I’ve had this familiar ‘core stability ‘ conversation with patients for a long time:
“I was told I really should do some exercises to ‘strengthen my core’ – I also heard it would help my back.”
“Oh – what kind of exercises were you told you should do?”
Invariably, the exercises include a battery of class based exercises and home based exercises such as:
- leg lifts (with or without circles, on side etc)
- plank exercises whilst on a medicine ball or yoga ball
- pelvic tilts and curls
- prone spinal extension
- kegel exercises
- twists and wobbles while on the back
- pressing the low back into the floor whilst breathing slowly
- bending sideways whilst pulling on an elastic band attached to something sturdy
- kneeling on a yoga ball
- hanging upside down whilst doing breathing rhythms
It has been explained to me that the rationale for these exercises is to allow the client/patient to ‘be aware’ of which muscles they have and how to precisely activate them so that they can have the ability to develop a stronger core – sometimes in order to help reduce back pain, sometimes to improve sport performance.
To me, this doesn’t make sense on several levels.
The question of ‘why’ that knowledge/awareness is necessary has never gotten a very satisfactory response. The response is usually along the lines of ‘so the client knows they are doing it right’.
The coordination of muscle activation – at just the right speed – in just the right amount of contraction – and in just the right pattern between all the muscles of the body – while on your feet and moving – while moving your arms in a myriad of ways – is a complex physiological and neurological marvel that adapts as needed to fit the physical challenge. It’s been that way for a long time – and it is that way because it has worked for us. Our bodies have operated well for a long time without us knowing how to activate an oblique or rectus abdominus whilst laying on the floor. (And neurologically it is impossible to activate a single muscle consciously – so why the emphasis on trying to do it?)
There is motor pattern response change in the abdomen during spinal pain – but no evidence that it causes or maintains back pain, and there is no evidence that substantiates that this kind of floorwork helps ‘normalise” the motor recruitment patterns. There is also no good evidence that ‘weak’ ‘core’ or spinal muscles are related to back pain. Isolated resistance exercise (in this case, against gravity as the person is on the floor) might be good for growing big or toned ‘cut’ muscles – but it is not very functional – meaning it doesn’t address the way the body needs to use those muscles together and in a neuromuscularly relevant way that addresses the needs of sport or daily living. It seems inefficient, and not an optimal way to help someone recover as fast as they can.
There is more emphasis on moving from floorwork to ‘being aware of the core’ while doing activities – and contracting the ‘core’ during activities – but there is still no evidence it helps and in fact appears to make trunk/’core’ posture less stable during activity. (Which makes sense – all the muscles working happily and in synergy and you consciously throw in a contraction to one or two of them that isn’t neurologically related to the overall movement goal….)
People have said to me that there is less back pain in those who do these exercises – and perhaps that is true – but I’d argue it is probably not about accomplishing a certain level of competence in a particular specialised form of exercise. I’d argue it is about getting someone who is sedentary moving again, doing anything – often in a group setting. There is nothing wrong with that in my view – its good for the heart, its good for the joints, it’s good for tissues, it’s good for people’s mental well being (especially as stress/anxiety and depression are so correlated with back pain). My gripe is not that it might be an entry into physical activity – but that it is ‘sold’ as ‘the way’ and that you have do to it ‘right’ and take lots of classes and sometimes buy expensive (!) equipment in order to get there. It is ‘sold’ as a specific solution to a certain set of functional problems which it – at best – is inefficient at helping resolve.
People have lifestyles or health issues which change our mechanics and cause us to not use our bodies as they evolved to be used – so certainly things do go wrong with the ‘core’ and with the pelvic floor – but I don’t think that spending weeks/months/years trying to activate those muscles in isolation and in non-functionally useful positions is the solution. Stamina for the conscious contraction in specific movements isn’t going to translate into a healthier ‘core’ when you’re unconsciously pulling weeds, moving boxes whilst chatting with your partner, packing away groceries, playing tennis, running for the bus etc. Doing appropriately graded functional exercise that mimics the most common patterns used in daily life (or in a sport, if you’re an athlete working on performance) is bound to get you closer to your physical goal – faster. Training specificity benefits are not a reality only for elite athletes – they are a physiological reality for everyone.