Evan Osar: Low Back Pain – The Myth of The Weak Core – Part 2

Introduction: Structural Low Back Pain

Many individuals experiencing structural low back pain (LBP) have been told that they have a weak core and need to undertake a core strengthening program. As we discussed in the first part of this article, I believe that many more individuals are experiencing low back problems related to a non-optimal core stabilization strategy than are experiencing issues related to core weakness.

The Wall Lift Off Test (WLOT) was introduced as a means of differentiating between an individual’s core strength and the strategy the individual is using to stabilize their core. If you missed the first part of the article, please read it before continuing as it sets the framework for the information presented here in part 2.

In this follow-up article, I will discuss the methods we use in our clinic to help our patients and clients develop a more efficient core stabilization strategy. Rather than cover countless numbers of core exercises, this article will help you understand the rationale for why and when to use the various types of patterns. You can then choose the ones that are most appropriate for your client.

Developing an Optimal Core Stabilization Strategy

Defining Core Stabilization
While the requirements for core stabilization in maintaining ideal posture and movement habits are quite obvious, the overall needs for developing a more optimal core stabilization strategy are not as clearly delineated. One of the most important reasons for helping an individual develop a more optimal core stabilization strategy has to do with the body’s response to pain.

Pain, especially of the chronic variety, will alter muscle recruitment and thus influence postural and movement patterns. I had the great fortune of seeing the late Vladimir Janda shortly before he passed and I recall him saying that pain is one of the factors that most directly impacts posture, stabilization and movement patterns.

Similarly, individuals with chronic LBP demonstrate less variability in their trunk and spine stabilization strategy (Hodges et. al. 2013). Individuals with chronic LBP will commonly demonstrate signs of atrophy in the deeper myofascial system, greater levels of resting superficial muscle tone and a decreased threshold to activating their superficial core muscles—meaning these muscles become predominately over-active.

Additionally, in the first part of this article, I discussed several non-optimal stabilization responses that I routinely detected in my patients with chronic LBP:

• Non-optimal trunk, spine and pelvic alignment,
• A poor breathing stereotype,
• Overusing their superficial muscles relative to their deep muscles, as well as
• Using a bearing down versus utilizing internal pressure regulation to suspend and support the low back.

Research and clinical evidence has supported the need to help our patients and clients experiencing chronic tightness, discomfort and inefficient posture and movement habits establish a more optimal core stabilization strategy. Before discussing how to help an individual develop a more optimal strategy, it is important to define the term core stabilization.

In our model, core stabilization is defined as the individual’s ability to maintain optimal alignment, breathing and myofascial control required to efficiently complete the desired task. There are two terms—efficient and optimal—that really differentiate this definition of core stability. Efficiency refers to using the least amount of energy possible required for the task whereas optimal refers to utilizing the most appropriate strategy to successfully complete the task. Using an example of bending over to pick up a newspaper versus bending over to pick up a child will help illustrate this concept of core stability.

Any movement—bending including—requires a certain level of core stabilization to support as well as minimize stress upon both the joints and soft tissues of the trunk and spine. Bending forward to pick up a light object, a newspaper for example, should not require the same level of muscle effort as is required to lift a child. The core needs to be activated because the joints and soft tissue structures need to be protected, however a high-level bracing (co-activation of the core muscles to stiffen the trunk and spine) strategy should not be required to lift the newspaper. Lifting the child however requires a greater level of joint control, therefore a bracing type of contraction is more appropriate in this situation.

The important concept here is that, in contrast to some industry methods, there shouldn’t be a universal or one-size fits all approach to stabilizing the core. The demands of life require that the intensity of core muscle activation is appropriate to safely and effectively complete the desired task.

