ArticlePDF AvailableLiterature Review

The Myth of Core Stability

January 2010
Journal of Bodywork and Movement Therapies 14(1):84-98

DOI:10.1016/j.jbmt.2009.08.001

Source
PubMed

Authors:

CPDO

The principle of core stability has gained wide acceptance in training for the prevention of injury and as a treatment modality for rehabilitation of various musculoskeletal conditions in particular of the lower back. There has been surprisingly little criticism of this approach up to date. This article re-examines the original findings and the principles of core stability/spinal stabilisation approaches and how well they fare within the wider knowledge of motor control, prevention of injury and rehabilitation of neuromuscular and musculoskeletal systems following injury.

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CRITICAL REVIEW

The myth of core stability

Eyal Lederman*

CPDO Ltd., 15 Harberton Road, London N19 3JS, UK

Received 26 October 2008; received in revised form 3 May 2009; accepted 4 August 2009

KEYWORDS

Core stability;

Spinal stabilisation;

Transversus abdominis;

Chronic lower back and

neuromuscular

rehabilitation

Summary The principle of core stability has gained wide acceptance in training for the

prevention of injury and as a treatment modality for rehabilitation of various musculoskeletal

conditions in particular of the lower back. There has been surprisingly little criticism of this

approach up to date. This article re-examines the original ﬁndings and the principles of core

stability/spinal stabilisation approaches and how well they fare within the wider knowledge

of motor control, prevention of injury and rehabilitation of neuromuscular and musculoskel-

etal systems following injury.

Introduction

Core stability (CS) arrived in the latter part of the 1990s. It

was largely derived from studies that demonstrated

a change in onset timing of the trunk muscles in back injury

and chronic lower back pain (CLBP) patients (Hodges and

Richardson, 1996, 1998). The research in trunk control has

been an important contribution to the understanding of

neuromuscular reorganisation in back pain and injury. As

long as four decades ago it was shown that motor strategies

change in injury and pain (Freeman et al., 1965). The CS

studies conﬁrmed that such changes take place in motor

control of the trunk muscles of patients who suffer from

back injury and pain.

However, these ﬁndings combined with general beliefs

about the importance of abdominal muscles for a strong

back, and inﬂuences from Pilates, have promoted several

assumptions prevalent in CS training:

That certain muscles are more important for stabilisa-

tion of the spine than other muscles, in particular

transversus abdominis (TrA).

That weak abdominal muscles lead to back pain

That strengthening abdominal or trunk muscles can

reduce back pain

That there is a unique group of ‘‘core’’ muscle working

independently of other trunk muscles

That back pain can be improved by normalising the

timing of core muscles

That there is a relationship between stability and back

pain

As a consequence of these assumptions, a whole industry

grew out of these studies with gyms and clinics worldwide

teaching the ‘‘tummy tuck’’ and trunk bracing exercise to

athletes for prevention of injury and to patients as a cure

* Tel.: þ44 207 263 8551.

E-mail address: cpd@cpdo.net

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for lower back pain (Jull and Richardson, 2000; Richardson

et al., 2002). In this article some of these basic assumptions

will be re-examined.

Assumptions about stability and the role of TrA

and other core muscle

In essence the passive human spine is an unstable structure

and therefore further stabilisation is provided by the

activity of the trunk muscles. These muscles are often

referred to in the CS approach as the ‘‘core’’ muscles,

assuming that there is a distinct group, with an anatomical

and functional characteristics speciﬁcally designed to

provide for the stability. One of the muscles in this group to

have received much focus is TrA. It is widely believed that

this muscle is the main anterior component of trunk stabi-

lisation. It is now accepted that many different muscles of

the trunk contribute to stability and that their action may

change according to varying tasks (see further discussion

below).

The TrA has several functions in the upright posture.

Stability is one, but this function is in synergy with every

other muscle that makes up the abdominals wall and

beyond (Hodges et al., 1997, 2003; Sapsford et al., 2001). It

acts in controlling pressure in the abdominal cavity for

vocalisation, respiration, defecation, vomiting, etc. (Misuri

et al., 1997). TrA forms the posterior wall of the inguinal

canal and where its valve-like function prevents the viscera

from popping out through the canal (Bendavid and

Howarth, 2000).

How essential is TrA for spinal stabilisation? One way to

assess this is to look at situations where the muscle is

damaged or put under abnormal mechanical stress. Would

this predispose the individual to lower back pain?

According to Gray’s Anatomy (36th edition 1980, page

555) TrA is absent or fused to the internal oblique muscle as

a normal variation in some individuals. It would be inter-

esting to see how these individuals stabilise their trunk and

whether they suffer more back pain.

Pregnancy is another state that raises some important

questions about the role of TrA or any abdominal muscle

in spinal stabilisation. During pregnancy the abdominal

wall muscles undergo dramatic elongation, associated

with force losses and inability to stabilise the pelvis

against resistance (Fast et al., 1990; Gilleard and Brown,

1996). Indeed, in a study of pregnant women (nZ318)

they were shown to have lost the ability to perform sit-

ups due to this extensive elongation and subsequent force

losses (Fast et al., 1990). Whereas all non-pregnant

women could perform a sit-up, 16.6% of pregnant women

could not perform a single sit-up. However, there was no

correlation between the sit-up performance and back-

ache, i.e. the strength of abdominal muscle was not

related to backache. Despite this, CS exercises are often

prescribed as a method for retraining the abdominal

muscles and ultimately as a treatment for LBP during

pregnancy. There is little evidence that localised muscu-

loskeletal mechanical issues, including spinal stability play

a role in the development of LBP during pregnancy. Often

cited predisposing factors are, for example, body mass

index, a history of hypermobility and amenorrhea (Mogren

and Pohjanen, 2005), low socioeconomic class, existence

of previous LBP, posterior/fundal location of the placenta

and a signiﬁcant correlation between foetal weight and

LBP (Orvieto et al., 1990).

Another interesting period for us, concerning the role of

abdominal muscles and stabilisation is immediately after

delivery. Postpartum, it would take the abdominal muscle

about 4e6 weeks to reverse the length changes and for

motor control to reorganise. For example, rectus abdominis

takes about 4 weeks postpartum to re-shorten, and it takes

about 8 weeks for pelvic stability to normalise (Gilleard and

Brown, 1996). It would be expected that during this period

there would be minimal spinal support/stabilisation from

the slack abdominal muscles and their fasciae. Would this

increase the likelihood for back pain?

In a recent study, the effects of a cognitive-behavioural

approach were compared with standard physiotherapy on

pelvic and lower back pain immediately after delivery

(Bastiaenen et al., 2006). An interesting aspect of this

research was that out 869 pregnant women suffering from

back pain during pregnancy, 635 were excluded because of

their spontaneous unaided recovery within a week of

delivery. This spontaneous recovery was during a period,

well before the abdominal muscles had time to return to

their pre-pregnancy length, strength or control (Gilleard

and Brown, 1996). Yet, this was a period when back pain

was dramatically reduced. How can it be that back and

pelvic pain is improving during a period of profound

abdominal muscle inefﬁciency? Why does the spine not

collapse? Has the relationship between abdominal muscles

and spinal stability been over-emphasised?

Similarly studies on weight gain and obesity and LBP

challenge the CS theory. One would expect, as in preg-

nancy, the distension of the abdomen to disrupt the normal

mechanics and control of the trunk muscles, including TrA.

According to the CS model this should result in an increased

incidence of back pain among this group. Yet, epidemio-

logical studies demonstrate that weight gain and obesity

are only weakly associated with lower back pain (Leboeuf-

Yde, 2000)According to the CS model we should be seeing

an epidemic of back pain in over-weight individuals.

Another area that can shed light on the control and

stability of the abdominal muscles is the study of abdom-

inal muscles that have been damaged by surgery. Would

such damage affect spinal stability or contribute to back

pain? In breast reconstruction after mastectomy, one side

of the rectus abdominis is used for reconstruction of the

breast. Consequently, the patient is left with only one side

of rectus abdominis and weakness of the abdominal

muscles. Such alteration in trunk biomechanics would also

be expected to result in profound motor control changes.

Despite all these changes there seems to be no relation-

ship to back pain or impairment to the patient’s

functional/movement activities, measured up to several

years after the operation (Mizgala et al., 1994; Simon

et al., 2004).

