Debunking “core stability”—evidence-based treatment for low back pain

Ahh, chronic low back pain—it’s a challenge most physios encounter frequently. Whether it’s one particular patient who keeps coming back without meaningful improvement, or an entire caseload of complex patients, this blog is for you! I’m going to give you an overview of Robin Kerr’s excellent Masterclass on motor control. Robin specialises in treating patients with failed lumbar surgeries, making her well-equipped to explore the latest advances in low back pain research and treatment. Read on for a summary of Robin’s expert insights:

Or, if you’d like to watch it for yourself and gain an in-depth understanding of the current state of low back pain research, see the full Masterclass HERE.

Core stability: A myth?

Despite its enduring popularity, the concept of “core stability” may be misleading. Robin encourages replacing it with the term “motor control,” as relying on “core stability” as a treatment modality implies an inherent spinal instability that requires correction. This belief can lead to overprotection, rigidity, and potential detrimental effects in the long-term. Robin argues that low back pain is far too complex to be addressed by a singular focus on core stability—a term she contends the fitness industry has capitalised on! Rather than emphasising isolated activation exercises for muscles like the Transverse Abdominus (TrA) by using things like ultrasound or pressure cuffs, Robin encourages adopting a broader approach with a focus on motor control.

A broader perspective: Motor control

Effective low back pain treatment requires a multifaceted, individualised approach grounded in the biopsychosocial model. Motor control, as Robin defines it, encompasses all sensory and motor processes involved in controlling spinal movement and stability. This includes everything from muscle activation and mechanoreceptor feedback to brain and spinal cord coordination. Research indicates that individuals with chronic low back pain may experience “cortical smudging”, which is a reorganisation of the motor regions of the brain, leading to altered motor control of the lumbar area (1). A recent study (2) also identifies that people with low back pain display a spectrum of changes in motor control, and categorises patients into two motor control subtypes:

1 – Tight control: This includes those patients who constrain movement, which may be useful to reduce pain in the acute stages, but sustained muscle contraction can cause fatigue, changes in muscle morphology, and altered activation (we’ve all seen these in clinic!). See Robin demonstrate a clinical case of this in the below snippet from her Masterclass:

2 – Loose control: this subtype includes patients who allow freer movement, which causes less muscle fatigue but can lead to tissue disuse, atrophy, and potential fatty infiltration. See an example in the video below from Robin’s Masterclass:

Clinical implications

Treatment must be tailored! Effectively addressing chronic low back pain requires a flexible, patient-specific approach. However, the more complex the case, the more challenging it can be to individualise treatment. Education is a crucial foundation, as addressing patients’ negative beliefs about back pain is essential for progress. However, the approach and next steps in treatment must be adapted to each patient’s unique presentation. Fortunately, current evidence supports subcategorisation as a valuable strategy for tailoring treatment. Robin explains how to customise treatment based on the patient’s primary pain mechanism. The first step is to identify your patient’s pain mechanism as one of the following:

1. Nociceptive pain: Persistent pain from ongoing nociceptor activation due to potential or actual physical damage to the tissues.
2. Neuropathic pain: Pain arising from a lesion or disease of the somatosensory nervous system.
3. Nociplastic pain: Pain continuing despite tissue healing, driven by altered nociceptive function.

Once you’ve identified what category your patient falls into, you can use this helpful treatment stratification tool to guide your clinical decision making. See Robin explain this excellent tool in this clip from her Masterclass:

Robin also outlines the subcategorising technique using the STarT Back screening tool. For low-risk patients, a single session may suffice for education and advice. In contrast, high-risk patients may benefit from psychologically informed physiotherapy, pacing strategies, and an emphasis on self-management strategies. If you’re wondering how to apply these techniques to your everyday cases, Robin includes various case studies that demonstrate these principles in action, so be sure to check it out!

Wrapping up

Low back pain remains one of the most common conditions physios treat, so staying current with the latest research is essential. As Robin reminds us, having patients “turn on” their TrA is no longer sufficient. Thanks to experts like her, we can stay updated on best practices, making our work with low back pain patients both effective and evidence-based.

Learn all the latest on chronic low back pain management by watching Robin’s full Masterclass HERE.