Problems arise when a bracing or high-level core stabilization strategy becomes an individual’s default strategy for how they live their life because they have lost the ability to use the appropriate levels of control for the activity they are doing. Recall that as we discussed above, individuals experiencing chronic low back pain tend to lose variety or become more rigid in their stabilization and movement strategy. Therefore, our primary goal in helping our patients and clients is to restore their ability to access and utilize the most appropriate level (low, moderate, or high) of core stabilization to meet the demands of their task.

The Principles of Core Stabilization
When we discuss the core we will be referring to the thoracopelvic cylinder (TPC). The TPC includes the thorax (thoracic spine and rib cage), lumbar spine and pelvis. The thorax is included in our discussion of the core because it dramatically affects alignment and control of the lumbar spine and pelvis. Because of the many myofascial connections between the thorax, lumbar spine and pelvis as well as its impact upon respiration, non-optimal alignment and control of the thorax is frequently an overlooked cause of low back, pelvis and hip dysfunction (Osar 2015).

There are three principles that are key to developing an optimal core stabilization strategy. These three principles form the basis of the Integrative Movement System™ and are referred to as the Foundational A, B, C’s—alignment, breathing, and control.

• Alignment: The individual must align and control their thoracopelvic cylinder (TPC). Optimal alignment is where the thorax is stacked over the pelvis and the spinal curves (cervical lordosis, thoracic kyphosis and lumbar lordosis) are maintained. When the individual has optimal alignment, their joints are best positioned for loading and there is a decreased likelihood of incurring acute or repetitive trauma of the joints and soft tissues. The loss of ideal alignment compromises the individual’s ability to activate their deep core muscles and to breathe three-dimensionally, which consequently affects both posture and movement (Osar 2015).

• Breathing: Three-dimensional breathing improves use of the diaphragm—as well as the other respiratory muscles—in regulating pressures within the thoracic and abdominal cavities. It is the ability to regulate internal pressure that enables an individual to both stabilize as well as decompress their TPC. This dual ability to maintain stability without over-compressing their joints and spinal discs is truly one of the key features of three-dimensional breathing. It is also why in many individuals that have focused primarily upon using a core bracing strategy will tend to over-compress their spine and increase the wear and tear upon their joints and intervertebral discs. This is a common cause of degenerative joint and disc disease.

Additionally, three-dimensional breathing helps activate the deep muscles that control the TPC (diaphragm, psoas, transversus abdominus, pelvic floor, etc.) (Osar 2015). When these muscles are pre-activated prior to the prime movers they help stabilize the trunk and spine so that the larger superficial muscles can do their primary jobs of moving the body and adding additional tabilization where necessary.

Three-dimensional breathing also mobilizes the thorax, thereby relaxing over-contraction of the superficial muscles like the abdominals and erectors. Thus three-dimensional breathing promotes optimal stability as well as mobility of the thorax.

• Control: After aligning the TPC and breathing, the individual must utilize their myofascial system (deep and superficial) to complete their functional tasks. It is important to note that while the muscles of the deep myofascial system can provide enough force to adequately control joint motion, they are alone not sufficient to provide the level of control required for most tasks in every day life.

To adequately meet postural and movement requirements, there must be a balance between the deep and superficial myofascial systems. The muscles of the deep myofascial system pre-activate (contract prior to movement) to stabilize and control joint motion while the muscles of the superficial myofascial system coordinate movement and provide a higher level of stabilization.

An imbalance between these two systems is one of the most common contributors to a non-optimal core stabilization strategy. Research over the previous two decades has repeatedly and consistently demonstrated deficits —timing delays, decreased endurance and atrophy—in the deeper core muscles (including the transversus abdominus, pelvic floor, multifidi and diaphragm) of individuals experiencing chronic LBP (Hodges et. al. 2013). Similarly, individuals experiencing LBP and sciatica tend to experience atrophy in their deeper muscles including the psoas and multifidi (Barker et. al. 2004, Hides et. al. 2008, Seongho 2014).