One area for further study would be that of subjects who

have had inguinal hernia repair. In this operation the TrA

is known to be affected by the surgical procedure

(Berliner, 1983; Condon and Carilli, 1994). To date there is

no known epidemiological study linking such surgery and

back pain.

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In summary we can conclude:

That abdominal musculature can demonstrate dramatic

physiological changes, such as during pregnancy, post-

partum and obesity, with no detriment to spinal

stability and health.

Damage to abdominal musculature does not seem to be

detrimental to spinal stability or contribute to LBP.

No study to date has demonstrated that LBP is due to

spinal instability. Despite a decade of research in this

area it remains a theoretical model.

The timing issue

In one of the early studies it was demonstrated that during

rapid arm/leg movement, the TrA in CLBP patients had

delayed onset timing when compared with asymptomatic

subjects (Hodges and Richardson, 1996, 1998). It was

consequently assumed that the TrA, by means of its

connection to the lumbar fascia, is dominant in controlling

spinal stability (Hodges et al., 2003). Therefore any

weakness or lack of control of this muscle would spell

trouble for the back.

This assumption is a dramatic leap of faith. Firstly, in our

body all structures are profoundly connected in many

different dimensions, including anatomically and biome-

chanically. You need a knife to separate them from each

other. It is not difﬁcult to emphasise a connection that

would ﬁt the theory, i.e. that the TrA is the main anterior

muscle that controls spinal stability. In normal human

movement postural reﬂexes are organised well ahead in

anticipation of movement or perturbation to balance. TrA is

one of the many trunk muscles that takes part in this

anticipatory organisation (Hodges and Richardson, 1997).

Just because in healthy subjects it kicks off before all other

anterior muscles (in one particular posture), does not mean

it is more important in any way. It just means it is the ﬁrst

in a sequence of events (Cresswell et al., 1994a,b). Indeed,

it has been recently suggested that earlier activity of TA

may be a compensation for its long elastic anterior fasciae

(Macdonald et al., 2006).

It can be equally valid to assume that a delay in onset

timing in subjects with LBP may be an advantageous

protection strategy for the back rather than a dysfunctional

activation pattern. Furthermore, it could be that during the

fast movement of the outstretched arm the subject per-

formed a reﬂexive pain evasion action that involved

delayed activation of TrA, an action unrelated to stabili-

sation (Moseley et al., 2003a,b, 2004). An analogy would be

the reﬂex pulling of the hand from a hot surface. One could

imagine that a patient with a shoulder injury would use

a different arm withdrawal pattern from a normal indi-

vidual. This movement pattern would be unrelated to the

control of shoulder stability but would be intended to

produce the least painful path of movement, even if the

movement is not painful at the time. A similar phenomenon

has been demonstrated in trunk control where just the

perception of a threat of pain to the back resulted in

altered postural strategies (Moseley and Hodges, 2006).

In the original studies of CS onset time differences

between asymptomatic individuals and patients with CLBP

were about 20 ms, i.e. one ﬁftieth of a second difference

(Hodges and Richardson, 1996, 1998; Radebold et al.,

2000). It should be noted that these were not strength but

timing differences. Such timings are well beyond the

patient’s conscious control and the clinical capabilities of

the therapist to test or alter.

Often, in CS exercise there is an emphasis on strength

training for the TrA or low velocity exercise performed

lying or kneeling on all fours (Richardson and Jull, 1995). It

is believed that such exercise would help normalise motor

control which would include timing dysfunction. This kind

of training is unlikely to help reset timing differences. It is

like aspiring to play the piano faster by exercising with

ﬁnger weights or performing push-ups. The reason why this

is ineffective is related to a contradiction which CS training

creates in relation to motor learning principles (similarity/

transfer principle) and training principles (speciﬁcity prin-

ciple, see further discussion below). In essence these

principles state that our bodies, including the neuromus-

cular and musculoskeletal systems will adapt speciﬁcally to

particular motor events. What is learned in one particular

situation may not necessarily transfer to a different phys-

ical event, i.e. if strength is required elift weights, if

speed is needed eincrease the speed of movement during

training and along these lines if you need to control onset

timing switch your movement between synergists at a fast

rate, and hope that the system will reset itself (Lederman,

2005, in press).

To overcome the timing problem the proponents of CS

came up with a solution eteach everyone to continuously

contract the TrA or to tense/brace the core muscle

(O’Sullivan, 2000; Jull and Richardson, 2000). By continuously

contracting it would overcome the need to worry about onset

timing. What is proposed here is to impose an abnormal,

non-functional pattern of control to overcome a functional

reorganisation of the neuromuscular system to injury:

a protective strategy that is as old as human evolution.

We now know that following injury, one motor strategy is

to co-contract the muscles around the joint (amongst many

other complex strategies, Figure 1).

This injury response has also been shown to occur in

CLBP patients (Nouwen et al., 1987; Arena et al., 1991;

Hubley-Kozey and Vezina, 2002a,b; Marras et al., 2005),

who tend to co-contract their trunk ﬂexors and extensors

during movement (van Dieen et al., 2003a,b). This strategy

is subconscious, and very complex. It requires intricate

interactions between the relative timing, duration, force,

muscle lengths and velocities of contraction of immediate

synergists (Shirado et al., 1995a,b; Radebold et al., 2000,

see Table 1). Further complexity would arise from the fact

that these patterns would change on a moment-to-moment

basis and with different movement/postural tasks (McGill

et al., 2003; Cordo et al., 2003; Moseley et al., 2003a,b).

This pattern of muscle activity observed in standing with

the arm outstretched is likely to change in bending forward

or twisting. Indeed, in the original studies of the onset

timing of TrA delays in onset timing were observed during

fast but not during slow arm movements (Hodges and

Richardson, 1996). Even during a simple trunk rotation or

exercise the activity in TrA is not uniform throughout the

muscle (Urquhart and Hodges, 2005; Urquhart et al.,

2005a).

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These studies demonstrate the complexity that a patient

re-learning trunk control may have to face. How would

a person know which part of the abdomen to contract

during a particular posture or movement? How would they

know when to switch between synergists during movement?

How would they know what is their optimal co-contraction

force? If CLBP patients already use a co-contraction

strategy why increase it? It is naı

¨ve to assume that by

continuously contracting the TrA it will somehow override

or facilitate these patterns. Furthermore no study to date

has demonstrated that core stability exercise will reset

onset timing in CLBP patients (Hall et al., 2007).

In summary we can conclude:

That there is motor reorganisation of the trunk muscles

in response to the experience or the fear of spinal pain

There is no evidence that such motor reorganisation is

the cause of spinal pain or recurrence of back pain

Most prescribed CS exercise/manoeuvres are not well

designed to challenge onset time of synergists and are

therefore unlikely to reset the onset timing of the trunk

muscles

No study to date have as demonstrated that core stability

exercise will reset onset timing in CLBP patients.

The strength issue

There is more confusion about the issue of trunk strength

and its relation to back pain and injury prevention. What

we do know is that trunk muscle control including force

losses can be present as a consequence of back pain/injury.

However, from here several assumptions are often made:

That loss of core muscle strength could lead to back

injury,

That increasing core strength can alleviate back pain

To what force level do the trunk muscles need to

co-contract in order to stabilise the spine? It seems that the

answer is enot very much (Figure 2).

During standing and walking the trunk muscles are mini-

mally activated (Andersson et al., 1996). In standing the deep

spinal erectors, psoas and quadratus lumborum are virtually

silent! In some subjects there is no detectable EMG activity in

these muscles. During walking rectus abdominis has an

average activity of 2% maximal voluntary contraction (MVC)

and external oblique 5% MVC (White and McNair, 2002).

During standing ‘‘active’’ stabilisation is achieved by very

low levels of co-contraction of trunk ﬂexors and extensors,

estimated at less than 1% MVC rising up to 3% MVC when

a 32 kg weight is added to the torso. With a back injury it is

estimated to raise these values by only 2.5% MVC for the

unloaded and loaded models (Cholewicki et al., 1997). During

bending and lifting a weight of about 15 kg co-contraction

increases by only 1.5% MVC (van Dieen et al., 2003a,b).

These low levels of activation raise the question why

strength exercises are prescribed when such low levels of

co-contraction forces are needed for functional movement.

Such low co-contraction levels suggest the strength losses

are unlikely ever to be an issue for spinal stabilisation. A

person would have to lose substantial trunk muscle or force

control before it will destabilise the spine.

