Low Back Pain: It’s not about Core Strength
Thursday, March 22, 2018
by: Tim Sobie, PT, Ph.D., GCFP

Section: Professional Develpment




Chronic back problems continue to be a leading cause of disability. It ranks among the most frequent reasons for consulting a primary care physician - second only to headaches and the common cold.

Typically, a pharmacy prescription for non-steroidal anti-inflammatories, muscle relaxants, and pain relievers will also include a referral for outpatient physical therapy. In addition to the usual physician recommendations to “evaluate & treat to therapist’s discretion” there is a high likelihood of a nearly universal recommendation to “include core stabilization and core strengthening.”

It is not uncommon for Feldenkrais® practitioners to encounter new clients with recurrent low back pain who have 'tried everything' and run the gamut of conventional approaches to no avail and are now looking to consult with non-traditional, complementary-alternative, and/or more integrative options. In all likelihood, they have already followed a prescribed therapeutic regimen of core exercises for low back pain and are regularly adhering to the proper performance of abdominal draw-in maneuvers before engaging any potentially challenging work or recreation activity so as protect the spine from segmental instability between individual vertebrae. This is a commonly suspected cause of persistent or recurrent low back pain – especially within the practice settings of conventional physical therapy, spine, and sports medicine.

Despite these adherences, and despite ‘core strength’ being the expectant standard of care, as well as being a ubiquitous cultural meme within the entire fitness industry, many people with recurring low back pain find that their symptoms continue to persist, and sometimes 
worsen, after following core exercise principles.

Feldenkrais practitioners have long recognized this artifice. By arbitrarily selecting the mid-section of the body as the most important region for isolated strength and conditioning – also known as ‘motor -control exercises’ and with adjacent parallels in the ‘Pilates’ approach to callisthenic routines, and even crossing over into yoga, these principles of  ‘isolated recruitment of core muscle groups’ are seen in our field to effectively interrupt the flow of action and continuities throughout the whole self through movement, including variations for breathing, such that patients with chronic low back pain are only adding an extra layer of co-contraction and protection to their already tensed and attitudinally protective muscular states. 
 
Criticisms regarding Core Strength as a posed solution to low back pain: 

In a 2010 landmark critical literature review summary of current research into ‘motor control’ principles and treatment interventions for low back pain entitled "The Myth of Core Stability," Professor Eyal Lederman, Physiotherapist, Ph.D., and Doctor of Osteopathy in London, UK summarized some then controversial but now valid viewpoints:
(a) Weak trunk muscles, weak abdominals, and imbalances between trunk muscles groups are not a pathology, just a normal variation;
(b) the division of the trunk into 
core and global muscle system is a reductionist fantasy, which serves only to promote Core Stabilization;
(c) weak or dysfunctional abdominal muscles will not lead to back pain;
(d) tensing the trunk muscles is unlikely to provide any protection against back pain or reduce the recurrence of back pain;
(e) core stability exercises are no more effective than, and will not prevent injury more than, any other forms of exercise or physical therapy;
(f) core stability exercises are no better than any other form of exercise in reducing chronic lower back pain. Any therapeutic influence is related to the exercise effects rather than stability issues;
(g) there may be 
potential danger of damaging the spine with continuous tensing of the trunk muscles during daily and sports activities; and
(h) patients who have been trained to use complex abdominal hollowing and bracing maneuvers should be discouraged from using them.
           
As both a physical therapist and a Feldenkrais practitioner in independent clinical practice in the Pacific Northwest, the bulk of my caseload indeed consists of patients presenting with chronic recurring low back pain who have ‘tried everything.’ I too have recognized that people who trained in core stabilization often present aberrant patterns of movement – and in such a manner that stiffness and rigidity perpetuated their low back pain on many levels.

