The Controversy of Core Stability Exercises For Low Back Pain

There has been quite a bit of discussion generated around the debate regarding core stability exercises (particularly transverus abdominis recruitment) versus general exercise in the treatment of low back pain. Here is my take on things. In this article, I provide a quick review of numerous studies comparing the effectiveness of core stability exercises versus general exercise in the treatment of chronic and acute non-specific low back pain, with a take-home message focused on clinical implications! Brace yourselves 😉

 

A Review of the Evidence

  1. Wang et al. 2012 (Meta-Analysis)

– Total of 5 trials involving 414 participants were included in the current analysis

– Core stability exercise was better than general exercise for reducing and at the time of the short-term follow-up

 

  1. Wajswelner et al. 2012 (RCT)

– Eighty-seven community volunteers with low back pain for ≥3 months and age 18-70 were randomized to either the Pilates (n = 44) or general exercise (n = 43) group

– No significant differences were found between interventions at 6, 12 and 24 weeks

– An individualized clinical Pilates program (consisting of lumbar stabilization exercises and core work) produced similar beneficial effects on self-reported disability, pain, function and health-related quality of life as a general exercise program in community volunteers with chronic low back pain.

 

  1. Bystrom et al 2013 (Meta-Analysis)

– Sixteen studies were included

– The pooled results favored motor control exercises compared with general exercise with regard to disability during all time periods and with regard to pain in the short and intermediate term

 

  1. Smith et al. 2014 (Systematic Review & Meta-Analysis)

– 22 studies (approximately 2300 pooled participants)

– Strong evidence that stabilization 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

 

  1. Saragiotto et al., 2016 (Cochrane Review)

– Included 29 trials (n = 2431) in this review

– There is low to high quality evidence that motor control exercise is not clinically more effective than other exercises for all follow-up periods and outcomes tested

 

  1. Shamsi et al., 2016 (RCT)

– A 16-session core stabilization (CSE) program and a general exercise (GE) program with the same duration were conducted for two groups of participants. Frequency of interventions for both groups was three times a week. Forty-three people (aged 18–60 years) with chronic non-specific LBP were alternately allocated to core stability (n = 22) or GE group (n = 21) when admitted.

– CSE is not more effective than GE for improving endurance core stability tests and reducing disability and pain in chronic non-specific LBP patients.

 

  1. Macedo et al. 2016 (Cochrane Review)

– Three trials evaluating acute or subacute pain in patients with LBP (n = 197 participants)

– Low to moderate quality evidence showed that MCE did not confer any additional benefit over spinal manipulative therapy, other forms of exercise or medical treatment for reducing pain or disability among patients with acute and subacute LBP. Whether MCE can prevent recurrences of LBP remains unclear.

 

  1. Coulombe et al. 2017 (Meta-Analysis)

– Five studies involving 414 patients were include

– In the short term (3 months), core stability exercise was more effective than general exercise for decreasing pain and increasing back-specific functional status in patients with LBP

 

  1. Gomes-Neto et al. 2017 (Systematic Review & Meta-Analysis)

– Eleven studies met the inclusion criteria (413 stabilization exercises patients, 297 general exercises patients, and 185 manual therapy patients)

– Stabilization exercises improved pain and disability compared with general exercises.

– Stabilization exercises does not provide greater benefit than manual therapy for pain and disability.

 

Conclusion

As clinicians, we have to be critical about the interventions we choose to use. Typically, we have between 30 to 60 minutes with patients. We need to ask ourselves, “what are the most effective interventions supported by evidence that I could use throughout my treatment to help my patient get better and achieve their goals?” If there are better interventions, or interventions with similar results that would provide more overall benefit to the patient, then we must consider them.

Although there is some research to suggest short term benefits with ‘core stability’ exercises compared to more general exercises, this approach does not seem to be more effective over the long term. Variable movement and motor control exercises are likely beneficial for chronic LBP. It is possible that no one form of intervention is right for all cases. However, considering the nature and needs of the chronic low back pain population, the short-term benefits of core stabilization shown by some studies no longer seem relevant as a specific form of treatment.

 

Questions To Reflect On

Teaching patients to contract their infamous transversus abdominis is still commonly used in clinical practice.Why teach the patient to be more “stable” in lying by trying to contract a muscle we can’t even reliably palpate, when we could simply just get them moving?

What does stability or instability even mean? Do we even have a universal definition of stability, or are we just throwing it around in practice?

Could we be wrong about why core stabilization works? 

– The muscular activation pattern of the chronic LBP patient is likely to be individual and task dependent (Hodges et al. 2011).

– Timing of muscle activation does not seem to be positively or negatively correlated with reduction in pain levels or perceived readiness for return to work. In addition, attempts to change timing of activation appear to have little impact on actual onset of activation (Vasseljen et al. 2012, Moreside et al., 2013).

Just some food for thought. Once again, thanks for reading!

Best,
Anthony Teoli MScPT
Registered Physiotherapist & Founder of InfoPhysiotherapy

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