These low levels of trunk muscle co-contraction also

have important clinical implications. It means that most

individuals would ﬁnd it impossible to control such low

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Figure 1 Motor control of movement is composed of several underlying factors which include force, velocity, range and

endurance (parametric group of abilities); co-contraction and reciprocal activation which represent the synergistic level of control

and the more complex composite motor abilities that include coordination, balance transition time between different activities

and motor relaxation. All these motor components play a part during movement. By altering one, all the other control factors will

also change. Adapted from: Lederman E, Neuromuscular rehabilitation in manual and physical therapy, to be published 2010.

London, Elsevier.

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Table 1 The complexity of motor reorganisation during spinal/trunk injury and pain. All the levels of motor abilities are affected. It is an overall control reorganisation rather than failure of

particular motor components. A therapeutic error is to focus on single issues such as force or co-contraction.

Conditions Parametric motor abilities Synergistic Composite

Force Length Velocity Endurance Co-contraction/

reciprocal

activation

Coordination Balance/postural

stability

Transition time Relaxation

Lower

back pain

Force losses in

trunk muscles in

acute and CLBP

patients

(Airaksinen et al.,

1996; Hides et al.,

1994, 1996; Ng

et al., 1998;

Shirado et al.,

1995a)

Loss of ﬂexion

relaxation in the

spinal muscles

during ﬂexion in

patients with

CLBP.Extensors

activation prevents

full forward

bending

(Shirado et al.,

1995b). Individuals

with high pain-

related fear had

smaller excursions

of the lumbar spine

for reaches to all

targets at 3 and 6

weeks, but not at

12 weeks following

pain onset (Thomas

et al., 2008).

Smaller stride

length

(Lamoth et al.,

2008)

Reduced velocity

of trunk movement

during induced

back pain (Zedka

et al.,

1999)Individuals

with high pain-

related fear had

smaller peak

velocities and

accelerations of

the lumbar spine

and hip joints,

even after

resolution of back

pain (Thomas

et al., 2008).

Walking velocity

signiﬁcantly lower

in LBP patients

(Lamoth et al.,

2006a,b, 2008)

Increased

fatigability trunk

muscles in patient

with CLBP (Roy

et al., 1989;

Shirado et al.,

1995a,b; Suter and

Lindsay 2001)

Impaired postural

control of the

lumbar spine is

associated with

delayed trunk/

abdominal muscles

response times in

CLBP patients

(Hodges and

Richardson, 1999;

Hodges et al.,

2003a,b; Hodges

and Richardson

1996, 1998;

MacDonald et al.,

2006; O’Sullivan

et al., 1997a,b;

Radebold et al.,

2001; Thomas and

France, 2007;

Thomas et al.,

2007).Increase in

trunk co-

contraction in

CLBP patients

(Cholewicki et al.,

2005; van Dieen

et al.,

2003a)Increased

co-contraction in

trunk during

walking and

additional

cognitive demands

(Lamoth et al.,

2008)

Lumbar spineehip

joint coordination

altered in back

pain subjects

(Shum et al.,

2005)Dis-

coordination in

pelvisethorax

coordination in LBP

(Lamoth et al.,

2006a,b)

Changes in

postural control in

CLBP (Leinonen

et al., 2001; Popa

et al.,

2007)Impaired

postural control of

the lumbar spine

associated with

delayed muscle

response times in

CLBP patients

(Radebold et al.,

2001)Changes in

postural control

unrelated to pain

in CLBP (della

Volpe et al.,

2006)Postspinal

surgery postural

control changes

both in pain and

pain-free subjects.

However, more

evident in the

symptomatic

subjects (Bouche

et al., 2006)Hip

strategy for

balance control in

quiet standing is

affected in CLBP

(Mok et al.,

2004)Experimental

muscle pain

changes

feedforward

postural responses

of the trunk

muscles (Hodges

et al., 2003)

Compared to

healthy controls,

persons with LBP

exhibited a

reduced ability to

adapt trunkepelvis

coordination and

spinal muscle

activity to sudden

changes in walking

velocity (Lamoth

et al.,

2006a,b)Slower

reaction time in

LBP patients.

Demonstrated

recovery of

reaction time with

training (Luoto

et al., 1996)

Not studied

(but should be)

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levels of activity or even be aware of it. If they are aware of

it they are probably co-contracting well above the normal

levels needed for stabilisation. This would come at a cost of

increasing the compression of the lumbar spine and

reducing the economy of movement (see discussion below).

Is there a relationship between weak abdominals (e.g.

TrA) and back pain? A common belief amongst therapists and

trainers who use CS is that trunk strength will improve existing

back pain. It has been shown that a muscle such as multiﬁdus

(Hides et al., 1994) can undergo atrophy in acute and CLBP

(although this is still inconclusive). Furthermore, it is well

established that the motor strategy changes in the recruit-

ment of the abdominal muscles in patients with CLBP (Ng

et al., 2002a,b; Moseley et al., 2003a,b), with some studies

demonstrating weakness of abdominal muscles (Helewa

et al., 1990, 1993; Shirado et al., 1995a,b). However,

strengthening these muscles does not seem to improve the

pain level or disability in CLBP patients (Mannion et al.,

2001a). Improvement appeared to be mainly due to changes

in neural activation of the lumbar muscles and psychological

changes concerning, for example, motivation or pain toler-

ance (Mannion et al., 2001b). To date there are no studies

that show atrophy of abdominal muscles or that strength-

ening the core muscles, in particular the abdominal muscle

and TrA, would reduce back pain (see discussion below).

There are also examples where abdominal muscle

activity is no different between asymptomatic and CLBP

subjects. For instance, in studies of elite golfers, abdominal

muscle activity and muscle fatigue characteristics were

similar between asymptomatic and CLBP subjects after

repetitive golf swings (Horton et al., 2001). Yet, this is the

type of sportsperson who would often receive CS exercise

advice.

Doubts have also been raised concerning the effective-

ness of many of CS exercise in helping to increase the

strength of core muscles. It has been shown that during CS

exercise, the maximal voluntary contraction (MVC) of the

‘‘core muscles’’ is well below the level required for muscle

hypertrophy and is therefore unlikely to provide strength

gains (Souza et al., 2001; Vezina and Hubley-Kozey, 2000;

Hubley-Kozey and Vezina, 2002a,b). Furthermore, in

a study of fatigue in CLBP, four weeks of stabilisation

exercise failed to show any signiﬁcant improvement in

muscle endurance (Sung, 2003) A recent study has demon-

strated that as much as 70% MVC is needed to promote

strength gains in abdominal muscle (Stevens et al., 2008). It

is unlikely that during CS exercise abdominal muscle would

reach this force level (Stevens et al., 2007).

We can conclude that:

There is no evidence that reduced trunk muscle

strength or endurance will predispose the individual to

LBP (Hamberg-van Reenen, 2007)

There are inconclusive ﬁnding regarding loss of trunk

muscle strength and atrophy in response to CLBP

CS exercises do not provide an overtraining challenge

that is expected to result in strength or endurance gains

in these muscles.

The single/core muscle activation problem

One of the principles of CS is to teach the individuals how to

isolate their TrA from the rest of the abdominal muscles or

to isolate the ‘‘core muscle’’ from ‘‘global’’ muscles.

It is doubtful that there exists a ‘‘core’’ group of trunk

muscles that are recruited operate independently of all

other trunk muscles during daily or sport activities (McGill

et al., 2003; Kavcic et al., 2004). Such classiﬁcation is

anatomical but has no functional meaning. The motor

output and the recruitment of muscles are extensive

(Hodges et al., 2000; Cholewicki et al., 2002a,b), affecting

the whole body. To speciﬁcally activate the core muscles

during functional movement the individual would have to

override natural patterns of trunk muscle activation. This

would be impractical, next to impossible and potentially

dangerous; as stated by Brown et al. (2006) ‘‘Individuals in

an externally loaded state appear to select a natural

muscular activation pattern appropriate to maintain spine

stability sufﬁciently. Conscious adjustments in individual

muscles around this natural level may actually decrease the

stability margin of safety’’.

