A Review of Core Stability Training in Rehab: Facts, Fallacies and Future Directions
Over the last two decades one of the most popular forms of exercise in the health and fitness industry is core stability training. While the fad is slowly starting to die off a bit you can still go to many PT clinics or gyms and see people being told to pull their bellybutton in when doing exercises.
I’ll confess, as a former student and current friend of McGill’s, the whole core stability concept (particularly the TVA/MF focus) has been a big thorn in my side for many years.
So where did this start? Where did we go wrong? That’s what I will explain in this article.
Before we get started I’d like to provide a definition of stability as stability means different things according to different people. The term stability has many meanings attached to it including control of movement, balance, stiffness or absence of movement, or structural stability. Webster’s definition of stability is
“ 1: the quality, state, or degree of being stable: as
a : the strength to stand or endure : firmness
b : the property of a body that causes it when disturbed from a condition of equilibrium or steady motion to develop forces or moments that restore the original condition
c : resistance to chemical change or to physical disintegration”
ORIGINS OF CORE STABILITY – PANJABI
In the early 1990s a researcher named Panjabi first defined the concept of the neutral zone as “A region of intervertebral motion around the neutral posture where little resistance is offered by the passive spinal column1,2.”
Panjabi proposed that a smaller neutral zone meant a joint was more stable. Panjabi recognized 3 contributors to spinal stability….
- Active subsystem: Spinal muscles
- Passive subsystem: Spinal column
- Control subsystem: Neural1,2
THE RESEARCH FROM AUSTRALIA ON THE INNER CORE
In the mid to late 1990s Paul Hodges, Carolyn Richardson and other researchers compared people with and without low back pain (LBP) to see how fast their core muscles activate in response to various arm and leg movements. What they found was that the transverse abdominnis (TVA) and multifidus (MF) were slower to activate in people with LBP compared to people without LBP. No other muscles were activated differently between groups3.
These studies created the idea that there is an inner core consisting of TVA, MF and the pelvic floor that contracts independently of the outer core. TVA was thought to increase spinal stability through its attachment to the thoracolumbar fascia. Drawing in or abdominal hollowing co-contracts the TVA and MF and increases intra-abdominal pressure3.
A 1997 study by Peter O’Sullivan et al showed that core stability exercises improved outcomes in people with spondylolisthesis compared to GP care4. Hides et al showed that training the inner core decreased the risk of developing LBP5.
As such it became believed that TVA and MF issues cause LBP, that everyone with LBP needs core stability exercises and that the inner core muscles are the most important muscles in spinal stability and low back health. Boom!! A new trend is born. Core stability exercises are still the most prescribed intervention for LBP.
What people who quote the research tend to miss is that Hodges et al’s research was cross sectional. As such we can’t tell if core muscle delays are a cause or consequence of pain. Pain can affect muscle activity and prospective research hasn’t found an association between baseline TVA function and LBP development6.
In addition the average delay in muscle activation was 20-50 ms across studies which is negligible. Some researchers have questioned the legitimacy of measuring MF via surface EMG as there is potential for crosstalk from the erector spinae. In addition some research has shown activation delays in other core muscles in people with LBP7.
STUART MCGILL AND THE GLOBAL APPROACH
In 2003 McGill et al measured the role of each muscle in spine stability and found that each muscle contributed fairly equally to spinal stability across various tasks8. His research also showed that drawing in decreased the activity of the outer core muscles and as such removed many stabilizing muscles from the equation9.
By contrast bracing (or stiffening all of the muscles in your core) contracts all muscles and has been shown to increase TVA and MF activity, increase spinal stability, and increase ability to respond to perturbations when compared to drawing in9. A recent study found efficacy for bracing exercises in LBP10.
Side note: some studies that claim to use bracing actually use hollowing or drawing-in.
However, most tasks (including lifting up to 70 lbs) require 4-8% core muscle maximal voluntary contraction for sufficient spinal stability. This level of core muscle activity can be generated naturally and reflexively without bracing unless you have a spinal cord injury or other neurological condition9.
Bracing does increase compressive forces on the lumbar spine11 and as such it may be appropriate for higher load tasks (ie heavy strength training) but it is “overkill” for day to day tasks.
PAIN SCIENCE AND THE BIOPSYCHOSOCIAL APPROACH
Through the work of researchers such as Peter O’Sullivan, Kieran O’Sullivan and others we know of the link between psychosocial factors and LBP.
A myriad of psychosocial factors are associated with the transition from acute to chronic LBP including stress, anxiety, depression, hypervigilance, fear avoidance, kinesiophobia, and catastrophizing12,13.
Some studies have also shown that some people with chronic low back pain have hyperactivity of their core muscles. The notion that the lumbar spine is unstable may cause these maladaptive beliefs and behaviours and may cause more focus on protection of the spine12,13.
