Core Training: Is it the Answer to Low Back Pain?
Presented at the Annual Meeting of the Greater New York Regional Chapter of the American College of Sports Medicine by,
Neal I. Pire, MA,CSCS, Director of Training, +1 Fitness
LBP presents unique challenges:
- It's common:
o
Back injuries are the leading cause of disability in the U.S. for people younger than 45 years
oMost expensive health care problem for the 30- to 50-year-old age group.
Bigos S, et al. Acute Low Back Problems in Adults. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, US Dept of Health and Human Services; 1994. Clinical Practice Guideline 14, AHCPR Publication 95-0642.
- It's costly:
oLow back pain accounted for 23% ($8.8 billion) of total workers' compensation payments in 1995.
Murphy PL, Volinn E. Is occupational low back pain on the rise? Spine. 1999;24:691-697.
- It's Chronic it keeps coming back!
oClient gets better (sometimes without intervention), but usually suffers a relapse
Treatments and their success varies
- Medical treatments
oSurgery
oPhysical therapy
oPain management
- Bed Rest
- Back School
- Exercise
History of Exercise as Tx
- Strength training equipment
oTraditional focus on abdominal and lower back muscle strengthening
oLoad applied to trunk flexors and extensors
Williams Flexion Protocol
- Paul Williams, MD
oTx goals: to strengthen glutes and Abs and stretch the lower back and Hamstrings
o"Exercises may significantly increased the pressure within intervertebral discs of the lumbar spine." (Nachemson, 1963)
Nachemson AL. the influence of spinal movements on the lumbar intradiscal pressure and on the tensile stresses in the annulus fibrosus. Acta Orthop Scand 1963;33:183-207.
- Janda's "Layer Syndrome"
oMuscle imbalances, inhibition and/or tightness cause compensatory effects that result in pain
oWeak muscles vs. Tight muscles
oTx Goals: focus on balance and proprioception, correct inhibition in "weak" muscles, and reduce tension in "tight muscles"
- McKenzie Extension Protocol
oRobin McKenzie, PT
oTx Goals: to "centralize" the pain (mechanism) to reduce compressive pressure on lumbar discs via lumbar extension
Why do they keep coming back?
- Value of traditional protocols is controversial
o"None of the various exercise options has been clearly shown to be more advantageous than another."
National Pain Foundation, 2001
What's missing?
- Can parallels be drawn with other conditions and treatments?
oKnee Pain (McConnell)
§Chondromalacia: general quad strengthening
§Mid 80's: patellar taping and target VMO
§Observation of onset of muscle firing patterns
o Shoulder Pain (Kibler)
§"Impingement": Surgery to "shave-down" acromion and Rot Cuff ST
§Cuff ST w/o Scapular stabilization won't help
Can we adopt these concepts when training the low back client?
- Timing of onset of muscle contraction
- Stabilization
What is the "core"?
Operative difinition: the osseoligamentous and neuromuscular systems that establish and maintain proximal stability thus providing for efficient distal mobility
What are the Core "Muscles"?
- Pelvic Floor Muscles
- Abdominal Wall
- Erector Spinae
- Multifidi (dense proprioceptor concentration)
- Fasciae: Thoracolumbar, Abdominal, and Leg
- Hip AB/AD Group
- Gluteals
- Latissimus Dorsi
What effects the "Core"?
- The Local System - directly attach to lumbar vertebrae and are responsible for providing segmental stability and directly controlling lumbar segments (Lumbar multifidus, Psoas major, Quadratus Lumborum, lumbar part of iliocostalis and Longissimus, TVA, posterior fibers of Internal obliques, and Diaphragm)
- The Global System large torque producing muscles that act on trunk and spine (Rectus abdominus, External obliques, thoracic part of Lumbar iliocostalis); provide general trunk stabilization
Bergmark, A. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand Suppl 1989;230:1-54
An "Anatomical Girdle"
- "Lateral Raffe" a local stabilizing system
Bogduk, N. The anatomical basis for spinal pain syndromes. Journal of Manipulative and Physiological Therapeutics, 1995; 18(9): 603-605
The Inner/Outer Units
Vleeming, et. Al. Movement, Stability & Low Back Pain The Essential Role of the Pelvis. New York: Churchill Livingstone, 1997.