New Research - Putting Core Stabilization / Traditional Core Exercises to the Test

As a doctoral research student in the physiological psychology program at Saybrook University, I decided to outline and complete a clinical research outcome study comparing the treatment effects between traditional core stabilization and a novel, Feldenkrais Method® - based approach to patients with chronic, non-specific low back pain for my graduate dissertation project. I became very interested in how recent scientific evidence was demonstrating how persistent pain pathways could shape, alter, and even smudge-upon the clarity and accuracy of both sensory acuity and movement dexterity of the body’s mapped representation within and throughout the human brain (i.e., the body schema).

My study involved designing and conducting a single-blind, randomized, controlled clinical trial – code speak for minimizing any influences of bias I would have as the principal investigator. I also designed it to ensure that any outcome effect of the difference between the Feldenkrais (experimental group) and the Core Stabilization patients (the control group) would be more attributable to the effects of each intervention and not due to random chance of statistical difference alone.


The Study
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Thirty participants with chronic, non-specific, low back pain of greater than three months were recruited from area medical centers and the immediate community. They were screened by both primary care and pain management physicians for meeting diagnostic inclusion/exclusion criteria. Individuals scoring unusually high for Fear-Avoidance and Catastrophizing personality traits were equally assigned to each group to constrain as a primary confounding variable.

Baseline measures were made using standardized clinical tools for measuring
1) pain intensity
2) perceived disability
3) patient-specific functional improvement, and
4) timed ability to endure and maintain an unsupported position in three dimensions of space (flexion/extension/side-planking).

Each group participated in twelve treatment sessions over the course of eight weeks.

The experimental group (Virtual Reality Bones™ VRB) & Feldenkrais movements) participated in a newly devised VRB3™ protocol using:
1) skeletal density-based, full-scale anatomical models of femurs, pelvis, and skull combined with
2) visual motion trajectory skeletal avatars, and
3) haptic self-touch as methods intended for improving body schema and sensory acuity for deep articular joints - for the first four preliminary sessions as Phase I of the total intervention.

Then, they underwent Feldenkrais movements commonly used within our field for improving low back pain – with 4-sessions for Phase II (developmental foundations of ground support) and 4-sessions for Phase III (synergistic motion trajectory variations) using FI® and ATM® - and perhaps most importantly - purposely ignoring any specific directed attention to the lumbar spine ( i.e. ‘the core’) itself  by more strictly involving a concept for prioritizing and engaging a ‘pelvis-hip opposite head strategy’ (i.e. center of gravity as a counterbalance to vestibular righting responses within the head-neck) for everyday movement.

In contrast, the matched control group followed a core-stabilization training protocol emphasizing biofeedback and hands-on assisted specific recruitment of Transverse Abdominis (TrA) and Lumbar Multifidus (LM) muscle groups – and by also using a Stabilizer™ Pressure Biofeedback Device as Phase I of the total intervention. Core muscular contractions were then generalized into Static (Phase II) and Dynamic / Rhythmic (Phase III) motor control activities and progressive callisthenic strengthening exercises for the remaining eight sessions. Most importantly, the prescribed ‘core muscle contractions’ and ‘abdominal draw-in maneuvers’ were deemed as necessary pre-sets for properly performing motor control exercises as a mechanism of control for unstable spine segments in the lumbar-pelvic region –being also suspected and disclosed as “the underlying cause for Low Back Pain” for this arm of the study.

Outcome results and repeated testing revealed that a novel eight-week Feldenkrais Method ‘sensory acuity’ & ‘movement dexterity’-based treatment approach demonstrated greater effectiveness across all relevant outcome measures for:
1) decreasing pain,
2) decreasing perceived disability,
3) increasing function,
4) increasing endurance, and
5) optimizing performance ratios for sustained holding of torso positions in comparison to more commonly accepted, medically endorsed, and popular Rx protocols for ‘Core Stabilization’ isolated recruitment of ‘core muscle groups’ and the usual performance of ‘Motor Control’ fitness-based exercises for a population of patients diagnosed with persistently chronic Low Back Pain problems.

