, those with and those without LBP, and those in 4 different categories of LBP. We used chi2 to examine the relationship between gender and LBP category. RESULTS: Lumbar curvature angle (lordosis) was 13.2 degrees larger for women than for men (t = 6.74; P<.01). There was no difference in lumbar curvature between people with undifferentiated LBP and people without LBP. There were differences in lumbar curvature between people in various categories of LBP, for example, subjects in the lumbar-rotation-with-extension category had 8.4 degrees more lumbar curvature than subjects in the lumbar-rotation-with-flexion category (t = 2.16; P<.05). Based on the frequency distributions, there was a significant relationship between gender and LBP category (chi2 = 10.19; P<.01). CONCLUSIONS: Measurements of lumbar curvature should be expected to differ between men and women and may be related to different types of low back pain.

PMID: 15493520 [PubMed - indexed for MEDLINE]

I have used an approach toward this style of exercise very similar to Jason's description, and today I read something in one of Feldenkrais' books that I think fits into this conversation of stability exercises and also of posture.
He speaks of healthy posture and movement being effortless, and without resistance.
Let's say that a person stands in lordosis, pain with extension activities, etc. We could teach them to better recruit the flexors and maintain a less extended position, and this would very likely reduce their pain. However, this position would be attained by balance between 2 over recruiting muscle groups, like 2 elephants sitting on a see-saw. We are, in essence, treating one compensation with another.
Feldenkrais speaks of reducing the resistance, thus making the movement or position effortless. So, if this same person could be taught to reach the neutral spine, healthy posture, by reducing the resistance of the extensors, less, if any, effort of the flexors would be required.
Upon looking at these two different scenarios the person may appear the same, but one is effortless, the other working his butt off to stay neutral. So, I think our approach toward finding that painfree posture is correct, but we may also want to achieve it effortlessly. Then the conditioning becomes more of engraining the movement pattern and less of gaining strength and endurance to sustain this incredible effort.

Cory

[BB]

For those of you who may have given up on my last post once you got to the name "sahrmann," please be sure to read the bottom "non-sahrmann" comments.

Cory

[bernard]

Cory, your analysis is just fine. Feldenkrais as many eastern approaches are interested by the lowest energy expenditure. This is far from our occidental strengthening.

Originally Posted by Nari

nobody denies that CS is useful

Hmmm, I do because it is bio-mechanically improbable, physically impossible and maintains the patient conditions.

[bernard]

Hi All,

I propose two little tests:

1/ bending forward around 30/45°

• Try it without fear and just let it go in an effortless manner.
• Try it with the CS principle with the "muscular brace".

What is the more comfortable?

2/ Take a flexion bent position around 40°

• Put a hand on your abs and the other on the paraspinals musculature.
• Contract your abs without moving and relax. 2/3 times.

What is your conclusion?

[nari]

Bernard

You're shooting me down in flames again, but that's OK.

Sure it maintains a tenseness and may lead to problems later in life - but for many it feels good, however deluded the reasons may be. That alone is a sufficient reason for it to be taught. It's strictly for the young and young at heart, but if that placebo effect works strongly - why not!!??

I tried your 2 tests.
#1 without CS was clearly more comfortable, which makes sense.
#2 I couldn't detect any difference between abs contracted and not. (And I have a fairly significant TA control - I've always had it)
Both circumstances felt quite OK.
What did I miss this time?

Nari

[bernard]

Originally Posted by Nari

And I have a fairly significant TA control - I've always had it

That's perhaps the problem but Newton said that an action carries ever a reaction.

If you contract your abs, normally something happens in your back.
You take first the bent position then put hands in place and then contract abs without moving.

[Diane]

BB, just want to say that I like how you think.
>We are, in essence, treating one compensation with another.

Exactly. You can't help the nervous system if you are trying to fix a "postural fault" by tightening up another muscle. The whole point of therapy should be to loosen the whole system or any regional part of the whole system, regardless of how big or small, enough in EVERY direction (front, back, sides, circumferential, top and bottom, spherically) that the anti-gravity mechanism can function freely without restriction, no effort.
How? Any way you can...

