WHAT CAUSES BACK PAIN?
Around 80% of people will suffer back pain at some time during their life. In fact, back pain is so common that it’s often described as a normal part of being human. Of course, when you have back pain it feels far from normal; but with the right approach to activity and acute care treatment, it is usually short-lived. What’s not normal is for back pain to continue and become a chronic issue.
There has been a huge amount of research into back pain. And what we now know is challenging a lot of the common beliefs about how we get back pain and how we recover well.
WHAT IS ‘THE CORE’?
One of the most popular ideas in physical medicine over the past 20 years has been the ‘core stability model’ of back pain, which describes back pain as a problem of weakness of the abdominal muscles, and that recovery depends completely on making them strong again.
The core muscles refer to the ring of muscles around your trunk and abdomen that support and move the spinal column; primarily the rectus and transverse abdominis muscles, and the internal and external oblique muscles. The abdominal group is central to controlling spinal and pelvic positioning during movement.
The idea that core strengthening can both prevent the onset of lower back pain as well as reduce existing pain has become so popular and engrained that many people we see for low back pain have already diagnosed themselves as having a ‘weak core’.
This idea makes sense intuitively, but scientific research into the relationship between core muscles and back pain has been surprising.
IS THERE A RELATIONSHIP BETWEEN CORE STRENGTH & BACK PAIN?
All of the core muscles work together with other muscles in very specific ways in response to signals from your nervous system. However, none of these muscles operate independently of the others. The isolation of a particular core muscle, as is often taught as part of core strengthening programs, rarely occurs during normal movement. It has also been demonstrated that even after weeks of training specific core muscle activation patterns people quickly revert to instinctive movement patterns during complex daily movements.1
Walking, sitting, bending and turning actually require surprisingly little effort from your core muscles. For example, studies measuring muscle activity during normal walking activity indicate that rectus abdominis muscle (your six-pack) expends only 2% of its maximal voluntary contraction. The external oblique muscles use only about 5%.2 This suggests that even quite weak core muscles can handle everyday movements with strength to spare. Of course, we need working muscles to move well, and they need to be strong enough to tolerate whatever activity we want to do, but do people with super-strong core muscles still get back pain? – Yes, they do!
The idea that specific strengthening of core muscles is necessary for a healthy back has been challenged in many research studies. General exercise programs can be equally effective in improving both core muscle activation patterns and pain symptoms when compared with specific core strengthening exercises.3
A 2014 research review of all clinical trials looking at the effectiveness of core stabilisation for low back pain found consistent and compelling evidence that core stabilisation exercises provide no greater relief of lower back pain than any other types of exercises.4
There is strong evidence stabilisation exercises are not more effective than any other form of active exercise in the long term.
Core strengthening is not proven to prevent the onset of lower back pain or reduce further flare-ups, either. In a study of 4325 soldiers, researchers found that education to help reduce the sense of fear and threat that can come with the idea that the spine is weak or damaged was more effective at preventing back pain episodes than core exercise.5
The current research evidence tells us that the causes of back pain are far more complex than simply your muscle strength. General health, psychological, social, work, and behavioral issues, as well as genetics all significantly influence back pain, too. Clearly, core stabilisation does not address these factors.
DOES THAT MEAN I DON’T REALLY NEED TO EXERCISE?
No, it doesn’t mean that.
The preferred method for treating back pain used to be bed rest. If you have ever tried it, you know that it can actually worsen the problem. Limiting movement is now well known to increase the likelihood that back pain will become chronic.
Taking a whole body approach to daily movement, mobility and light exercise is typically more effective for most people with back pain than trying to strengthen a specific muscle group. And very short sessions of movement or exercises regularly can be a good way to avoid additional strain and maintain good blood flow around healing tissues.
Many chronic back pain disorders are associated with excessive trunk muscle contraction and the inability to relax the core muscles (often due to habitual fear of movement, anxiety and negative beliefs about how the spine works). Relaxed back muscles are often more important than strong ones. Gentle stretches and flexibility exercises keep your back and core muscles limber and your back relaxed. Slow gradual stretching, encouraging stressed muscles to incrementally relax and soften, helps free up your movement so your back can function more naturally.
So, we know that movement is good, but exercises that focus on core strengthening have no special power to alleviate or prevent back pain. And for some kinds of back pain, certain core exercises can aggravate your pain in the short term. When back pain is bad, most patients don’t need their movement regimented by highly specific core control exercise. In fact, what they need is permission and guidance to move in a creative way that helps ease discomfort and builds their self-confidence.
Once your pain has resolved, it’s a great idea to condition your back to be able to tolerate dynamic activity. If you love Pilates, fantastic! Keep doing it. Or, do yoga, or swimming, or Barre, or dance, or F45, or powerlifting. Probably the most important thing is that you enjoy your exercise, otherwise you won’t be consistent long-term.
If you don’t enjoy any exercise yet, you’ll have to learn to enjoy something. 🙂 Of course, if you are experiencing a new episode of back pain, be sure to consult with your osteopath before starting an exercise regimen that could potentially aggravate it.
PS: If you want to know if your core muscles are functioning, see if you can blow up a packet of balloons.
References:
1. The Myth of Core Stability
2. Abdominal and erector spinae muscle activity during gait: the use of cluster analysis to identify patterns of activity.
3. Altered postural responses persist following physical therapy of general versus specific trunk exercises in people with low back pain
4. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis
5. Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military (POLM) cluster randomized trial
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