Studies in 2012 and 2014 have shown that core stability exercises were not superior to general exercise in improving outcomes14,15. One important thing to note is that the general exercise protocols in many studies often included general core exercises (ie planks, birddogs etc). A study in 2017 showed core stability exercises provided better outcomes at 3 months compared to general exercise but no measures were made at 6 & 12 months and a 2018 review showed that core stability exercises were more effective than general exercises 16,18.
A 2013 systematic review found no correlation between changes in TVA and MF activation and clinical outcomes in people with LBP6. A 2017 paper showed that spinal stability in people with back pain didn’t significantly change after performing a motor control program or a general exercise program17.
As of the Spring of 2022 when I have updated this article there are a million and one articles looking at the effects of core stability vs general exercise for LBP and comparing muscle activity in people with LBP vs people without LBP. Rather than wasting millions of dollars on research funding to beat a dead horse, in my humble opinion, more effective initiatives should be directed at…
- Methods to promote physical activity, physical health & mental health across the general population
- Education, both for the general public and for health + fitness professionals, on
- The information above
- That pain doesn’t have a 1:1 relationship with tissue damage & is influenced by multiple factors
- When imaging, injections & surgery are and aren’t appropriate
- Better training for health providers on the above as well as
- How to better prescribe exercise
- How to better engage patients in healthy lifestyle behaviours
- How to educate patients that hurt doesn’t always mean harm
This may be a bit of clickbait – but the future directions regarding core stability research don’t actually relate much to core stability itself but rather more evidence-based methods of spinal health.
Core exercises by themselves are not necessarily evil – it just depends on how they’re marketed. If they’re used as a means of movement and exercise that’s tolerated by the individual (assuming they are well tolerated) than that’s OK. If you say “you need to get your core working to keep your spine stable” you are more than likely delivering a nocebo effect.
Drawing in in isolation (i.e. when lying on your back & lifting your legs/arms up) is OK but isn’t advisable when doing advanced core exercises, heavy lifting, or balance exercises.
Are you saying you hate core exercises and disagree with them?
A piece of feedback I got on the original article was that I was bashing the McGill Method and bashing core exercises. In fact – I use a lot of core exercises in certain situations but definitely not with everyone … and there is a reasoning process behind it.
People whom I use core exercises with are
- People who find core bracing helps alleviate symptoms. This is part of Stu McGill’s assessment methods (refer to his books for more detail on the specifics).
- People for whom a lack of core control or endurance may be a contributor to symptoms. Examples of these could be…
- People who have back pain exacerbated by standing in extension or by arching the back when lifting the arms overhead to do work. If teaching them to pull their ribs down slightly dramatically reduces the pain anti-extension exercises MAY be very beneficial.
- Or conversely someone who has back pain exacerbated by prolonged flexion and lacks back extensor endurance.
- People who like and-or buy in to them: the best exercises are the ones you will do AND tolerate
People whom I don’t use core exercises with are
- People who find core bracing worsens symptoms
- People who are very tense, guarded and/or fear avoidant
- People who aren’t likely to do them. In general I try to make most of my exercises for most of my clients ones that can be done in sitting or standing just to make compliance easier.
Bear in mind too some common exercises provide a fair deal of core stimulus such as
- Anti-Extension: pushups, overhead press, front/goblet squats
- Anti-Side Flexion: any kind of unilateral carry or movement where weight is held in one hand
- Anti-Rotation: any kind of 1 arm row, a lunge/split squat with weight opposite to the working leg, single leg rdls with weight in the opposite hand
- Anti-Flexion: any kind of kettlebell swing or deadlift
So just as everything else I believe in – there’s a nuanced answer.
To summarize this long article
- Core muscle activity can be altered in people with LBP but it’s relevance to spine stability and LBP is questionable
- The TVA and MF aren’t any more important to core stability than any other muscles
- Exercises designed to focus on the TVA and MF haven’t produced any more favourable outcomes in LBP than general exercise
- Doing draw-in exercises in isolation is OK but drawing in shouldn’t be used when doing advanced core exercises, lifting, or balance exercises
- Bracing is appropriate when extra stability is needed (ie lifting heavy loads) but shouldn’t be used for day to day tasks
- The belief that “your spine is unstable” may (in theory) cause issues like fear avoidance, hypervigilance and guarding which are associated with chronic LBP
This was originally posted on Eric Bowman’s website. You can click here to read more blogs from him.
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- Panjabi MM. The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. J Spinal Disord. 1992;5(4):383-389; discussion 397. http://www.ncbi.nlm.nih.gov/pubmed/1490034. Accessed September 27, 2017.
- Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Disord. 1992;5(4):390-396; discussion 397. http://www.ncbi.nlm.nih.gov/pubmed/1490035. Accessed September 27, 2017.
- Hodges PW. Is there a role for transversus abdominis in lumbo-pelvic stability? Man Ther. 1999;4(2):74-86. doi:10.1054/math.1999.0169.