Sorry for butting in. Back to ab testing.

[christophb]

Feldenkrais wrote that it is important to distinguish posture from position. Most of my patients come in stating they have poor "posture" and need core strengthening to maintain that. Posture is ever-changing and I think Feldenkrais took it to mean the ability to move in and out of positions effortlessly. (much like Cory just stated). I think it takes some critical thinking and willingness to give up old ways of thinking to move through a Sahrmann article and come to the conclusion Cory did. Our clinic has the new Sahrmann book and just glancing through it make you anxious about having all sorts of "movement disorders" that need correction. To stay out of coercion mode I look at core ex as playgrounds for people to explore options to current habitual movements. I let them decide what feels good or not.

Chris

[nari]

I had thought Sahrmann, in her new book, was acknowledging the CNS..oh well.

Chris, that is how I see the endless parades of CS 'classes' - as long as coercion is kept out of it, people would find it both useful and fun.

Perhaps PTs could abandon the "I will correct your posture for you" thinking; and instead invite pts to find their most comfortable positioning. That would take some shifting in thought.
One of the many things I found contradictory about clinical practice is this:

Patient: (who has poor posture) When I straighten up it hurts.
PT: Keep practising until it stops hurting..

Patient: (with a painful back) When I do this, it hurts.
PT: Then stop doing it. (then teaches CS to pt)

Does anyone else find this ludicrous? Yet it continually happens...

Nari

[Diane]

From http://www.artofperformance.co.uk/, sent in by Ian. Go to the link, click on articles, click on "core stability, pure stupidity?":

Core stability, pure stupidity?

okay, I admit its an inflammatory title but I feel its an issue that needs debating and it probably got your attention. Its become a term used increasingly in rehabilitation, remedial exercise and even sports training. But what is meant by it and does anyone know if it is really desirable and beneficial? I also worry that these exercises, originally devised for people with spinal injuries, are widely used by athletes with no pathology!

I wrote the following article in 2001 which had quite an impact, even resulting in abusive correspondence from several quarters - needless to say they were not scientific in nature!

- - - - -

In 1989 the International Union of Physiological Sciences Conference debated the head-neck sensory motor systems as a factor in movement and balance. As a result, over one hundred papers were written on the subject in the following three years. In the editor’s preface to the publications Berthoz wrote: -

It is therefore difficult to explain and justify the current popularity of exercises used by many therapists to promote what is known as ‘core stability’. These exercises were devised in response to the perceived problem of poor support. The patient is encouraged to concentrate on using specific muscles to stabilise the core to support an area known to have a weakness. The problem with this action is that it is contrary to the function of the nervous system.

Gerald Gottlieb, a respected scientist working in the field of motor control stresses that one of the functions of our central nervous system is to minimize muscle stress. This, he argued, is why we should not override this directive by concentrating on individual muscle activation during activity. Are we in danger of over doing it when we try to control the actions of specific muscles? Remember this is physiologically impossible anyway! Whilst the nervous system is in favour of minimising stress to help maintain free joint movement and reduce pressure on the internal organs, we are consciously doing the opposite. Following on the back of this paper sports scientist Dr Mel Siff writes: -

and

We should not attempt to directly control muscle recruitment for movement or exercise, it should be the thought of an act that initiates our total muscle response and the subsequent movement that determines ongoing involvement. When the managing director decides to sweep the factory floor instead of staying in the boardroom making the big decisions, he interferes with the operation of the whole organisation.

If our innate balance mechanisms are allowed to perform their function unimpeded there is no need to consciously engage muscle or strengthen the middle of the structure independently. In the absence of interference, the reflexes responding to gravity will help to ensure optimum balance and movement.