Training focused on a single muscle is even more

difﬁcult. Muscle-by-muscle activation does not exist

(Georgopoulos, 2000). If you bring your hand to your mouth

the nervous system ‘‘thinks’’ hand to mouth rather than

ﬂex the biceps, then the pectorals, etc. Single muscle

control is relegated in the hierarchy of motor processes to

spinal motor centres ea process that would be distant from

conscious control (interestingly even the motor neurons of

particular muscles are intermingled rather than being

distinct anatomical groups in the spinal cord) (Luscher and

Reduce spinal stability

Reduce spinal compression

Increase range of movement

Reduce energy expenditure

Increase spinal stability

Increase spinal compression

Reduce range of movement

Increase energy expenditure

Range of active stability

Increase co-contraction

Diminish co-contraction

Optimal level

Figure 2 Co-contraction has several roles during movement such as to help stabilise the joints and reﬁne movement. The co-

contraction levels in the trunk are kept at optimal low levels ean increase in co-contraction will raise the compression force on the

disc and it is more energy consuming. It also tends to rigidify the trunk which is an unsuitable control strategy where range of

movement or ﬂexibility is required.

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Clamann, 1992). Indeed, it has been demonstrated that

when tapping the tendons of rectus abdominis, external

oblique and internal oblique the evoked stretch reﬂex

responses can be observed in the muscle tapped, but also

spreading extensively to muscles on the ipsilateral and

contralateral sides of the abdomen (Beith and Harrison,

2004). This suggests sensory feedback and reﬂex control of

the abdominal muscles is functionally related and would

therefore be difﬁcult to separate by conscious effort.

This simple principle in motor control poses two problems

to CS training. First, it is doubtful that following injury only

one group or single muscles would be affected. Indeed, the

more EMG electrodes applied the more complex the picture

becomes (Cholewicki et al., 2002a,b). It is well documented

that other muscles are involved emultiﬁdus (Carpenter and

Nelson, 1999), psoas (Barker et al., 2004), diaphragm

(Hodges et al., 1997, 2003), pelvic ﬂoor muscles (Pool-

Goudzwaard et al., 2005), gluteals (Leinonen et al., 2000),

etc. Basically in CLBP we see a complex and wide reorgan-

isation of motor control in response to damage or pain.

The second problem for CS is that it would be next to

impossible to contract a single muscle or speciﬁc group.

Even with extensive training this would be a major problem

(Beith et al., 2001). Indeed, there is no support from

research that TrA can be singularly activated (Cholewicki

et al., 2002a,b). The novice patient is more likely to

contract wide groups of abdominal muscles (Sapsford et al.,

2001; Urquhart et al., 2005a,b). So why focus on TrA or any

other speciﬁc muscle or muscle group?

We can summaries that:

The control of the trunk (and body) is whole. There is

no evidence that there are core muscles that work

independently from other trunk muscle during normal

functional movement.

There is no evidence that individuals can effectively

learn to speciﬁcally activate one muscle group inde-

pendently of all other trunk muscles.

CS and training in relation to motor learning

and training issues

Further challenges for the CS model arise from motor

learning and training principles.

CS training seems to clash with three important

principles:

The similarity (transfer) principle in motor learning and

speciﬁcity principle in training

Internaleexternal focus principles

Economy of movement.

Similarity/speciﬁcity principles

When we train for an activity we become skilled at per-

forming it. So if we practice playing the piano we become

a good pianist, hence a similarity principle. We can’t learn

to play the piano by practicing the banjo or improve playing

by lifting weight with our ﬁngers. This adaptation to the

activity is not only reserved to learning processes, it has

profound physical manifestations ehence a weight trainer

looks physically different to a marathon runner (speciﬁcity

principle in training, Roels et al., 2005).

If a subject is trained to contract their TrA or any

anterior abdominal muscle while lying on their back (Karst

and Willett, 2004), there is no guarantee that this would

transfer to control and physical adaptation during standing,

running, bending, lifting, sitting, etc. Such control would

have to be practiced during some of these activities

(Lederman, in press, see Figure 3). Anyone who is giving CS

exercise to improve sports performance should re-famil-

iarise themselves with this basic principle.

It seems that such basic principles can escape many of the

proponents of CS. This is reﬂected in one study which

assessed the effect of training on a Swiss ball on core stability

muscles and the economy of running (Stanton et al., 2004)! In

this study it was rediscovered that practicing the banjo does

not help to play the piano. The subjects got verygood at using

their muscles for sitting on a large inﬂatable rubber ball but it

had no effect on their running performance. An often quoted

study by Tsao and Hodges (2008) does show transfer of

learning from CS training to postural activity. However, this is

a low quality study, carried out on a small number of subjects

(nZ9) without any control/sham. The transfer observed in

this study is in conﬂict with the vast knowledge of motor

control that suggests that suchtransfer is highly unlikely (see

Schmidt and Lee, 2005 for extensive review of transfer of

learning).

Trunk control will change according to the speciﬁc

activity the subject is practicing. Throwing a ball would

require trunk control, which is different to running. Trunk

control in running will be different in climbing and so on.

There is no one universal exercise for trunk control that

would account for the speciﬁc needs of all activities. Is it

possible to train the trunk control to speciﬁc activity? Yes,

and it is simple ejust train in that activity and don’t worry

about the trunk. The beauty of it all is that no matter what

activity is carried out the trunk muscles are always

speciﬁcally exercised.

Internal and external focus in training

CS has evolved over time in response to many of the model’s

limitations described above. Currently, the control of TrA is

attempted in different standing and moving patterns

(O’Sullivan, 2000). Speed of movement, balance and coor-

dination has been introduced to the very basic early elements

of CS. The new models encourage the subjects to ‘‘think

about their core’’ during functional activities. One wonders if

David Beckham thinks about the ‘‘core’’ before a free kick or

Michael Jordan when he slam-dunks or for that matter our

patient who is running after a bus, cooking or during any other

daily activities. How long can they maintain that thought

while multitasking in complex functional activities?

Maybe thinking about the core is not such a good idea for

sports training. When learning movement a person can be

instructed to focus on their technique (called internal focus)

or on the movement goal (called external focus). When

a novice learns a novel movement focusing on technique

(internal focus) could help their learning (Beilock et al.,

2002) For a skilled person, performance improves if training

focuses on tasks outside the body (external focus) but it

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reduces when the focus is on internal processes within the

body (McNevin et al., 2000, 2003). For example, there is

greater accuracy in tennis serves and football shots when the

subjects use external focus rather than internal-focus

strategies (Wulf et al., 2002, 2003). This principle strongly

suggests that internal focus on TrA or any other muscle group

will reduce skilled athletic performance. Interestingly,

tensing the trunk muscle has even been shown to potentially

degrade postural control (Reeves et al., 2006).

What about movement rehabilitation for CLBP patients?

Would internal focus on speciﬁc muscles improve functional

use of trunk muscles? Let’s imagine two scenarios where we

are teaching a patient to lift a weight from the ﬂoor using

a squat position. In the ﬁrst scenario, we can give simple

internal-focus advice such as bend your knees, and bring the

weight close to your body, etc (van Dieen et al., 1999; Kingma

et al., 2004). This type of instruction contains a mixture of

external focusing (e.g. keep the object close to your body

and between your knees) and internal focus about the body

position during lifting. In the second scenario which is akin to

CS training approach, the patient is given the following

instructions: focus on co-contracting the hamstrings and the

quads, gently release the gluteals, let the calf muscles

elongate, while simultaneously shortening the tibialis ante-

rior etc. Such complex internal focusing is the essence of CS

training, but applied to the trunk muscles. It would be next to

impossible for a person to learn simple tasks using such

complicated internal-focus approach.

Economy of movement

The advice given to CS trainees is to continuously tighten

their abdominal and back muscles. This could reduce the

efﬁciency of movement during daily and sports activities.

Our bodies are designed for optimal expenditure of energy

during movement. It is well established that when a novice

learns a new motor skill they tend to use a co-contraction

strategy until they learn to reﬁne their movement (Lay et al.,

2002). Co-contraction is known to be an ‘‘energy waster’’ in

initial motor learning situations. To introduce it to skilled

movement will have a similar ‘‘wasteful’’ effect on the

economy of movement. Minetti (2004) states: ‘‘to improve

locomotion (and motion), mechanical work should be

limited to just the indispensable type and the muscle efﬁ-

ciency be kept close to its maximum. Thus it is important to

avoid: .. using co-contraction (or useless isometric force)’’.

Such energy wastage is likely to occur during excessive

use of trunk muscles as taught in CS. In sporting activity this

would have a detrimental effect on performance. Anderson

(1996) in a study on the economy of running states: ‘‘At

higher levels of competition, it is likely that ‘natural

selection’ tends to eliminate athletes who failed to either

inherit or develop characteristics which favour economy’’.

