A very common statement that we hear from clients during their initial assessment is that they have been told that they have back pain because they have a “weak core”. Unfortunately, this gives a very incorrect understanding of the cause of the lower back pain, what to do about it and the role of core stability in the whole process.
Pain is a very personal experience, warning your body of either damage or “potential” damage to the body. Pain sensitive structures in the lower back, such as the discs, facet joints in the back (joints responsible for both guiding the direction of movement in the back and some degree of load bearing) and irritation of the nerves directly can cause pain in the lower back when irritated or damaged. For example, with repeat heavy lifting, there is the potential to cause the fluid on the inside of the disc (nucleus pulposus) to travel into the back of the disc (especially the outer third), which has a nerve supply and can cause pain.
In addition, after pain has been present in the area for a while (approximately 3 months), the nerves in the area, their connections to the spinal cord and their nerve pathways to the brain become hypersensitized so they send more “enhanced” signals to the brain that pain is present or can even start to send normal movement signals as pain signals to the brain.
These structures and their signals to the brain are the cause of the pain and change in function in the lower back.
Core stability, the muscles that support the lower back (in particular the multifidus muscle group and transversus abdominus) act specifically to stabilise the movement of the vertebrae, stopping the excessive movement of one segment on the other which can cause potential damage to the pain sensitive structures and lead to pain over time. The pain sensitive structures, such as the discs, are great at resisting the normal rotation movement of one vertebrae on another, however, when you move, each vertebrae also glides forward a bit. It is this glide movement that these pain sensitive structures can’t handle well and is the part the core stabilisers control.
Therefore, poor core stability allows the excessive glide and slide of one vertebrae on another, which increases the load on pain sensitive structures, that can ultimately lead to damage and pain.
Weak core stability – Specific exercises to reduce back pain
Core stability exercises alone won’t reduce lower back pain. As the cause of the lower back pain is specific to the person, based on which area is being irritated and how sensitised the area is, the first purpose and choice of exercises is to reduce irritation of the area and start to restore some use of the lower back.
For example, in general, with a disc bulge (one of the most common causes of lower back pain), choosing extension based (backwards moving) exercises can help reduce the disc bulge (by allowing the fluid in the centre of the disc to move forward) and reduce pain. However, if the primary cause of irritation is the facet joints in the back, flexion based (forwards moving) exercises may reduce irritation and help manage pain.
The first purpose of exercise is therefore to help modulate pain, by either reducing irritation and load to the painful structures and facilitate normal movement which helps to modulate pain and downplay the “enhanced” sensitivity of nerves, spinal cord pathways and brain to pain signals in the area.
Weak core stability – The role of core stability
The role of the core stabilisers is to reduce and control the excessive glide of one vertebrae on another. Sadly, the direct nerves that supply the signals to the core stabilising muscles are the same nerves that supply the pain sensitive structures, such as the facet joints. This means that when there is irritation and pain to these structures, the signal to these muscles is reduced and they “switch off”. So, when you need these muscles the most, when there is damage in the area, they automatically stop working and on top of this, when the pain reduces (due to the natural healing process in the area), these muscles do not automatically start working again and doing their job once again.
Therefore, once the pain settles, the pain sensitive structures are more vulnerable to injury in the future because the core stabilisers have not started doing their job and must be re-trained.
Core stability exercises can be started immediately and in parallel to pain modulating exercises. The choice of exercises is dependant on the type of injury, but can be carefully selected to allow the muscles to contract and be re-trained without causing further pain or damage to the area.
For example, if you have a recent disc bulge, a simple exercise such as kneeling on all fours and lifting one arm up at a time will facilitate the activation of the multifidus muscle, whilst keeping you in a very neutral position of the lower back and in an extension direction.
The choice and progression of these appropriate exercises is where the specific role of the health professional lies.
Weak core stability – The role of strength training
Core stability is not enough to keep your back strong for the activities required for everyday life activities and harder activities, such as playing sport, running, lifting, carrying children and other normal tasks.
Core stabilisers stop the excessive glide of one vertebrae on another, but the resistance to load and strength comes from the power muscles around the back, especially the gluteal muscle groups, such as gluteus maximus, one of the strongest muscles in the body.
The core stabilisers provide the base for these power muscles to do their job properly. Ultimately, both are required for complete rehabilitation of the lower back over time and for the tasks required by most people in everyday life.
Again, starting to work on the power muscles can begin in parallel with exercises to modulate the injury and restore core stability. Selection must be specific for the individual to ensure that you can handle the load and is progressed in a safe and appropriate manner.
Therefore, doing exercises to improve the strength of the lower back and gluteals, such as deadlifts is great in the long term, if selected at the right time with the appropriate load and progressed specifically over time.
The key to all lower back rehabilitation programs is not just working on core stability, but the appropriate selection of pain/injury modulating exercises, core stability exercises and strength exercises specifically selected and progressed over time to match your needs and requirements for where you want to take your life in the long term.
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