The Hydraulic Amplifier
Gracovetsky, S. The Spinal Engine. Wien, New York: Springer-Vertag, 1988
How is Segmental Stability Maintained?
- Osseoligamentous Passive System
- Myofascial Active System
- Neural Control Systems
Panjabi, M. The Stabilizing System of the Spine. Part 1 and Part 2. Journal of Spinal Disorders, 1992; 5(4): 383-397.
- "Coordinated recruitment between systems during functional activities ensures that mechanical stability is maintained"
Cholewicki, J., McGill, S. Mechanical Stability of the in-vivo Spine: implications for injury and chronic low back pain. Clinical Biomechanics, 1996 11(1): 1-15
Neuromuscular control
- TVA and Multifidi recruitment patterns are preferentially impaired in LBP
oCart before the horse?
- Progressive focus:
oMotor learning
oInner Unit (Segmental activation/stabilization)
oOuter Unit (Global System development while maintaining "core stability"
Hodges, P., Richardson, C. Inefficient muscular stabilization of the lumbar spine associated with low back pain: a motor control evaluation of the Transverse abdominis. Spine, 1996; 21(22): 2640-2650
Strength or Endurance?
- Endurance: In an undeviated spine, "sufficient stability" is achieved with very modest levels of co-activation (Cholewicki & McGill, 1996)
- Stronger back and abdominal muscles has no preventive value; muscle endurance has been shown to be protective (Mcgill, 2001)
McGill, S. Low Back Stability: From formal description to issues for performance and Rehabilitation. Exercise and Sport Science Reviews, 2001 29(1): 26-31.
Stability vs. Flexibility
- Adoption of posterior pelvic tilt actually increases risk of injury by flexing lumbar spine and loading passive tissues (McGill, 2001)
- Greater lumbar mobility leads to increased back troubles
Biering-Sorensen, F. Physical measurements as risk indicators for low back trouble over a one year period. Spine, 1984; 9: 106-119.
Safest Mechanically Justifiable Approach to Spine Stabilization
- Maintain neutral spine
- Focus on endurance, not strength
- Encourage abdominal co-contraction and bracing in a functional way
The Exercise Goals
- Activate the TVA
- Learn "neutral spine"
- Learn to co-contract inner unit muscles while maintaining neutral spine
- Increase muscular endurance, not strength
- Enhance functional strength and flexibility of muscles that provide a dynamic challenge to core stability
The Exercise Progression
- Three Stages of Motor Learning
oCognitive (Focus on isolation w/o global involvement)
oAssociative (Refine motor patterns)
oAutonomic (Dynamic stabilization during daily activities)
Shumway-Cook A, Woollacott M 1995 Motor control ± Theory and practical applications. Williams & Wilkins, Baltimore
- Activating the Transverse Abdominis
oTeaching cues
oBiofeedback mechanisms
- "Neutral Spine w/TVA Activation"
Core Stabilization Exercises
- The Cat
oRhythmic movement
o"Floss" the nerve roots and enhance mobility
- Prone Bridge
- Superman vs. The Bird-Dog
- Prone Bridge / Bird-Dog Progressions
- Side Bridge
- Side Bridge Progressions
- Supine Bridge
- Bridge progressions on Balance Ball
Dynamic Stabilization Exercises
- Dynamic Bridging
- Integrated Trunk Drills
- Dynamic Bird-Dog
Functional Integration of Core Exercises
- Squatting
- Lunging
- Bending
- Pushing
- Pulling
- Twisting
- Gait (walking, running, sprinting)
Conclusions:Where do we start?
- Gather all pertinent info (history, lifestyle, behaviors, etc.)
- Physician's or PT's interaction whenever possible
- Educate client so they understand how's and why's
- Teach progressive stabilization
- Condition the "whole system"- Do not ignore the "complete" kinetic chain
