What Should You Do For The Best When You Exercise?!

Last week I asked whether we should do core muscle exercises or not.

I said that in my opinion, you should.

The two different types of muscle we possess perform different activities and it has long been thought that if we can isolate the core muscles, we should in an attempt to prevent or reduce low back pain from recurring.

Really it is only since the 1990’s that core stability has been thought to be important in aiding recovery and preventing recurrence of low back pain.

Indeed any back or neck pain was thought to benefit from having a strong core to work from.  If you reach for something or throw a ball, the idea was that if you have weak deep core muscles as I explained last week, you may not have enough tonic muscle strength to avoid the joints or ligaments or discs in your spine being over stretched. If you perform the movement to make a huge throw you can overload the tissues immediately or if you keep repeating the movement with poorly stabilised joints, the same injury can occur over a longer period when the ‘last straw’ is reached.

That one big throw!

You throw; the deep muscles don’t protect the joint enough and you effectively ‘sprain’ the joint or tear a disc or ligament and pain ensues.

Core Stability Theory Explained

In reality, we need ALL of our muscles to function optimally in order to reduce the likelihood of developing musculoskeletal pain.

However, it has been questioned recently whether there is a gap between the theory and the actual mechanism of why we need and if we need core stability, however feasible it may seem.

Hides et al published a paper in Australia in 2001 entitled  “Long-Term Effects of Specific Stabilising Exercises for First-Episode Low Back Pain” that concluded “Long term results suggest that specific exercise therapy in addition to medical management and resumption of normal activity may be more effective in reducing low back pain recurrences than medical management and normal activity alone”.

Briefly summarising the research undertaken, a group of 39 patients with first episode acute low back pain were randomly allocated to 2 treatment groups.

The control group received

Bed Rest

Took time off work

Prescribed medication

Advised to return to normal activity as they could tolerate it.

The specific exercise group

Were advised to do all of the above plus

A 4 week exercise program consisting of twice weekly supervision performing specific exercises to activate the multifidus – the small deep postural muscles that area found to be atrophied and contain fat in those with chronic low back pain – in order to train stability in the spine, along with transversus abdominis muscle training. 

A core stability exercise that is recommended for rectus abdominis and multifidus strengthening


The results sounded promising.

Over a one-year period following the intervention the specific exercise group had a recurrence of lower back pain of 30%, while the control group had a recurrence of 84%. Over a three-year period the specific exercise group had a recurrence rate of the lower back pain of 35% while the control group had a recurrence of 75%.

Following on from that I was enthused to provide patients with low back pain these specific stabilising exercises, based on reputable evidence that said they were less likely to experience recurrent pain and would gain greater control over their back.


Why is Core Stability being questioned?

However, we have learned a lot since then and it is now thought, after examining research over the years that patients improve with core stability programs not because of improvements in the “core” specifically because really, any improvements in “core muscle” function do not explain improvements with exercise programs, nor are “dysfunctions” in these muscle related to low back pain.

Some of the research articles that support this view are as follows:

Mannion et al (2012):

They said that neither baseline lateral abdominal muscle function nor its improvement after a programme of stabilisation exercises was a statistical predictor of a good clinical outcome.

Therefore is difficult to attribute improvement in recurrence of low back pain to any specific effects of the exercises on these trunk muscles.

They thought that based on their findings, patients who stopped catastrophizing (when you worry that everything you are about to do might cause back pain) had better outcomes than those who undertook stabilisation exercises. The researchers did, however, say more research should be done into the effects on the brain of doing the exercises as opposed to any increase in the functioning of the core muscles.

Herbert et al (2014):

The relationship between lumbar multifidus intramuscular adipose tissue (fat) – due to atrophy as I discussed last week – and low back pain or leg pain is inconsistent and may be modified by age and that in their opinion, lumbar multifidus intramuscular adipose tissue did not predict future LBP or leg pain.

Wong et al (2014):

This systematic review highlighted that changes in strength or activation of transversus abdominis following conservative treatments tend not to be associated with the corresponding changes in clinical outcomes. The relation between post treatment changes in characteristics of lumbar multifidus and clinical improvements remains uncertain.

Suri et al (2015):

Few lumbar muscle characteristics have limited evidence for an association with future low back pain and physical performance outcomes, and the vast majority have limited evidence for having no association with such outcomes.

Le Cara et al (2014):

There was no relation between multifidus muscle strength and function in this cohort of patients with low back pain.

Gubler et al, (2010:

There seems to be no delay in activation of the core muscles in those performing “core muscle” activation in those with chronic lower back pain.

They also said that in their opinion, it also does not really seem to matter what sort of exercise we do in the treatment of chronic low back pain:

Macedo et al (2016):

Evidence of very low to moderate quality indicates that core exercises showed no benefit over spinal manipulative therapy, other forms of exercise or medical treatment in decreasing pain and disability among patients with acute and subacute low back pain. However, they did say “whether core stability exercises can prevent recurrences of LBP remains uncertain”.

Smith et al (2014):

There is strong evidence stabilisation exercises are not more effective than any other form of active exercise in the long term. The low levels of heterogeneity and large number of high methodological quality of available studies, at long term follow-up, strengthen our current findings, and further research is unlikely to considerably alter this conclusion.

More worrying is that they also note there is a trend for increasing levels of fear in patients undertaking core stability programs. This was thought to be because patients create in their thoughts and belief systems a “pathoanatomical”, ” biomechanical” or “biomedical” view that they must “activate”, “tense”, or magically “swell”  some sort of muscle group prior to moving or they risk “damaging”  their spine further.

Yamato et al, 2015

Pilates was not found to be more effective than other exercise, probably for exactly the same reasons as above.

Saragiotto et al (2016):

If you are going to perform exercises to try to prevent your low back pain from recurring, you should just go with what you enjoy best they concluded.

So What Should You Do?

So – what should you – the patient – make of all of that .. what should you do for the best?

In my opinion, when you have injured any joint, you need to sort out the injury and then exercise the muscles, ligaments and tendons that surround or influence that joint in any way so that all tissues that protect and move the joint are functioning optimally.

Injuries are either as a result of one big overload of the tissues or as a result of lots of repeated injuries – like a repetitive strain as I described at the beginning of this article.

You can either choose to do nothing, wait to recover and see what happens to you – because you have no idea how genetics has influenced your ability to heal. Or you can try as many things possible to restore your body to its best.

The choice is yours – and if you would like to do exercises, we are available to show you the most evidence based ones for your problem. If you don’t want to do anything then we will be here for you too. Research on this is still going on and there is enough of good quality for me to think it is worth encouraging you to exercise as much as you feel you can and in the right way!