Mulder and Hulstyn’s research published over twenty years ago ('Sensory feedback therapy and theoretical knowledge of motor control and learning'. Am J Phys Med 63:226-244, 1984.) stated

More recently Stuart McGill Ph.D (Physiology) published a paper stating

also

( my bold text )

So perhaps a misunderstanding of the problem has led to a short-term remedy. A number of therapists are starting to question the thinking behind core stabilisation techniques as to date there is no convincing clinical evidence to prove their effectiveness. Because it may appear to achieve a result and ‘feel’ good it is not surprising to find the core stabilisation theory featuring in numerous popular exercise philosophies. Again Dr Siff writes: -

At the very outset, we have to dispel the belief that it is possible to focus on 'core stability' on its own. Unless one's entire body is off the ground or is immersed in water, the idea of stabilising the core separate from other parts of the body is sheer nonsense, since the ability of the core in all sports in which one is in touch with a static or moving surface depends strongly on peripheral stability (the limbs). If one is carrying out some movement such as lifting weights, doing aerobics, running, jumping or playing some ground-based sport, the body stabilises as a whole, with interacting contributions from the periphery and the core….. The world of core stabilisation currently remains far too heavily based in marketing and belief than in valid science.

The actions encouraged to promote core stability may feel like they are strengthening the centre of our body. In the absence of ‘valid science’, they appear to protect the spine because it must make sense to support the body from the centre. But the theory ignores the role that limbs play in maintaining stability and the overall controlling influence of the balance and righting reflexes. The few disciplines that do recognise the importance of the head, neck and back relationship resort to what they know best to ‘improve’ it - exercising the muscles of the neck! The exercises designed to achieve this have the effect of increasing interference in an area that requires none. Alexander’s method to promote correct use of the primary control (the relationship between the head, neck and back) is not about right position or strength of the neck and shoulder muscles. In reality the only thing we can directly do in relation to the righting reflexes is to unknowingly interfere with their function. Anthropologist, Raymond Dart, wrote:

Alexander stressed that if we stop doing the wrong things the right things take care of themselves. If we learn to stop stiffening the neck, the head will ‘find’ its own balance and bring about the most appropriate muscle tone for the current situation to facilitate our innate righting reflexes. As we do not know what the optimum tone should be for each muscle it is not something we should try to achieve. Activities performed with minimal interference with our balance mechanisms will ensure the most appropriate muscle response. Good quality movement promotes the right type of conditioning and removes the need for additional ‘specialist’ exercises.
So how do we attain good movement in order to get into shape? First we need to establish what it is we have been doing to get out of shape, and then we have to learn to stop doing it before we attempt anything else.

- - - - -

I have included below a reply from Stuart McGill PhD (Physiology) Dept of Kinesiology, University of Waterloo, Canada in response to my question regarding core stabilisation techniques. He has published over one hundred papers in this area.

Nice robust piece.

[Diane]

I've been glancing through the third edition of Grieve's Modern Manual Therapy: The Vertebral Column, from 2004.

In another thread I talked about how much more streamlined it has become.. aparently the first edition, which I do not have, was over 900 pages! Also, this edition has a lot more in it about the nervous system.

I thought I would bring this little section forward. (I found it interesting in that it sort of supports one of my own pet theories, that the epaxial muscles are more primitive/ under less "conscious" control than hypaxial trunk muscles and/or later-evolved limb muscles... they don't distinguish among various trunk muscles here though.)

From page 125, in a chapter called "Motor Control of the Trunk":

Controller
It is beyond the scope of this chapter to provide a detailed description of the organization of the control system. However, several important issues require consideration. Firstly, trunk muscles receive inputs from various parts of the CNS including corticospinal inputs (Plssman & Gandevia 1989), which to some extent, unlike the limb muscles, course the spinal cord bilaterally or send collaterals to both sides (Kuypers 1981, Mori et al 1995). However, it is generally considered that there is more significant control of the trunk muscles by the brain stem and spinal structures (Kuypers 1981), for example the vestibulospinal and reticulospinal systems. This is consistent with the relatively small size of the representation on the motor and sensory homunculi. The following section will consider the mechanisms of control of the trunk muscles from a behavioral perspective, that is, consideration of the organization of muscle recruitment rather than the consideration of the specific neural structure and events involved in their production.