We can conclude for the evidence that:

CS exercises are in conﬂict with motor learning and

training principles

CS exercises are dissimilar and out of context to normal

physiological movement. This represents the most

ineffective approach to learning motor skills

The internal-focus approach on individual muscles in CS

is likely to degrade motor learning as well as skilled

performance

Additional tensing of trunk muscles during daily activi-

ties or sports are likely to be more energetically taxing

on the body

stlit civlep-orbmuL

roolf eht no decitcarp

gnicarb ro gnisnet eroC

eht no esicrexe noisnetxE

roolf

ralimissiD

txetnoc fo tuo

klaW ni gnicarb ro gnisnet eroC

gniklaw

.gnisirprus mees yam siht(

However, as long as the person is

gnicitcarp era yeht gniklaw

ralimissid ehT .gniklaw

sa tnadnuder si tnemevom

)gninrael rotom sa raf

gnivom roolf eht no gniyaL

ekil-gniklaw a ni sgel htob

nrettap

gnirud lortnoc knurT

gniklaw

ralimiS

txetnoc nihtiw

ralimissiD

txetnoc nihtiw

ralimiS

txetnoc fo tuo

:gnitatilibaheR

Highly transferable

Least transferable

Figure 3 Similarity and context principle. Training and practice of movement can be dissimilar and out of context, similar but out

of context, dissimilar within context or similar and within context. Ideal neuromuscular organisation to movement occurs when the

movement is in similar patterns to the goal movement and practiced in context of the particular movement. Most CS training

regimes contain movement patterns that are dissimilar and out of context to the trunk patterns used during normal activities.

Adapted from Lederman E, Neuromuscular rehabilitation in manual and physical therapy, to be published 2010. London, Elsevier.

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CS in prevention of injury and

therapeutic value

Therapist and trainers have been exalting the virtues of CS

as an approach for improving sports performance (Kibler

et al., 2006), preventing injury and as the solution to lower

back pain. No matter what the underlying cause for the

complaint CS was going to save the day. However, these

claims are not supported by clinical studies:

Abdominal/stability exercise as

prevention of back pain

In one study, asymptomatic subjects (nZ402) were given

back education or back education þabdominal strength-

ening exercise (Helewa et al., 1999). They were monitored

for lower back pain for one year and the number of back

pain episodes were recorded. No signiﬁcant differences

were found between the two groups. There was a curious

aspect to this study, which is important to the strength

issue in CS. This study was carried out on asymptomatic

subjects who were identiﬁed as having weak abdominal

muscles. Four hundred individuals with weak abdominal

muscles and no back pain!

Another large-scale study examined the inﬂuence of

a core-strengthening programme on low back pain (LBP) in

collegiate athletes (nZ257). In this study too, there were

no signiﬁcant advantage of core strengthening in reducing

LBP occurrence (Nadler et al., 2002).

CS a treatment for recurrent LBP and CLBP

At ﬁrst glance, studies of CS exercise for the treatment of

recurrent LBP look promising esigniﬁcant improvements

can be demonstrated when compared to other forms of

therapy (O’Sullivan et al., 1997a,b; Hides et al., 2001;

Moseley, 2002; Rasmussen-Barr et al., 2003; Niemisto et al.,

2003; Stuge et al., 2004; Goldby et al., 2006). Indeed,

systematic reviews found stabilisation exercise to be better

than general practitioner care, but not from any other form

of physical therapy (Rackwitz et al., 2006; Ferreira et al.,

2006; Macedo et al., 2009).

However is could be argued that none of these studies

actually showed a relationship between improvement in

LBP and spinal stabilisation or core control. In all the

studies there was no attempt to effectively identify

patients who had timing or other control issues or had

underlying instability. There was no attempt to evaluate

how well the subjects learned CS manoeuvres and whether

they were able to maintain that learning throughout the

duration of the studies. Furthermore, there was no attempt

to evaluate if there is a correlation between improvement

of the condition and the recovery of stabilisation. It should

also be noted that many of these studies did not have

a control group. This means that although CS training may

be better when compared to another form of therapy, we

still don’t know if it is any better than a placebo/sham

treatment.

An interesting trend emerges when CS exercise are

compared to general exercise (Table 2). Both exercise

approaches are demonstrated to be equally effective

(Ariyoshi et al., 1999; van der Velde and Mierau, 2000;

Franke et al., 2000; Reeves, 2006; Nilsson-Wikmar et al.,

2005; Koumantakis et al., 2005; Cairns et al., 2006).

Systematic reviews repeat this message (van Tulder et al.,

2000; Abenhaim et al., 2000; Hurwitz et al., 2005).

These studies strongly suggest that improvements are due

to the positive effects that physical exercise may have on the

patient rather than on improvements in spinal stability (it is

known that general exercise can also improve CLBP)

(Ariyoshi et al., 1999; van der Velde and Mierau, 2000).

So why give the patient complex exercise regimes that

will both be expensive and difﬁcult to maintain? Perhaps

our patients should be encouraged to maintain their own

preferred exercise regime or provide them with exercises

that they are more likely to enjoy. This of course could

include CS exercise. But the patient should be informed

that it is only as effective as any other exercise.

We can thus conclude:

That CS exercise may better than general medical care

(which is not difﬁcult to achieve)

CS exercise is no better than other forms of manual or

physical therapy or general exercise

Find out what exercise the patient enjoys and add it to

the management plan.

CS in relation to aetiology of back pain

Why has CS not performed better than any other exercise? In

part, due to all the issues that have been discussed above.

More importantly, in the last decade our understanding of

the aetiology of back pain has dramatically changed.

Psychological and psychosocial factors have become

important risk and prognostic factors for recurrent back pain

and the transition of acute to chronic pain states

(Hasenbring et al., 2001). Genetic factors (MacGregor et al.,

2004) and behavioural/‘‘use of body’’ are also known to be

contributing factors. Localised, structural factors such as

trunk/spinal asymmetries, have been reduced in their

importance as contributing factors to back pain (Dieck,

1985; Nadler, 1998; Franklin and Conner-Kerr, 1998; Levan-

gie, 1999; Fann, 2002; Norton, 2004; Poussa, 2005; Reeves,

2006; Mitchell et al., 2008). This shift in understanding LBP

would include stability issues which are an extension of

a biomechanical model.

It is difﬁcult to imagine how improving biomechanical

factors such as spinal stabilisation can play a role in

reducing back pain when there are such evident biopsy-

chosocial factors associated with LBP conditions. Even in

the behavioural/biomechanical spheres of spinal pain it is

difﬁcult to imagine how CS can act as prevention or cure.

This can be clariﬁed by grouping potential causes for back

injury into two broad categories:

Behavioural group: individuals who use their back in

ways that exert excessive loads on their spine, such as

bending to lift (Gallagher et al., 2005) or repetitive

sports activities (Fairclough et al., 1986; Renstro

¨m,

1996; Reid and McNair, 2000).

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Bad luck group: individuals who had suffered a back

injury from sudden unexpected events, such as falls or

sporting injuries (Fairclough et al., 1986).

In the behavioural group, bending and lifting is associ-

ated with a low level increase in abdominal muscle

activity, which contributes to further spinal compression

(de Looze et al., 1999). In patients with CLBP lifting is

associated with higher levels of trunk co-contraction and

spinal loading (Marras et al., 2005). Any further tensing of

the abdominal muscles may lead to additional spinal

compression. Since the spinal compression in lifting

Table 2 CS studies, description of study, CS compared to other therapeutic modalities and outcome.

