"You have a weak core, that's why you have back pain." This is a statement that gets thrown around within the medical and exercise communities without much consideration. Not only does this lead to a societal assumption that back pain and "core" strength go hand in hand, but it creates a belief that our spines are structures that are fragile and vulnerable. How accurate is this?
Now don't get me wrong, I'm all for improving lumbopelvic strength. The idea of having proximal stability to allow for distal mobility definitely makes sense (insert analogies such as the idea that a strong foundation of a house allows for a sturdy second and third floor or trying to shoot a cannon out of a canoe). But while this subgroup of muscles may enhance athletic and functional performance, can you truly just plank your way into a pain-free lifestyle?
To answer this, we have to look at the big picture first. Odds are you are going to experience back pain at one point and time in your life (in fact, nearly 80% of people will). And if you had it once, there's a high likelihood that you'll have it again. But not all back pain is created equal; therefore, a homogenous treatment approach cannot be taken. Hicks et al. originally identified four factors that clued clinicians into a potential benefit from prescribing stabilization exercises:
- Age less than 40 years (ie, younger)
- Average straight leg raise > 91 degrees (ie, bendy and flexible)
- Aberrant movements during lumbar movement (ie, awkward, not controlled movements)
- Positive prone instability test (ie, engaging "core" muscles makes things hurt less)
What do these mean? If you identified someone with three out of four of these factors, the likelihood that stabilization exercises would improve one's symptoms increased from 33% to 67%. While this study was not validated, think of the majority of the individuals who complain of back pain. Do they fall into this grouping? If not, how can we just assume they all have a "weak core."
Now think about what happens at that moment when you bend forward, hear the dreaded POP in your low back, and your body seizes into one giant spasm. Will tightening your "core" muscles make you feel better or worse? Try this: make a fist, and clench it really hard. You'll feel tension throughout the forearm muscles, but your fingers and wrist should feel compressed. Muscle contractions cause compression across the joints, and bracing your spine does the same thing as well. At times, this can lead to or augment pain. Go back to that fist; what happens if you clenched it all day long? How fatigued would your muscles be? Would this enhance muscular performance? More food for thought.
If we take a look at the literature, there is even more evidence that our lumbopelvic musculature activity changes in states of pain. Arendt et al. found that the lumbar paraspinal muscles remained activated during phases of gait that in healthy controls were quite calm. Hemming et al. made similar findings; higher tonicity of "core" muscles during lifting, stair climbing, and standing out of a chair. Dankaerts et al. saw some individuals with chronic low back pain have significant increases in muscle activity even while sitting. Now all of these examples aren't even that strenuous of tasks, yet, the commonality is that people with back pain have difficulty calming these tissues down. Still, think those 6-pack abs will take your pain away?
If you are still not convinced, take a few minutes to listen to this interview with Peter O'Sullivan, one of the most well respected and leading physiotherapists in the management of low back pain.
One of the most thought-provoking statements he makes is that we do not think about "pre-tensing" other areas of our body before using them, so why should the spine be any different?
So if strengthening the core muscles is not the answer, what is? Well in that acute flare-up period of time, things such as walking, working on diaphragmatic breathing, keeping a positive mindset, and getting the muscles to RELAX may be the best exercise prescription you can get. So go ahead, strengthen your "core," but let's stop telling people it's the reason why their back pain hasn't gone away.