Here's an article I wrote looking at some of the evidence about core stability training and lower back pain. It's quite long - so if you're less interested in looking at the science and more interested in getting out of pain, the take home message is quite simple.
Lots of different kinds of exercise can help to improve your back pain, and the best one for you probably depends on individual factors and takes into account what you enjoy doing. For individual advice, please contact us on 0845 4747 507 or book an appointment online here.
True or false: core stability training can help to cure your back pain
Unless you’ve been living under a rock for the last decade or so, you’ve probably heard everyone from physical therapists and personal trainers to women’s magazines and internet articles promising a “total body transformation” talking about “core stability training”. For a while, it was the big in-thing in the fitness world and it seemed as though brightly coloured inflatable balls were breeding like bunny rabbits in the dark corners of every gym. Which led, of course, to videos of this sort of thing going around on youtube…
Then came the backlash, of course – which you may also have seen. Amongst serious strength training circles, “core stability” started to become synonymous with ineffectual trendy balance exercises that detracted from actually lifting any heavy weight or getting stronger.
In amongst all this confusion, the original idea seems to have been lost. In fact, there are many people who would struggle to tell you what “core stability” actually is. Some people are vaguely aware that it might have something to do with big inflatable balls, others talk about “co-contracting transverse abdominis”, while a few strength coaches I know maintain that “core training” is anything that takes place “between the nipple and the knee”. So, before we ask whether core stability training is any good for back pain, we’d better take a closer look at how we’re defining it.
What exactly is “core stability training”?
According to Wikipedia, “core stability” is simply a person’s ability to control the position and movement of their core / torso. That sounds pretty vague, but perhaps that’s just Wikipedia. What about a more technical definition, such as the widely accepted one quoted by this article?
“The capacity to maintain equilibrium of the vertebral column within its physiologic limits by reducing displacement from perturbations and maintaining structural integrity.”
More scientific, perhaps, but still incredibly broad. These definitions mean that an awful lot of very different kinds of exercise that can be shoehorned into the “core stability” bucket, and this lack of specificity accounts for much of the confusion, and likely some of the ambivalent research results on the topic.
Various authors have focused on different elements of this picture. Some have noted that back pain tends to be associated with lower activation in certain muscle groups, and have focused on teaching patients to specifically recruit and activate those muscles, including transversus abdominis and multifidus; others have argued that isolating particular muscles rather than training them as a group doesn’t make a lot of sense. Some therapists have worried that too much focus on fine motor control and keeping the spine in a perfectly neutral position might actually increase patients’ anxiety about movement and make their pain worse.
What does the research say?
A recent systematic review on the topic looks at 29 different studies comparing core stability exercises to other interventions, ranging from placebo to spinal manipulation and general exercise. They found core stability exercises to be effective in the short term, but rather grandly announce “there is strong evidence stabilisation exercises are no more effective than any other form of active exercise in the long term”. Previous meta-analyses have reached similar conclusions. So, does that mean that all those exercises your physiotherapist gave you are no better than walking your dog? Well, not so fast.
A careful look at the review reveals that the “core stability” groups from the various studies are quite different from each other; but more strikingly, the “general exercise” group can consist of anything from cycling to exercise classes consisting of things like push ups, sit ups and planks. Yes – you read that correctly: in some cases exercises that many people (especially coaches and personal trainers) would file under the heading of “core stability” have been included in the “general exercise” group.
To complicate things further, the “long term” outcome measurements in the studies were often taken several months after participants had stopped doing the exercise program. As could reasonably be predicted, the relative benefits of “core stability” compared to general exercise seemed to decrease after the end of the intervention period, to the point where it was no longer statistically significant on long term follow up. It’s possible that this might change with more studies and a larger sample size.
It should come as no great surprise that many different forms of movement and exercise turn out to be beneficial for back pain; but a careful reading of this systematic review doesn’t give us enough information to categorically conclude either that some are better than others, or that there’s no difference and it doesn’t matter what you do. Much research, unfortunately, tends to fall into the trap of premature extrapolation.
True; but with caveats. The exact interpretation depends on what you think “core stability” means.
Specific exercises focusing on motor control and isolation of certain muscles have been found in these studies to be somewhat effective in the treatment of back pain compared to a range of other modalities. Over the long term, it’s unclear whether specific core stability exercises are better than general exercise. (Remember, though, that “general exercise” can still include exercises that "work the core" – such as push ups and sit ups – but focus less on individual muscle recruitment).
Although no treatment works for everyone, if you want to get rid of your back pain, then working with someone like a physical therapist who is trained to assess and teach therapeutic core stability exercises may be worth a try in the short term. For longer term relief and prevention, consider focusing less on individual muscles and more on movements that challenge your body as a whole. Many types of general exercise or strength training can help you to do this.
If you’re looking for the holy grail of an evidence based “best” training plan to reduce or prevent back pain – the jury is still out, and it probably depends (to a large extent) on individual factors such as the nature of your back pain, your training history, general health, current level of fitness and personal preference. If you focus on finding a type of exercise that you enjoy doing, this makes it most likely that you’ll continue doing it.