“Nipples to Knees”, that’s how Tony Horton describes the area classically referred to as the core exercise group. We hear it far too often in the clinic setting, schools, and blogs. Telling people to ensure they “engage their core” during or before exercise to help protect or reinforce their back. But this lays strong suggestion that people are just walking around and performing ADL’s without their core group being engaged. This suggestion begs this question. What is more normal? Being pain free and moving while having subconscious core muscle sequencing? Or being pain free and sustaining the world’s longest abdominal isometric and limiting fluid motion?
There is research noting how hard the trunk stabilizers (identified as the obliques, rectus abdominis, QL, psoas, deep erecti spinal) are acting during activities like standing ,walking, and lifting. Its about 0 to 3-4% max voluntary contraction for standing and walking, and raises 2-3% for bending and lifting 15lbs (1). Doesn’t really line up for the patient crushing planks for 5 minutes because their “core is weak.”
If the goal for people with LBP is to have them eliminate their pain and return to their pre-back pain state, then what makes more sense? Being able to move freely with unconscious “core” control?
Or, brace yourself…brace yourself!
Peter O’Sullivan has done several YouTube vids on this very topic and is blends pain science into his Cognitive Functional Therapy. But in an attempt to over simplify what it takes to go from chronic back pain to living a normal life again can be broken down into three phases.
- 1) Move.
- 2) Gain strength and resiliency
- 3) Move.
In my opinion, it is imperative that these phases be completed in order. Too often I find patients enter my clinic after episodes of back pain that have been told to NEVER bend, twist or lift again! Stop moving and cope with your new life essentially. Our first line caregivers have unfortunately fallen into an awful habit of condemning people to a life of early disability because of an acute subjective report. Or worse, an MRI read. So after I spend 30 minutes with my patient on debunking the myth of their low back pain that was so helpfully planted by my fellow healthcare providers, I can then start on having them make their climb back to their pre-pain state and begin having them move their back- phase 1!
This is where I get my monies worth on the Motion Guidance system. Anxiety about moving is a real barrier. Adding visual feedback and goals gives a patient real time input on if and how they are starting to move their back. It also is more consistent with research in that, internal cues (like “draw in your belly and contract this or that while marching your legs on your back”) are not realistic, or transferrable, while external cues “keep the laser beam here, while reaching for this target” are dynamic, transferable, and visual.
Once ROM has been established, then a variety of strength and conditioning exercises can be applied. The therapist may have to identify if the patient is using an adaptive strategy (ie a strategy that is implemented by the body subconsciously or consciously that actually protects them at the given time, considering the level of real tissue damage or just perceived threat) or the patient may be using a maladaptive strategy (performing something to protect themselves, often consciously from fear avoidance, that actually impedes healing or progress). The former may be acceptable in the acute stages, but the end goal should be effortless movement, in variable contexts.
There are sooo many theories on how to get the body “back to normal”, and so very few proven to consistently work, it isn’t worth the ‘short blog’ time to begin to list em. Further, it is looking like “specific” core exercise focused on the tranny & friends are of no more benefit than “non-specific” exercise (2) - so we can simplify things a bit. But then, whatever you chose, phase 3 has to be completed. Move, function, reach, lift, carry, sit, jump, stay fit. Keep moving….
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1) Eyal Lederman: The Myth of Core Stability. CPDO Online Journal (2007), June, p1-17
2) Saragiotto BT, et al. Motor Control Exercise for Non-specific Low Back Pain: A Cochrane Review. Spine (Phila Pa 1976). 2016.