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]

...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]

Why am I always the odd one out around here?

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