Description of

condition

CS compared to Result Notes

O’Sullivan

et al., 1997a,b

CLBP (spondylolysis/

spondylolisthesis)

General exercise

consisted of swimming,

walking and gym

work þpain relief

including heat

application, massage

and ultrasound

CS better General exercises were

not of the

same duration as CS

exercise.The pain

relief methods chosen

are known to have

little effect on

back pain

Hides et al., 2001 First episode LBP General practitioner

care þmedication

CS better

Moseley, 2002 CLBP CS þMT compared to

medical management

CS/MT better than

medical care

We still don’t know if

CS is better because it

was combined

with MT

Rasmussen-Barr

et al., 2003

CLBP Manual therapy

(muscle stretching,

segmental traction,

soft tissue and facet

mobilisation

CS better in the short

term but not long-term

The duration of MT was

shorter than the CS

exercise

Stuge et al., 2004 LBP in pregnancy Physical therapy CS better

Niemisto et al., 2003 LBP CS þMT þphysician

care compared to:

physician care

CS/MT better We still don’t know if

CS is better because it

was combined

with MT

Goldby et al., 2006 CLBP Back education and MT CS >MT >education Generally considered

to be poor quality

study

Bastiaenen

et al., 2006

LBP postpartum Cognitive-behavioural

therapy (CBT)

CBT better

Nilsson-Wikmar

et al., 2005

LBP in pregnancy General exercise Same

Franke et al., 2000 CLBP General exercise Same

Koumantakis

et al., 2005

Sub-acute or CLBP General exercise General exercise

slightly

better

Cairns et al., 2006 Recurrent LBP Exercise þMT Same

Ferreira et al., 2007 CLBP CS þCBT compared to:

1. General exer-

cise þCBT þstretching

and strengthening all

main muscles groups in

body, þcardiovascular

exercise

2. Spinal manipulation

(SM)

SM and CS same

outcome but slightly

better than general

exercise in the short

but not long term

Other studiers suggest

that CS is better than

MT..

Critchley et al., 2007

1. MT

2. Pain

management þCBT

3. General exercise

No difference

between the groups

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approaches the margins of safety of the spine, these

seemingly small differences are not irrelevant (Biggemann

et al., 1988). It is therefore difﬁcult to imagine how CS can

offer any additional protection to the lumbar spine during

these activities.

Often in CS advice is given to patients to brace their core

muscle while sitting to reduce or prevent back pain.

Although sitting is not regarded as a predisposing factor for

LBP (Hartvigsen et al., 2002), some patients with existing

back pain ﬁnd that standing relieves the back pain of

sitting. This phenomenon has been shown in CLBP patients

who during sitting exhibit marked anterior loss of disc space

in ﬂexion or segmental instability (Maigne et al., 2003).

Sitting, however, is associated with increased activity of

abdominal muscles (when compared to standing) (Snijders

et al., 1995). Increasing the co-contraction activity of the

anterior and back muscles is unlikely to offer any further

protection for patients with disc narrowing/pathology.

Conversely, it may result in greater spinal compression. It is

unknown whether core tensing can impede the movement

of the unstable segments during sitting. This seems unlikely

because even in healthy individuals creep deformation of

spinal structures will eventually take place during sitting

(Hedman and Fernie, 1997). The creep response is likely to

be increased by further co-contraction of trunk muscles.

In the bad luck group, CS will have very little inﬂuence

on the outcome of sudden unexpected trauma. Most

injuries occur within a fraction of a second, before the

nervous system manages to organise itself to protect the

back. Often injuries are associated with factors such as

fatigue (Gabbett, 2004) and overtraining (Smith, 2004).

These factors when combined with sudden, unexpected

high velocity movement are often the cause of injury

(Fairclough et al., 1986). It is difﬁcult to see the beneﬁt of

strong TrA, abdominals or maintaining a constant contrac-

tion in these muscles in injury prevention.

Potential damage with CS?

Continuous and abnormal patterns of use of the trunk

muscles could also be a source of potential damage for spinal

or pelvic pain conditions. It is known that when trunk muscles

contract they exert a compressive force on the lumbar spine

(van Dieen et al., 2003a,b) and that CLBP patients tend to

increase their co-contraction force during movement (Chol-

ewicki et al., 1997). This results in further increases of spinal

compression (Marras et al., 2005; Brown et al., 2006).

Another recent study examined the effects of abdominal

stabilisation manoeuvres on the control of spine motion and

stability against sudden trunk perturbations (Vera-Garcia

et al., 2007). The abdominal stabilisation manoeuvres were

eabdominal hollowing, abdominal bracing and a ‘‘natural’’

strategy. Abdominal hollowing was the most ineffective and

did not increase stability. Abdominal bracing did improve

stability but came at a cost of increasing spinal compression.

The natural strategy group seems to employ the best strategy

eideal stability without excessive spinal compression.

An increase in intra-abdominal pressure could be

a further complication of tensing the trunk muscle (Cress-

well et al., 1994a,b). It has been estimated that in patients

with pelvic girdle pain, increased intra-abdominal pressure

could exert potentially damaging forces on various pelvic

ligaments (Mens et al., 2006).

Maybe our patients should be encouraged to relax their

trunk muscle rather than hold them rigid? In a study of the

effects of psychological stress during lifting it was found

that mental processing/stress had a large impact on the

spine. It resulted in an increase in spinal compression

associated with increases in trunk muscle co-contraction

and less controlled movements (Davis et al., 2002).

Psychological factors such as catastrophising and soma-

tisation are often observed in patients suffering from CLBP.

One wonders if CS training colludes with these factors,

encouraging excessive focusing on back pain and

re-enforcing the patient’s notion that there is something

seriously wrong with their back. Perhaps we should be

shifting the patient’s focus away from their back. (I often

stop patients doing speciﬁc back exercise).

Furthermore, CS training may shift the therapeutic focus

away from the real issues that maintain the patient in their

chronic state. It offers a simplistic solution to a condition

that may involve complex biopsychosocial factors. The

issues that underline the patient’s condition may be

neglected, with the patient remaining uninformed about

the real causes of their condition. Under such circumstance

CS training may promote chronicity.

Conclusion

Weak trunk muscles, weak abdominals and imbalances

between trunk muscles groups are not a pathology just

a normal variation.

The division of the trunk into core and global muscle

system is a reductionist fantasy, which serves only to

promote CS.

Weak or dysfunctional abdominal muscles will not lead

to back pain.

Tensing the trunk muscles is unlikely to provide any

protection against back pain or reduce the recurrence

of back pain.

Core stability exercises are no more effective than, and

will not prevent injury more than, any other forms of

exercise or physical therapy.

Core stability exercises are no better than other forms

of exercise in reducing chronic lower back pain. Any

therapeutic inﬂuence is related to the exercise effects

rather than stability issues.

There may be potential danger of damaging the spine

with continuous tensing of the trunk muscles during

daily and sports activities.

Patients who have been trained to use complex

abdominal hollowing and bracing manoeuvres should be

discouraged from using them.

Epilogue

Many of the issues raised in this article were known well

before the emergence of CS training. It is surprising that the

researchers and proponents of this method ignored such

important issues. Despite a decade of extensive research in

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this area, it is difﬁcult to see what contribution CS had to the

understanding and care of patients suffering from back pain.

Acknowledgement

I would like to thank Prof. Jaap H. van Diee

¨n, for his kind

help in writing this article.

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ARTICLE IN PRESS

The myth of core stability 15

+MODEL

Please cite this article in press as: Lederman, E., The myth of core stability, Journal of Bodywork & Movement Therapies (2009),

doi:10.1016/j.jbmt.2009.08.001

Effect of an 11-Week Repeated Maximal Lumbar Movement with Controlled Breathing on Lumbar Sagittal Range of Motion in Elite Swimmers: A Randomized Clinical Trial

Article

Full-text available

Feb 2025

Lumbar range of motion (ROM) is essential to develop effective movements during the underwater undulatory swimming technique. Core exercises are used to improve the strength of the muscles that participate in that technique, and variations in sensory input and attentional focus may modulate neuromuscular responses and impact training outcomes. The aim of this study was to investigate the impact of an 11-week program of repeated maximal lumbar movements with closed eyes and without focused attention on lumbar sagittal ROM in elite swimmers versus executing them solely with proper exercise technique with controlled breathing. Methods: A sample of 57 professional swimmers, including 34 males (20.2 ± 4.2 years) and 23 females (20.7 ± 3.3 yrs), volunteered to complete this study. They were randomly divided into two experimental groups (EG1 and EG2) and one control group (CG). All subjects underwent the same type of training program in parallel with the EG intervention. EG1 and EG2 performed three sets of ten repetitions of lumbar flexion and extension exercises at breathing pace, 6 days a week for 11 weeks. EG1 performed the core workout with closed eyes and focused attention on the lumbar movement, while EG2 only followed the technique of the exercises at a controlled breathing pace. Lumbar flexion (F), extension (E), and total ROM (TROM) were assessed by an electrogoniometer in a seated, relaxed position over a Swiss ball. Results: Repeated measures ANOVA showed significant differences in the multivariate profiles across groups and over time. F (8, 48) = 3.495, p = 0.002. EG1 had non-significant increases in lumbar ROM, EG2 had significant increases in TROM and extension ROM, and CG had no changes. Conclusions: The results suggest that repeating maximal lumbar movement at a controlled breathing pace, with opened eyes and non-focusing attention on the movement, increases lumbar ROM in the sagittal plane.