Bold mine.
Could it be that the ortho people are starting to carefully venture slightly away from mesoderm over into neuro land?

[Nick]

Jason wrote, "It's disadvantages are that the exercises are fairly choreographed (though they are individualized to the person's patterns of painful movement and positions) and they do not encourage freedom of movement/ideomotor movement."

To me, this is the crux of the matter. Not only do they not encourage freedom of movement, they actively discourage it. The spine is meant to move and the attempts to stiffen it for support are way over-emphasized in my opinion. McGill seems to believe that the spine should never flex. The whole notion of stability leads to the fearful belief in instability and the adoption of abnormal movement patterns. If flexion hurts and I avoid flexion, I am likely to hurt less; however, I am also going to become more restricted into that range and more fearful of performing it. Understanding potential mechanical deformation of the neural tissue requires thinking beyond that potentially imposed by abnormal accessory joint motion or disc bulges.


Ian's article includes the following quote from Mel Siff:
"Research into motor control has never shown that training of individual muscle actions enhances skilled complex motor activities. The maxim of "the body knows of movements, not muscles" is constantly reiterated to emphasise this fundamental point. The learning of the motor skills required to execute a given sporting movement are acquired by regular practice of the movement itself, not by teaching isolated joint or muscle actions that are believed to play some contributory role in the sporting movement."

Agreed - in one sense. This points to the need to differentiate between physical conditioning and skill conditioning (big implications for the discipline of work hardening here). Skill conditioning is very specific. However, contrary to the apparent opinion of many on this board (whose thinking I greatly respect on most issues) physical conditioning through building strength also has many, many benefits. While this may not be directly related to pain, it is still relevant to physiotherapy. Even though neurophysiology is paramount and even if pain is the primary issue we are concerned with treating, the benefits of training the muscular system should not be overlooked IMO. Sarcopenia is a huge problem and, though its effects may take longer to manifest, it will lead to major functional deficits and likely contribute to discomfort. There is value to strength.

Further, McGill's work seems to make to great a delineation between strength and endurance. These are not independent variables and, surely one way to increase muscular endurance is to physically train the musculature.

I want to be clear that strengthening is not my chosen method for treating pain (even though there are some studies that support it - I agree that this falls mostly into cognitive-behavioural changes). However, I think it is the only rational means for treating a number of conditions related to loss of muscle mass that begins at the age of physical maturity. I know every one here focusses on pain and nothing has had more influence on my professional growth than what I have learned from all of you.

Nick

[nari]

Nick

It has always seemed odd that in rehabilitation of the TBI or stroke patient, careful attention is paid to "functional" movements and not exercises for strength. The latter are often applied once the functional improvement has occurred. Admittedly, there is recognition that exercises do not improve strength where brain function is affected.
Yet, faced with a person with an intact brain who has lost ROM and function, has pain and reduced quality of life, the immediate response is often to stretch and strengthen through choregraphed movements. There is rarely an attempt to restore function with neurorehab thinking. I can't base this on studies as I have not found any that compare natural and choreographed movements.
It is this separation between musculoskeletal and neural "conditions" that bothers most of us, and which tends to sway us into neurothought.

However, I agree that with debilitation and inactivity, a general strengthening program is useful. I would also argue that physiotherapists are not the only ones who can do this program; and sending such a patient off to classes run by fitness trainers and the like, leaves us time to treat the tricky dysfunctional patients.

Nari

[Nick]

Good points, Nari. And I agree. Except that fitness trainers usually do not have the knowledge of special conditions that a PT has and, therefore, would have more difficulty developing a program appropriate for special populations, including a program that would not aggravate someone's pain. I think there is a large role for PTs here as well.

Nick

[Barrett Dorko]

Another great post Nick.

And Nari's right; we're necessary when orthopedic problems go bad, as in when they become neurologic problems. Of course, when this happens strengthening procedures take a back seat to our efforts toward recoordination and perceptual problems.

If we're going to handle these patients, maybe we should handle them as Bobath would have.