To compensate for these deficits, individuals will commonly over-activate the superficial myofascial system. A common clinical finding in patients experiencing chronic LBP is psoas weakness, a non-optimal breathing strategy and hypertrophy as well as general over-activity of the superficial muscles during even low-level activities (ex. sitting, standing, lifting something light off the floor, etc.). Motor control training specifically targeting the muscles of the deep myofascial system have proven useful in reversing atrophy and reducing pain and disability in both general population as well as high level athletes experiencing low back pain (Hides et. al. 2008, Hides, et. al. 2014, Hodges, et. al. 2013, Seongo et. al. 2014).

The most important method we have for helping our clients develop a more optimal core stabilization strategy is to incorporate these principles—alignment, breathing, and control—into a corrective and functional exercise program. Utilizing these principles is the most effective way I have found to consistently help our patients and clients maintain a more optimal postural and movement strategy and reduce symptoms related to chronic low back tightness and discomfort.

Corrective Exercise Strategy
Corrective exercise is one of the most effective and appropriate approaches for helping individuals with chronic LBP develop a more optimal core stabilization strategy. Unfortunately corrective exercise has come under considerable scrutiny as of late primarily from the proponents suggesting that individuals just need to get stronger.

Another issue surrounding the use of corrective exercise is that it is often thought of as a ‘correction’ or ‘fix’ for common postural, movement and pain syndromes or that it is the only exercise an individual should be doing. Corrective exercise is neither a ‘fix’ nor is it the only type of exercise an individual should be doing. In The Integrative Corrective Exercise Approach™, corrective exercise is defined as follows:

Corrective exercise is an approach that includes assessment, a specific corrective exercise strategy, which addresses the individual’s primary driver, and integrates these concepts into a functional training program designed to improve their posture and movement strategy. Corrective exercise is not a fix or a correction but rather involves an overall approach to addressing the individual’s primary issues and developing a strategy for helping them accomplish their functional goals. (Osar 2015)

Therefore, corrective exercise is an overall approach to addressing and improving an individual’s stabilization and movement strategy rather than a collection of remedial exercises. I am often asked two questions by my patients and attendees at training workshops I conduct: “What is the best corrective exercise for the core?” and “What are the best core strengthening exercises?” While I used to give these individuals a 30-minute answer explaining the anatomy, biomechanics, and control of different types of core exercises, I have since shortened my response to two sentences and one question? They are:

Essentially there are no good or bad core exercises. There are only exercises that help an individual move closer towards—or maintain—an optimal core stabilization strategy and exercises that move them further away from ideal.

When choosing a particular corrective or functional exercise pattern you must ask yourself the following question: “Is this exercise, and just as importantly, is the way my client is performing this exercise, helping them move closer towards—or helping them maintain—an optimal core stabilization strategy?

Answering these questions will help you decide whether or not a core exercise and/or overall approach to core stability is appropriate for your patient or client.

As to what exercises are used with our patient and clients, we incorporate very traditional corrective exercise patterns, including, but not limited to, Happy Baby (supported, unsupported, with breathing, heel lifts, drops, etc.), Modified Dead Bug (breathing, with and without heel drops), Supported patterns (Squat, Split Squat, Hinges), Prone Lengthening, Modified Wall Plank.

This approach is less about the exact exercises used and focuses more upon the specificity in which the principles of alignment, breathing, and control are incorporated into each exercise pattern. The most important concept is that you choose exercises that enable your client to be successful, i.e. maintain optimal alignment, breathing and control throughout the pattern.

Supported Squat

Happy Baby

Modified Dead Bug with Heel Drop

Functional Progressions
Once the individual understands how to develop more optimal alignment, breathing and control, they must integrate the concepts from their corrective exercises into functional exercise progressions. There are two ways to categorize these higher-level core exercises:
Exercises that train control of neutral TPC alignment, and
Exercises that challenge the ability to maintain control during rotary movements of the TPC.