- O’Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine (Phila Pa 1976). 1997;22(24):2959-2967. http://www.ncbi.nlm.nih.gov/pubmed/9431633. Accessed September 27, 2017.
- Hides JA, Jull GA, Richardson CA. Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine (Phila Pa 1976). 2001;26(11):E243-248. http://www.ncbi.nlm.nih.gov/pubmed/11389408. Accessed May 27, 2017.
- Wong AYL, Parent EC, Funabashi M, Kawchuk GN. Do changes in transversus abdominis and lumbar multifidus during conservative treatment explain changes in clinical outcomes related to nonspecific low back pain? A systematic review. J Pain. 2014;15(4):377.e1-35. doi:10.1016/j.jpain.2013.10.008.
- McGill S. Ultimate Back Fitness and Performance (6th Edition-2017) – Backfitpro. 6th ed. BackFitPro Inc.; 2017. http://www.backfitpro.com/books/ultimate-back-fitness-and-performance-6th-edition-2017/. Accessed September 27, 2017.
- McGill SM, Grenier S, Kavcic N, Cholewicki J. Coordination of muscle activity to assure stability of the lumbar spine. J Electromyogr Kinesiol. 2003;13(4):353-359. http://www.ncbi.nlm.nih.gov/pubmed/12832165. Accessed September 27, 2017.
- Grenier SG, McGill SM. Quantification of lumbar stability by using 2 different abdominal activation strategies. Arch Phys Med Rehabil. 2007;88(1):54-62. doi:10.1016/j.apmr.2006.10.014.
- Aleksiev AR. Ten-Year Follow-up of Strengthening Versus Flexibility Exercises With or Without Abdominal Bracing in Recurrent Low Back Pain. Spine (Phila Pa 1976). 2014;39(13):997-1003. doi:10.1097/BRS.0000000000000338.
- McGill SM. Low Back Disorders: The Scientific Foundation for Prevention and Rehabilitation. Champaign, IL: Human Kinetics; 2002.
- O’Sullivan P. Diagnosis and classification of chronic low back pain disorders: Maladaptive movement and motor control impairments as underlying mechanism. Man Ther. 2005;10(4):242-255. doi:10.1016/j.math.2005.07.001.
- O’Sullivan P. Common misconceptions about back pain in sport: Tiger Woods’ case brings five fundamental questions into sharp focus. Br J Sports Med. 2015;49(14):905-907. doi:10.1136/bjsports-2014-094542.
- Wang X-Q, Zheng J-J, Yu Z-W, et al. A Meta-Analysis of Core Stability Exercise versus General Exercise for Chronic Low Back Pain. Eldabe S, ed. PLoS One. 2012;7(12):e52082. doi:10.1371/journal.pone.0052082.
- Smith BE, Littlewood C, May S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskelet Disord. 2014;15(1):416. doi:10.1186/1471-2474-15-416.
- Coulombe BJ, Games KE, Neil ER, Eberman LE. Core Stability Exercise Versus General Exercise for Chronic Low Back Pain. J Athl Train. 2017;52(1):71-72. doi:10.4085/1062-6050-51.11.16.
- Shamsi M, Sarrafzadeh J, Jamshidi A, Arjmand N, Ghezelbash F. Comparison of spinal stability following motor control and general exercises in nonspecific chronic low back pain patients. Clin Biomech. 2017;48:42-48. doi:10.1016/j.clinbiomech.2017.07.006.
- Gomes-Neto M, Lopes JM, Conceição CS, Araujo A, Brasileiro A, Sousa C, Carvalho VO, Arcanjo FL. Stabilization exercise compared to general exercises or manual therapy for the management of low back pain: A systematic review and meta-analysis. Phys Ther Sport. 2017 Jan;23:136-142. doi: 10.1016/j.ptsp.2016.08.004. Epub 2016 Aug 18.
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There are two main subject in this article (which I like, constructive criticism here): first the narrative about core stability and second the different technics of core activation (drawing in vs bracing). Of course, the narrative should not be nocebo but this more a general matter concerning physios, persona trainers … On the second point the purpose of “drawing in” has never been to teach advanced or heavy lifting exercises. As an example, I am a PT and a Pilates teacher; to teach dead-lift, cited in the article, I won’t use Pilates teaching as reference, but I will use Pilates to teach core awareness. Something like learn to “draw in” before learning to “brace”. In my opinion, they are complementary teachings; some people have no clue anymore to activate any part of their core muscles … As written in the article the 2017 study shows some benefits of core training. I decided to become a Pilates teach because of 3 months I noticed a real difference in my LBP (I fully agree on the multi dimensionality of LBP issue by O’Sullivan). I think we should have a practical approach to know how and when to use each technic! I even teach breathing exercises to reduce/relief back pain! A last point the “future directions” were kind of missing.
Thank for your work.