It was thereby concluded that body schema based somatic education interventions, like the (VRB3)™ / Feldenkrais Method protocol, were determined to be more efficacious in the treatment of chronic low back pain as compared to the current standard of care – specifically traditional physical therapy ‘Core Stabilization’ maneuvers & exercises, and that these approaches now deserve further investigation. Future multi-site RCT studies with larger sample sizes for statistical power are recommended.

A web link to my abstract summary of this study - plus the entire dissertation in full text - is available via public domain free-access from Pro-Quest publishing.
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Conclusions and Considerations for Selecting the Feldenkrais Method

In Dr. Lederman's book, Neuromuscular Rehabilitation in Manual and Physical Therapies: Principles to Practice (2010), the author brings forth a more expansive alternative to the usual and accustomed structural or pathologic biomedical models being deployed through conventional physical therapy. He proposes a co-created process model - an inclusive approach that encompasses the cognitive, behavioral, and neurophysiological dimensions of the individual. Lederman's model is inclusive of sense and movement.

The features summarized in his book correspond well with the experimental intervention process I conducted within the scope of my breakthrough comparative research study using the Feldenkrais Method as an effective approach to chronic back pain. They are also antithetical toward endorsing isolated ‘core strength’ as the solution:         
1. Co-create an environment in which an individual’s recovery (including underlying biological processes of healing, neural regulation, and repair) can be optimized. 
2. Intervention should be all-inclusive…a combination of cognitive, psychosocial, behavioral, organizational, and neuromuscular approaches. 
3. In the neurological dimension, there is no injury specific rehabilitation. A body area is rehabilitated according to its function rather than to the underlying pathology. Think movement --not muscles.
4. Neuromuscular Rehabilitation is a creative process --it is not protocol based. It is more about facilitating cognitive-sensory-motor processes by providing a stimulating and variations-rich environment. Recovery of motor control is an intrinsic person / nervous system process. It is not just exercising. 
5. Specific exercises or techniques that aim to target, strengthen or "correct" a specific region, a muscle group, or other structural deviation are unlikely to contribute to recovery, nor serve as a means to improve daily function. This approach does not work. Forget about it (Lederman, 2010a, p. 171).
 
In summary, “...unless there is significant change within a person’s internal model for the sensory representation of effective action, becoming expressed and confirmed through new attention to new movement, then there is really no change at all...”

Having helped thousands of persons with complex pain syndromes, debilitating mobility problems, and everyday discomforts, Dr. Tim Sobie, Ph.D. is the founder and clinical director of Alliant Continuum Care, Physical Therapy and Integral Medicine, PLLC. Tim has over thirty years’ experience as a physical therapist and over twenty years’ experience as a Feldenkrais practitioner with five-plus years as a clinical applications principal investigator and scientific researcher. Find out more.

© 2018 Tim Sobie, PT, Ph.D., GCFP. All Rights Reserved
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Comments (4)
Linda Natanagara
4/10/2018 12:04:21 PM
There's a joke in my household that no one is allowed to say the word "core" around me.

Thank you for this article. We've all been seeing for a long time that which you have so clearly laid out, point by point. I am always looking for approaches with my clients that do not alienate them (because I feel so strongly about this issue particularly, that would be possible), but to slowly shine the light on a more sophisticated approach than one global contraction/scoop.

Some of my students are ready for this article, some not quite yet.


carrie lafferty
4/4/2018 2:02:30 PM
Awesome job Tim! This article is very well written. i am going to share...Carrie


Josef DellaGrotte
3/25/2018 7:41:16 AM
Excellent analysis. I am in agreement with most and have had similar results using this integrative approach but with specific detail. But some differences. For exampleF himself had back pain . Several of his trainers had and have back pain. And most FMpractitioners I know DiNitto have consistent results. I myself resolved stenosis, worse than back pain , using what is close to your observations but adding in very necessary specific alignment , fascial and of course awareness of movement connections. Josef DellaGrotte, Gcfp -physio, founder of Core Movement Integration


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