Effect of core stability exercises and Russian electrical stimulation in non specific low back pain(Narrative Review)

Article

Apr 2025

kitap merged

Book

Jan 2018

Süleyman Bilgin

The comparison of core training programme that is carried out for 8 weeks to the young footbal- lers and volleyball players, with the physichal conditions and parameters of performance The aim of this study was to plan the physical condition and performance parameters of the core training program for young male footballers and volleyballers for 8 weeks. Twenty male soccer players (the mean age 15,40±0,82, mean leght 1,70±0,06 m, mean body weight 59,85±5,00 kg) who play football at Pursaklar Municipality Sports Club with 14 male volleyball players (the mean age 15±00, mean leght 1,86±0,06 m, mean body weight 73,57±7,24 kg) who play volleyball at Halk- bank Volleyball Clup were included in study on a voluntary basis. Before the trainings, pre-test sco- res ( speed 10-20m, sit-up 30 sn, 20 m shuttle run, vertical jump, core stabilization and prone bridge ) were recorded. İn addition to the normal training of both groups, the core training was applied for 8 weeks including the first 6 weeks (3 days / week) and the last 2 weeks (2 days / week). At the end of the training, the final test measurements of the groups were taken in accordance with the proto- col. The data obtained were evaluated using the IBM SPSS Statistics 22.0 statistical program. Ac- cording to statistical process result, there was a significant increase in performance tests of football and volleyball players. There was a significant difference in anaerobic power performance values only for football players. While there was a significant increase in the final measurement values of prone bridge, trunk flexion and trunk extensions of both groups, there was no significant difference in letheral flexion test in volleyballs. When performance and core stabilization tests of football and volleyball players were compared, the performance values showed a significant difference, but this difference was not observed in trunk flexion test (p<0.05). As a result, it was observed that the 8 week core training sessions that will be applied in addition to football and volleyball training have contributed to the performance improvement of young pla- yers and volleyball players such as strength, speed and endurance. It is considered that the inclusion to training of the young players will improve the performance of the athleticks positively.

Les unes qui font les titres!

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Gaëlle Jungo

Techniques de rééducation abdominale et spinale et du contrôle sensorimoteur pour le patient souffrant de lombalgie chronique

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Evaluation of the Performance of Blueback Physio ® Medical Device in the Management of Patients Suffering from Chronic Low Back Pain: Randomized Clinical Trial

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The Effect Of CX WORX Exercises On Postural And Functional Stability And Specific Skill In Basketball Players With Trunk Defects

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Full-text available

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Activité physique et lombalgies

Chapter

Full-text available

Oct 2013

Yannick Tousignant-Laflamme

Abdominal Drawing-In Maneuver is Less Effective for Core Stability During High Load Tasks: A Systematic Review

Article

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Julio Cesar Aragón Salamanca

Context: The abdominal drawing-in maneuver (ADIM) is a technique commonly used to activate deep core muscles for the prevention and rehabilitation of low back pain. However, its benefits during high-load tasks (HLT) are unclear. Objectives: The primary objective of this article is to review the literature to determine whether the use of ADIM enhances core stabilization during HLT. Additionally, we will examine if other factors, beyond load, could influence the effectiveness of this activation maneuver. Methods: A search was conducted using PubMed databases for studies that compared interventions using ADIM to those without ADIM. The literature search spanned from January 1981 to March 2024. Only studies that included kinematic assessments were selected. Results: The search yielded 359 studies, of which 24 were included in the final analysis. Task load was analyzed based on Mottram and Comerford's criteria, alongside other approaches such as the source of the perturbation applied to the subject and body position. In conditions using ADIM, better performance was observed in only 16.66% of interventions with HLT, whereas other conditions (OC) without ADIM performed better in 83.33% of interventions using HLT. When core stability was tested against external perturbations, ADIM was less effective in all scenarios. In lying positions, ADIM performed better in 4 tasks, while OC performed better in 2. In upright positions, ADIM was more effective in 7 tasks, while OC performed better in 6. Conclusions: The findings suggest that ADIM should not be used if the goal is to train core stability and strength during HLT. Abdominal drawing-in maneuver was less effective for stabilizing the core during tasks involving external perturbations, and its use was also less effective in upright positions.

Identification of Abdominal Muscle Co-Contraction Patterns in Motion From sEMG for Physiotherapy Rehabilitation: A Pilot Study

Article

Oct 2024

Current technologies are unable to identify the simultaneous contraction of deep and superficialmuscles when the subject is in motion. In this contribution, we propose a method to identify the co-contraction patterns of four muscles of the abdominal wall, namely the rectus abdominis, obliquus externus, obliquus internus and transversus abdominis, with only two pairs of surface electrodes. Surface electromyography (EMG) signals are acquired from two bipolar leads placed on the lower abdomen of the volunteers. Following the extraction of features, a principal component analysis is conducted to optimize the data representation, and a random forest classifier is employed to classify the co-contraction patterns. Our method achieves up to 86.30% accuracy, which demonstrates the possibility of identifying fourteen co-contraction patterns of four different muscles of the abdominal wall, either surface or deep muscles. Conclusion: This method does not need to be adapted to a new patient, which is better suited to the physiotherapists’s practice. Moreover, it opens a field of research regarding the role of deep muscles in motion either during exercises or daily life tasks as well as in pathologies with complex etiology. EMG research will benefit from this method, which provides a better understanding of muscle co-contractions, but also reduces the number of sensors needed to acquire relevant information, while remaining non-invasive. The clinical interest lies in the improvement of the physiotherapeutic management. Indeed, a better knowledge of the patient’s co-contractions patterns makes it easier to adapt the physiotherapist’s treatment plan to the patient’s needs.

The Biology and Anatomy of Inguinofemoral Hernia

Article

Full-text available

Jun 1994

The purpose of this article is to discuss the biology of hernia and covers such features as the male predominance of hernia, the causal significance of a patent processus vaginalis, the effect of the shape of the skeleton on liability to the development of hernia, and the alterations in collagen structure and metabolism that may be involved in the genesis of hernia. In addition, the influence of such factors as peritoneal dialysis, appendectomy, and pregnancy are reviewed. The anatomy of the groin is outlined in detail. The lower abdominal region is a layered structure; the defect in musculoaponeurotic continuity that leads to a hernia exists only in the transversus abdominis layer. The external oblique and internal oblique layers are not primarily involved in the genesis of hernia. The major structures within the transversus abdominis layer are described and illustrated including the deep inguinal ring, iliopubic tract, transversus abdominis arch, femoral sheath, and Cooper's ligament. The structure of the inguinal canal and spermatic cord, and the continuities of investing fascia from the abdominal wall to the spermatic cord are also described in detail. The essential features of anatomic repair of groin hernias are reviewed. Anatomic repairs are always conducted within the transversus abdominis lamina. The structures that need to be apposed in primary repair are specified.

Effectiveness and cost-effectiveness of three types of active physiotherapy used to reduce chronic low-back pain disability: A pragmatic randomised trial with economic evaluation

Conference Paper

Apr 2006

Lumbar muscle fatigue and chronic lower back pain

Article

Sep 1989

There currently is a clinical need for an objective technique to assess muscle dysfunction associated with chronic lower back pain. A Back Analysis System for objectively measuring local fatigue in the back extensor muscles is presented. The reliability and validity of this technique was evaluated by testing chronic low-back pain patients and control subjects without back pain. Concurrent surface electromyograms (EMG) were detected from multiple back muscles during sustained isometric contractions at different force levels of trunk extension. Median frequency parameters of the EMG power density spectrum were monitored to quantify localized muscle fatigue. Results indicated: 1) high reliability estimates for repeated trials; 2) significant differences (P less than 0.05) in median frequency parameters between lower back pain patients and control subjects for specific combinations of contractile force level and muscle site tested; 3) Median Frequency parameters correctly classified lower back pain and control subjects using a two-group discriminant analysis procedure. The applicability of this technique as a treatment outcome measure and diagnostic screening method for lower back pain patients is discussed.