Examples of exercises we use to train TPC neutral include planks, Fall Outs with suspension straps, push ups, chops, cable press outs, cable push and pull patterns, carrys and loaded squats and deadlifts.

Training neutral TPC control: Kettle Bell Carry (top); Fall Out (above) 

One final, yet equally important, concept when working with individuals with chronic tightness and discomfort is that they are appropriately progressed. Too often, patients I consult with are being given exercises that are far too challenging and beyond their current level of control. Usually this problem arises because the thinking is that the harder the exercise pattern is or the more the individual ‘feels’ their core working, the better the exercise must be. It is imperative when working with individuals experiencing chronic tightness, discomfort as well as habitual postural and movement dysfunction, that they are appropriately progressed.

Rather than moving them in a positive direction, exercises that focus too greatly upon intensity without ensuring optimal alignment, breathing, and control will move the individual further away from achieving an optimal core stabilization strategy.

Therefore, patterns that incorporate spinal rotation are only introduced once the individual can properly control neutral alignment through a variety of positions and exercise progressions. We use a variety of cable chops and rotations as well as cable push and pull patterns with spinal rotation to integrate these concepts into functional and task-specific movement patterns.

Training rotation with TPC control: Cable rotation (top); Cable row (above)

Conclusion
In this two-part article series, we discussed how many individuals experiencing structural low back pain are dealing with issues related to a non-optimal core stabilization strategy rather than having a ‘weak’ core. The Wall Lift Off Test is an easy-to-perform assessment that helps differentiate between an individual’s core strength and their stabilization strategy.

If the individual is simply dealing with an issue of strength, then virtually any progressive exercise program can be instituted to improve their issues. However, if the individual has a non-optimal core stabilization strategy that is driving their low back dysfunction—tightness, discomfort, postural or movement dysfunction—then a more specific approach is required.

Integration of the core principles of the Integrative Movement System™—alignment, breathing and control—into corrective and functional exercise progression can be instrumental in helping these individuals develop a more optimal core stabilization strategy. The important concept in this approach is to choose exercises that help the individual successfully maintain optimal alignment, breathing and control throughout their exercise patterns.

While there are no guarantees, if your client is maintaining optimal alignment, three-dimensional breathing and the appropriate level of control for the exercises they are performing, you can rest assured that you have likely helped them establish a more optimal core stabilization strategy. This approach can ultimately help chronic low back pain sufferers safely and effectively move towards accomplishing their functional goals while reducing tightness and discomfort.

References:
Barker KL, Shamley DR, Jackson D. 2004. Changes in the cross- sectional area of multifidus and psoas in patients with unilateral back pain. Spine; 29(22):E515–E519.
Hides, J. A., Stanton, W.R.: 2014. Can Motor Control Training Lower the Risk of Injury for Professional Football Players? Journal of the American College of Sports Medicine; 762-768.
Hides, J., Stanton, W., McMahon, S., Sims, K., Richardson, C.: 2008. Effect of Stabilization Training on Multifidus Muscle Cross-sectional Area Among Young Elite Cricketers With Low Back Pain. Journal of Orthopaedic & Sports Physical Therapy. 38:3; 101-112.
Hodges, P.W., Cholewicki, J., van Dieen, J.H.: 2013. The Rehabilitation of Back Pain: State of the art and science. Churchill Livingingston; Sydney, AT.
Osar, E.: 2015. The Integrative Corrective Exercise Approach™. http://integrativecorrectiveexercisespecialist.com/
Osar, E.: 2015. The Integrative Movement Specialist™ Certification. Course Handouts; Chicago, IL.
Seongho, K., Hyungguen, K., and Jaeyeop, C.: 2014. Effects of Spinal Stabilization Exercise on the Cross-sectional Areas of the Lumbar Mulftifidus and Psoas Major Muscles, Pain Intensity, and Lumbar Muscle Strength of Patients with Degenerative Disc Disease. Journal of Physical Therapy Science; 26:579-582.

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