[nari]

Nick

I was thinking of just debilitated and inactive people being sent off to fitness instructors et al - not those with concomitant pain. They should remain with us, until their pain has largely resolved. An exception might be the person who has not responded to physio intervention or our education and may benefit from group dynamics/structured activity.

Nari

[Diane]

Articles Ian sent to be put here:

Kavcic N, Grenier S, McGill SM. Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine. 2004 Jun 1;29(11):1254-65.



University of Waterloo, Faculty of Applied Health Sciences, Waterloo, Ontario, Canada.

STUDY DESIGN: A systematic biomechanical analysis involving an artificial perturbation applied to individual lumbar muscles in order to assess their potential stabilizing role. OBJECTIVES: To identify which torso muscles stabilize the spine during different loading conditions and to identify possible mechanisms of function. SUMMARY OF BACKGROUND DATA.: Stabilization exercises are thought to train muscle patterns that ensure spine stability; however, little quantification and no consensus exists as to which muscles contribute to stability. METHODS: Spine kinematics, external forces, and 14 channels of torso electromyography were recorded for seven stabilization exercises in order to capture the individual motor control strategies adopted by different people. Data were input into a detailed model of the lumbar spine to quantify spine joint forces and stability. The EMG signal for a particular muscle was replaced either unilaterally or bilaterally by a sinusoid, and the resultant change in the stability index was quantified. RESULTS: A direction-dependent-stabilizing role was noticed in the larger, multisegmental muscles, whereas a specific subtle efficiency to generate stability was observed for the smaller, intersegmental spinal muscles. CONCLUSIONS: No single muscle dominated in the enhancement of spine stability, and their individual roles were continuously changing across tasks. Clinically, if the goal is to train for stability, enhancing motor patterns that incorporate many muscles rather than targeting just a few is justifiable.




Effects of different levels of torso coactivation on trunk muscular and kinematic responses to posteriorly applied sudden loads. Clin Biomech (Bristol, Avon). 2006 Jun;21(5):443-55. Epub 2006 Jan 27.

Vera-Garcia FJ, Brown SH, Gray JR, McGill SM.

Faculty of Applied Health Sciences, Spine Biomechanics Laboratory, Department of Kinesiology, University of Waterloo, 200 University Ave W., Waterloo, ON, Canada N2L 3G1.

BACKGROUND: Studies examining rapid spine loading have documented the influence of steady-state trunk preloads, and the resulting levels of trunk muscle preactivation, on the control of spine stability. However, the effects of different levels of muscle coactivation, and resulting spine loads, on the response to a perturbation of the externally unloaded trunk are unclear. METHODS: Fourteen male subjects coactivated the abdominal muscles at four different levels (approximately 0%, 10%, 20% and 30% of the maximal voluntary contraction) monitored by an electromyography biofeedback system while semi-seated in a neutral lumbar spine position. They were loaded posteriorly in two directions (0 degrees and 30 degrees from the sagittal plane) and with two different loads (6.80 and 9.07 kg). Force perturbation, spine displacement and electromyography activity were measured, and torso compression and stability were modeled. FINDINGS: Abdominal coactivation significantly increased spine stability and reduced the movement of the lumbar spine after perturbation, but at the cost of increasing spinal compression. Preactivation also reduced the frequency and magnitude, and delayed the onset of muscle reactions, mainly for the back muscles and the internal oblique. The higher magnitude load and the load applied in an oblique direction both showed more potentially hazardous effects on the trunk. INTERPRETATION: Torso coactivation increases spinal stiffness and stability and reduces the necessity for sophisticated muscle responses to perturbation. Although further investigation is needed, it appears there is an asymptotic function between coactivation and both stiffness and stability. There also appears to be more hazard when buttressing twisting components of a sudden load compared to sagittal components. Patients with trunk instability and intolerance to spine compression may benefit from low to moderate levels of coactivation.

Brown SH, Vera-Garcia FJ, McGill SM. Effects of abdominal muscle coactivation on the externally preloaded trunk: variations in motor control and its effect on spine stability. Spine. 2006 Jun 1;31(13):E387-93.