The Role of Activity in the Therapeutic Management of Back Pain

Article

Feb 2000

Body Weight and Low Back Pain

Article

Jan 2000

Charlotte Leboeuf-Yde

Study Design. A systematic review of the epidemiologic literature. Objective. To establish if body weight is truly associated with low back pain (LBP) and whether the link may be causal. Summary of Background Data. Because obesity and LBP are prevalent in western society, it is of interest to establish whether obesity can induce LBP. Methods. Fifty-six original research reports, reporting on 65 studies published between 1965 and 1997, were systematically reviewed for the frequency of positive associations between body weight and LBP. In addition, the presence of positive findings was examined in relation to several study characteristics. Based on these results, only studies emanating from the general population with a sample size exceeding 3000 were included in the additional search for causality using some of the classical Bradford–Hill criteria. The review was carried out by the author, blindly at 2 months’ interval. Results. Thirty-two percent of all the studies report a statistically significant positive weak association between body weight and LBP. Studies that fulfilled the post hoc criteria never report a rate ratio above 2, but there is possibly a positive biological gradient. These studies had no information on temporality or reversibility and there was no obvious consistency of findings. Conclusions. Due to lack of evidence, body weight should be considered a possible weak risk indicator, but there is insufficient data to assess if it is a true cause of LBP. Low back pain (LBP) is a common yet elusive disorder. It cannot be comfortably diagnosed through clinical procedures and little is understood about its etiology. 11,14 From a public health perspective, it would be important to know if lifestyle factors, such as body weight, play an important role in its genesis. However, a look at the literature reveals some confusion. There are several hypotheses relating to a link between obesity and LBP. Increased mechanical demands resulting from obesity have been suspected of causing LBP through excessive wear and tear, 2,4,5,6,9,12,15 and it has been suggested that metabolic factors associated with obesity may be detrimental. 2 Thus some consider it a possible, but not particularly strong, contributing factor of LBP, 13 whereas others do not think that it is a risk factor of LBP. 7,10 It has also been postulated that obesity may be a marker 6 or a confounder 2,5 for some other factor that is a true cause of LBP. A systematic literature review seemed warranted to appraise this area.

Low Back Pain in College Athletes

Article

Apr 1998

Study Design. A prospective evaluation of the incidence of low back pain in college athletes was under‐taken. Objectives. To evaluate prospectively leg length discrepancy, hip flexor tightness, and lower extremity acquired laxity or overuse as predictive factors for low back pain in college athletes. Summary of Background Data. A pilot study found an association between low back pain and the factors to be studied. Several allusions to the kinetic chain theory appear in the literature, but little prospective research has been done in examining the effects of lower extremity involvement on the back. Methods. Two‐hundred fifty‐seven college athletes representing nine varsity sports were screened during a preseason sports physical examination. Measures of flexibility, ligamentous stability, leg length discrepancy, and overuse syndromes were recorded. Athletes were observed throughout the ensuing year for low back pain requiring treatment by the athletic trainer. Those athletes with low back pain as the result of direct trauma to the region were excluded from the data. Results. Twenty‐four athletes (9.3%) received treatment for low back pain. Thirteen of 87 women (15%) compared with 11 of 170 men (6%) required treatment for low back pain (P = 0.048). Of 57 athletes with lower extremity acquired laxity or overuse, low back pain developed in 14 (P < 0.001). Conclusions. Athletes with lower extremity acquired ligamentous laxity or overuse may be at risk for the development of noncontact low back pain during athletic competition. Female athletes with lower extremity involvement appeared to have a higher incidence of low back pain treatment compared with their male counter‐parts. Inflexibility of the lower extremities or leg length discrepancy were not associated with future low back pain treatment.

The Impact of Mental Processing and Pacing on Spine Loading

Article

Dec 2002

Study Design. The impact of various levels of mental processing and pacing (during lifting) on spine loading was monitored under laboratory conditions. Objectives. To explore how mental demands and pacing influence the biomechanical response and subsequent spine loading and, to determine whether individual characteristics have a modifying role in the responses. Summary of Background Data. Modern work often requires rapid physical exertions along with demands of mental processing (both psychosocial stressors). While the effect of physical workplace factors on spine loading has been widely documented, few studies have investigated the impact that interaction of psychosocial factors and individual factors has on spine loads. Methods. For this study, 60 subjects lifted boxes while completing two types of mental processing tasks: 1) series tasks with decisions occurring before the act of lifting, and 2) simultaneous tasks with decisions occurring concurrently with the lift. For both of these mental processing conditions, two intensities of mental load were evaluated: simple and complex. Task pacing was also adjusted under slow and fast conditions. Finally, individual characteristics (personality and gender) were evaluated as potential modifiers. An electromyographically assisted model evaluated the three-dimensional spine loads under the experimental conditions. Results. Simultaneous mental processing had the largest impact on the spine loads, with the complex intensity resulting in increases of 160 N with lateral shear, 80 N with anteroposterior shear, and 700 N with compression. Increased task pace produced greater lateral shear (by 20 N), anteroposterior shear (by 60 N), and compression loads (by 410 N). Gender and personality also influenced loadings by as much as 17%. Conclusions. Mental processing stress acted as a catalyst for the biomechanical responses, leading to intensified spine loading. Mental stress appeared to occur as a function of time pressures on task performance and resulted in less controlled movements and increases in trunk muscle coactivation. These adjustments significantly increased spine loading. These results suggest a potential mechanism for the increase in low back pain risk resulting from psychosocial stress caused by modern work demands.

Inefficient Muscular Stabilization of the Lumbar Spine Associated With Low Back Pain

Article

Nov 1996

Study Design: The contribution of transversus abdominis to spinal stabilization was evaluated indirectly in people with and without low back pain using an experimental model identifying the coordination of trunk muscles in response to a disturbance to the spine produced by arm movement. Objectives: To evaluate the temporal sequence of trunk muscle activity associated with arm movement, and to determine if dysfunction of this parameter was present in patients with low back pain. Summary of Background Data: Few studies have evaluated the motor control of trunk muscles or the potential for dysfunction of this system in patients with low back pain. Evaluation of the response of trunk muscles to limb movement provides a suitable model to evaluate this system. Recent evidence indicates that this evaluation should include transversus abdominis. Methods: While standing, 15 patients with low back pain and 15 matched control subjects performed rapid shoulder flexion, abduction, and extension in response to a visual stimulus. Electromyographic activity of the abdominal muscles, lumbar multifidus, and the contralateral deltoid was evaluated using fine‐wire and surface electrodes. Results: Movement in each direction resulted in contraction of trunk muscles before or shortly after the deltoid in control subjects. The transversus abdominis was invariably the first muscle active and was not influenced by movement direction, supporting the hypothesized role of this muscle in spinal stiffness generation. Contraction of transversus abdominis was significantly delayed in patients with low back pain with all movements. Isolated differences were noted in the other muscles. Conclusions: The delayed onset of contraction of transversus abdominis indicates a deficit of motor control and is hypothesized to result in inefficient muscular stabilization of the spine.

Article

Mar 2002

Study Design. A cross-sectional case–control study. Objectives. To examine the effect of fatigue on torque output as well as electromyographic frequency and amplitude values of trunk muscles during isometric axial rotation exertion in back pain patients and to compare the results with a matched control group. Summary of Background Data. Back pain patients exhibited different activation strategies in trunk muscles during the axial rotation exertions. Fatigue changes of abdominal and back muscles during axial rotation exertion have not been examined in patients with back pain. Methods. Twelve back pain patients and 12 matched controls performed isometric fatiguing axial rotation to both sides at 80% maximum voluntary contraction in a standing position. During the fatiguing exertion, electromyographic changes of rectus abdominis, external oblique, internal oblique, latissimus dorsi, iliocostalis lumborum, and multifidus were recorded bilaterally. The primary torque in the transverse plane and the coupling torques in sagittal and coronal planes were also measured. Results. No difference in the endurance capacity was found between back pain and control groups. At the initial period of the exertion, back pain patients demonstrated a statistical trend (P = 0.058) of greater sagittal coupling torque as well as lower activity of rectus abdominis and multifidus and higher activity in external oblique. During the fatigue process similar changes of coupling torque were demonstrated in both sagittal and coronal planes, but a smaller fatigue rate for right external oblique, increase in median frequency for latissimus dorsi, and lesser increase in activity for back muscles were found in the back pain group compared with the control group. Conclusions. Alterations in electromyographic activation and fatigue rates of abdominal and back muscles demonstrated during the fatigue process provide insights into the muscle dysfunctions in back pain and may help clinicians to devise more rational treatment strategies.

Motor Control and Learning: A Behavioral Emphasis

Book

Jan 1999

The Myth of Core Stability

Abstract

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