No matter how we try to ignore it ’core stability’ continues to intrigue. Firmly established within the lexicon of movement disciplines few topics are as divisive. In the eyes of many movement professionals, for a programme to prove successful, core workouts may often need to nestle alongside other modalities such as ’functional’ exercise, or even high intensity training. A recently published, two part article considering ’Core Stabilisation’ exercises endeavours to supply some clarity on how core training might be best employed (Brumitt et al., 2013).
Brumitt, J., Matheson, J. and Meira, E. P. 2013. Core Stabilization Exercise Prescription, Part I Current Concepts in Assessment and Intervention. Sports Health: A Multidisciplinary Approach, 5 (6), pp. 504.
This particular article examines the rehabilitation strategies available when dealing with non specific low back pain; by definition a problematic patient group when seeking to identify which diagnosis/ mechanical problem elicits their condition.
Brumitt 2013 suggests a broad classification of ”function lumbar segmental instability” (FLSI), for which they explain there are two differing rehabilitation strategies.
Strategy 1– Local muscle control
Brumitt (2013) outlines the concepts of local muscle activation as discussed by Richardson and the team from Queensland University. They identify local muscles are advantaged in comparison to global muscles in controlling shear loads and that unnecessary excessive compression loads the spine.
Strategy 2– Global muscle control
The second strategy focuses on a McGill influenced approach incorporating all global muscles a rationale grounded in the local muscle system’s inability to address global dysfunction. This exercise regime involves isometric contraction of the posterior chain as produced through a back extension against gravity to fatigue, supine bridge, lateral muscle activation in a side plank position and activation of the flexor anterior chain area as a flexor endurance test (incline crooklying and prone plank position).
Both strategies are at times valid and worthy of further discussion. There are certainly many patients who experience low back pain accompanied by marked disability and / or restrictions just as there are numerous elite athletes with chronic low back pain. Just as each group differ in profile, each group need a tailor fitted exercise approach to meet their needs. As Richardson et al, explain, local muscle control has been shown to correct segmental translation problems. Similarly, as McGill extolls, isometric muscle activation of the trunk in different positions trains the core muscles to work isometrically under high load to better withstand fatigue. In functional, everyday living we require a dynamic system that can effectively control segmental translation, be robust under high loads and downregulate, so as to compliantly bend, rotate and even relax without the demands of fatiguing load. Rehabilitation therefore would appear to be even more complicated than dual strategies Brumitt suggests.
Comerford and Mottram have forwarded a wider approach. Unlike other authors in this field Comerford and Mottram discuss an management approach based on movement analysis and clinical reasoning. Their Performance Matrix system tests where the movement fault lies and at which movement load the fault, a process allowing for a classification of the dysfunction. In short, the client receives bespoke training sartorially fitted to their specific needs. Previous low back pain interventions have been criticised due to a ”wash out effect” evident of problems in study design. As the treatment groups considered possess varying movement disorders, each of which demand specific exercise solutions a single exercise intervention, unsurprisingly, only proves effective for a small, fortunate, percentage.
In Part 2 : Core Stabilisation Exercise prescription, A Systematic Review of Motor Control and General ( global ) Exercise Rehabilitation Approaches for Patients with Low Back Pain, Brumitt compares the effects of seven studies using a general exercise program for patients with low back pain against six studies using a motor control (low load, high repetition) local muscle programme. Interestingly, they noted that two studies showed no difference between the two interventions (motor control and general exercise). In fact, all participants improved in disability, pain and psychological stress scores. The next two studies demonstrated active functional exercise programmes as significantly better in all outcomes. Brumitt concludes that current evidence suggests that it maybe unnecessary to include interventions that activate local muscles. Are clinicians wasting their own and their patients’ time? This is a point of high relevance when the role of and the pain related behaviour of local muscles is revisited; they control intersegmental translation and become dysfunctional in episodes of pain. Therefore a number of questions are posed before Brumitt et al. can be supported in their conclusions:
- are local muscles the sole source of pain disorders in patients with low back pain?
- are local muscles the only muscle group to provide stability or / movement in the low back?
The answer is no. The literature clearly identifies what the role of local muscle in the body are as well as how to retrain these structures (Tsao & Hodges, 2008). More reasonably it could and should be argued that any clinician should only introduce a local muscle correction strategy when a process of analysis indicates this is required rather than employing a one strategy which supposedly fixes all approach. There is no movement panacea but there can be rigour in analysis and subsequent exercise prescription.
The same must also apply to general exercise if it is postulated that low back pain can be mitigated by increased strength/endurance in the muscles that prevent fatigue and enhance tolerance to load. In this instant, a general exercise program as indicated by Brumitt may prove hugely beneficial in patients. If the classification of movement deficits exists where the system needs strength and conditioning in specific planes and positions then low load local muscle training is clearly not going to supply results.
We are designed to move and be on the move. The interpretation of the evidence needs to move forward, as well. In order to identify what is effective training we first need to identify what problem we seeking to address, classify this disorder, and be specific in the retraining that follows. A far as the literature shows The Performance Matrix is the only system available to the client which meets these demands. Only when we specifically address the disorder with the correct strategy can we assess the effectiveness of the strategy, then and only then can we really discuss what core training is.
So Core stabilisation – what does this really mean? Core Control (Mottram & Comerford) is perhaps a more appropriate title. It is control in all planes, under all types of movement intensites, high and low, from one end of the movement spectrum to the other. Core control is the ability to co-ordinate and control movement at all joints with minimal compensation. It is the ability to adjust automatically to the different loads the body has to cope with, daily. The question is not if the exercise is functional or scientific, the real question clincially is does the exercise correct the movement fault so that the client can function normally? Clinically, is this not what all patients or clients want?
The body’s control components need to be able to withstand high load movements symmetrically and asymmetrically, alongside low load movements such as posture in standing, sitting at a desk, holding and lifting a small child, cycling etc. There is a requisite to withstand load isometrically, isotonically and most functional of all, eccentrically. Surely, when we think of the complexity of the control the body requires two rehab strategies appears inadequate.
In fact, in order to solve such movement and potential performance problems there is the need to examine the issue in more depth. The Performance Matrix offers such a system within its battery of 10 movement tests, offering an overall, yet highly personalised picture of movement control. It identifies which movement direction (flexion, extension etc...), at which training intensity and at which segment of the body this particular client requires bespoke exercise prescription for. With such a highly tailored process of analysis there is no need for a hierarchy of approaches as all may now sit democratically, each to be chosen as and when their specific benefits are required.
Brumitt, J., Matheson, J. and Meira, E. P. 2013. Core Stabilization Exercise Prescription, Part I Current Concepts in Assessment and Intervention. Sports Health: A Multidisciplinary Approach, 5 (6), pp. 504
Brumitt, J., Matheson, J. and Meira, E. P. 2013. Core Stabilization Exercise Prescription, Part 2 A Systematic Review of Motor Control and General (Global) Exercise Rehabilitation Approaches for Patients With Low Back Pain. Sports Health: A Multidisciplinary Approach, 5 (6), pp. 510.
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