From the Spine Biomechanics Laboratory, Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada.

STUDY DESIGN.: A repeated measures biomechanical analysis of the effects of abdominal bracing in preparation for a quick release of the loaded trunk. OBJECTIVES.: To quantify the ability of individuals to abdominally brace the externally loaded trunk, and assess their success in achieving and enhancing appropriate spine stability. SUMMARY OF BACKGROUND DATA.: Spine stability requires trunk muscle coactivation, which demands motor control skill that differs across people and situations. The quick release protocol may offer insight into the motor control scheme and subsequent effect on spine stability. METHODS.: There were 10 individuals who sat, torso upright, in an apparatus designed to foster a neutral spine position. They were instructed to support a posteriorly directed load to the trunk in either their naturally chosen manner, or by activating the abdominal muscles to 10%, 20%, or 30% of maximum ability. The externally applied load was then quickly released, thereby unloading the participant. Muscle pre-activation patterns, spine stability, and kinematic measures of trunk stiffness were quantified. RESULTS.: Participants were able to stabilize their spine effectively by supporting the load in a naturally selected manner. Conscious, voluntary overdriving of this natural pattern often resulted in unbalanced muscular activation schemes and corresponding decreases in stability levels. CONCLUSIONS.: Individuals in an externally loaded state appear to select a natural muscular activation pattern appropriate to maintain spine stability sufficiently. Conscious adjustments in individual muscles around this natural level may actually decrease the stability margin of safety.

[nari]

Most interesting conclusions; especially in the light of the manip/realtime US imaging thread on RE that has just begun.

Perhaps these papers could be referred to in that discussion?

Nari

[Jon Newman]

Hi Nari,

This window of opportunity business makes it sound like manipulation doesn't have any lasting effect--so better start 'strengthening as pain management' before they start hurting again. Neither of the above makes much sense to me and I don't see how US imaging adds much. Although taking pictures of disks seemed like a good idea when the technology came around so I guess I can see the attraction.

That said, I'm at least glad there is an effort underway to begin strengthening after someone hurts less if strengthening is deemed necessary.

[nari]

jon,

I agree with your sentiments but did not express them as openly as you did.
I suspect sending the above papers would not go down too well...

To me, it is the pervasive meme that one can see pain which holds therapists in its grip. It is a bothersome one.

Nari

[Jon Newman]

It's bothersome? Are you going for the understatement of the year? It seemed like so many in that conversation have contributed so much and come so far with an appreciation for the neurobiology of pain and all of a sudden it's "quick! let's spend our research dollars on taking a picture".

[nari]

jon,

As a person who enjoys a bit of sarcasm, you should appreciate that an understatement can convey a strong emotion...

Nari

[Jon Newman]

Author: Brown, Stephen H. M. MHK; Vera-Garcia, Francisco J. PhD; McGill, Stuart M. PhD

Title: Effects of Abdominal Muscle Coactivation on the Externally Preloaded Trunk: Variations in Motor Control and Its Effect on Spine Stability.

SourceSpine. 31(13):E387-E393, June 1, 2006.

AbstractStudy Design. A repeated measures biomechanical analysis of the effects of abdominal bracing in preparation for a quick release of the loaded trunk.

Objectives. To quantify the ability of individuals to abdominally brace the externally loaded trunk, and assess their success in achieving and enhancing appropriate spine stability.

Summary of Background Data. Spine stability requires trunk muscle coactivation, which demands motor control skill that differs across people and situations. The quick release protocol may offer insight into the motor control scheme and subsequent effect on spine stability.

Methods. There were 10 individuals who sat, torso upright, in an apparatus designed to foster a neutral spine position. They were instructed to support a posteriorly directed load to the trunk in either their naturally chosen manner, or by activating the abdominal muscles to 10%, 20%, or 30% of maximum ability. The externally applied load was then quickly released, thereby unloading the participant. Muscle pre-activation patterns, spine stability, and kinematic measures of trunk stiffness were quantified.

Results. Participants were able to stabilize their spine effectively by supporting the load in a naturally selected manner. Conscious, voluntary overdriving of this natural pattern often resulted in unbalanced muscular activation schemes and corresponding decreases in stability levels.

Conclusions. Individuals in an externally loaded state appear to select a natural muscular activation pattern appropriate to maintain spine stability sufficiently. Conscious adjustments in individual muscles around this natural level may actually decrease the stability margin of safety.

Late entry:
Oops. I didn't realize this was already one of the abstracts Ian had posted. Ah well. Hey look kids, there's Big Ben, and there's Parliament.

[nari]

This is a worthy rebuff to core stability buffs.

Somehow, it makes sense. The Qld studies did not seem logical, but maybe that is just my interpretation.

Thanks Ian

Nari

[Diane]

I look forward to reading the whole thing! I see it hasn't even been published quite yet. I look forward to the demolishment of this incredibly tenuous construct (TrA conditioning to "stabilize" spine) that everyone leaped onto as if it were PT salvation or something.

[Randy Dixon]

I'm not sure where this hostility towards core stability comes from. Then again, perhaps I do, I know when legitimate ideas like "functional training" become popular and gimmicky and the real value they had is lost, I get the same feeling.

The TrA activation/stability model is unlikely to go away anytime soon. Why? Because the evidence of its efficacy is growing. I've seen some ideas attributed to this model on this forum that the original researchers didn't make. It's pretty simple, the TrA was shown to be inhibitied in LBP patients, there were also biomechanical changes, the sequence of these three things wasn't known, did the pain cause inhibition, or the inhibition cause mechanical deformation which caused pain or any version of these three.(This may have been resolved since I last studied the research) It was shown that the TrA could be selectively activated, and that this seemed to break the cycle. They didn't suggest that the TrA was the only, or even the most important muscle in stabilizing the spine, or that TrA activation should be consciously performed after the dysfunction was corrected, or that functional activities are not part of "core strengthening" or that things such as perturbation and extremity loading had no value. Basically they found a neuromuscular patterning problem that could be resolved by consciously changing the pattern. I don't know why there is so much resistance to this idea on a neuroscience forum.

[Diane]

Randy, I guess we'll all know more when this paper gets published. I gather it is a balanced deconstruction of the "myth."

I can't speak for everyone, just me, but the issue I always had with it was that it was a meme that got out of control, a runaway meme. Maybe the TrA was not the only muscle that mattered, yet I saw brochures in clinics depicting "hoops" around the lower trunk suggesting that TrA was the only muscle that mattered, and it was from one of Paul Hodges own slides. (I went to hear him speak about it, explain his research. Heard all about pigs and bacon and anal probes.)

There was a real craze on for awhile, but the brochures gradually disappeared, thank goodness.

Basically they found a neuromuscular patterning problem that could be resolved by consciously changing the pattern. I don't know why there is so much resistance to this idea on a neuroscience forum.

My question to you would be, what happens when people let go of their conscious contraction of their TrA as soon as they get distracted? Does the back pain come straight back? Or is it supposed to be gone once they've learned to resolve the neuromuscular patterning problem (if indeed that is even possible..)? If I have back pain, and holding my belly button in against the front of my spine "helps", am I supposed to hold it in the rest of my life? How will my diaphragm, how will my autonomics like that idea?

[nari]

Randy,

I think the runaway Tr/Multifidi/pelvic floor meme is the problem; I don't think anyone denies that contracting TrA doesn't change pain, because it does, during that contraction phase. But a few other bits and pieces are bound to be joining in as well....

The long term management is dodgy.
In the 'old' days, mid 80s, everyone went beserk on pelvic floor retraining (--> 350 times a day) and abdo bracing, to bring out the obliques to provide balance against RA. Eventually, the notion went away, teachers became less fanatical and incorporated the principle into general exercise.
If we think in terms of a few weeks of TrA and/or M activation actually providing that stability long term, then that's fine. But is it true?

Nari