The Effectiveness of Core Stability Exercise in the Management of Chronic Non-Specific Low Back Pain: Difference between revisions

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<div class="noeditbox">Welcome to &lt;a href="Nottingham University Spinal Rehabilitation Project"&gt;Nottingham University's Spinal Rehabilitation Project&lt;/a&gt;. Students are currently creating this page. Please check back in January 2014 to see the finished result.</div> <div class="editorbox">
<div class="editorbox">'''Original Editor '''- [[User:Yann Moysey|Yann Moysey]], [[User:Josh Plail|Josh Plail]], [[User:Timothy Sheehy|Timothy Sheehy]] and [[User:Samuel Soroya|Samuel Soroya]],  as part of the [[Nottingham University Spinal Rehabilitation Project]]
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</div>
== Introduction  ==
[[Image:Lower-back-pain.jpg|thumb|right|lowerleftbackpain.info/wp-content/uploads/2012/09/lower-back-pain.jpg]]<u></u><u></u><u></u><u></u>Low back pain is an extremely common patient complaint with approximately 80% of the World population developing low back pain at some point<ref name=":0">Deyo RA, Weinstein JN. New England Journal of Medicine. NEJM. 2001;344(5)):363-70.</ref>. 1/3 of the UK population will experience back pain each year<ref name=":1">Savigny P, Watson P, Underwood M. Early management of persistent non-specific low back pain: summary of NICE guidance. Bmj. 2009 Jun 4;338:b1805.</ref>. It is the main cause of years lived with disability<ref>Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V, Abraham J. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The lancet. 2012 Dec 15;380(9859):2163-96.</ref>. It is among 10 of the leading reasons for patient visits to medical facilities.<ref>Patel AT, Ogle AA. Diagnosis and management of acute low back pain. American family physician. 2000 Mar;61(6):1779-86.</ref> Non-specific low back pain is tension/soreness and or stiffness in the lower back region whereby it is not possible to find a cause for the pain<ref name=":1" />. Most cases resolve fairly quickly, but a significant number of patients develop chronic lower back pain. Patients experience unremitting pain and often become functionally impaired. Chronic LBP represents a greater financial burden in the form of direct costs resulting from loss of work and medical expenses, as well as indirect costs<ref>Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. The spine journal. 2008 Jan 1;8(1):8-20.</ref>.&nbsp;
== Prevalence<u></u><u></u>  ==


'''Top Contributors''' - &lt;img _fck_mw_template="true" _fckrealelement="0" _fckfakelement="true" src="http://www.physio-pedia.com/extensions/FCKeditor/fckeditor/editor/images/spacer.gif" class="FCK__MWTemplate"&gt; &nbsp;
<u></u><span style="line-height: 1.5em;">Generally there is a scarcity of information on the prevalence and incidence of chronic low back pain, partly due to lack of agreement about its definition.  Chronic low back pain is mostly defined as persistent pain occurring on most days and lasting longer than 3 months</span><ref>Maher CG. Effective physical treatment for chronic low back pain. Orthopedic Clinics. 2004 Jan 1;35(1):57-64.</ref><ref>Von Korff M, Saunders K. The course of back pain in primary care. Spine. 1996 Dec 15;21(24):2833-7.</ref><ref>Waddell G, Schoene M. The back pain revolution. Elsevier Health Sciences; 2004.</ref><span style="line-height: 1.5em;">. Others also define it as pain exceeding normal healing times and frequently reoccurring back pain over long periods.  Acute and chronic LBP warrant separate consideration as they may respond differently to the same interventions</span><ref>Sierpina V, Curtis P, Doering J. An integrative approach to low back pain. Clinics in Family Practice. 2002 Dec;4(4):817-31.</ref><ref>Van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions. Spine. 1997 Sep 15;22(18):2128-56.</ref><span style="line-height: 1.5em;">.</span>  
</div>  
== Chronic Low Back Pain  ==


==== <u>Introduction</u> ====
== Causes ==


<u></u>This wiki page aims to investigate the effectivness of core stability exercises for chronic non- specific low back pain. &nbsp;We will discuss the evidence for and against the intervention, measuring "effectivness" using pain (primary) and function (secondary) as our outcome measures. In conjunction we have provided a overview of [[Chronic Low Back Pain|chronic low back pain]] and [[Core stability|core stability exercises ]](To see more extensive details please see links to other relvant physiopedia pages). From reading this we hope students and clinicians a like can make their own mind up about the use of core stability exercises in clinical practice.[[Image:Lower-back-pain.jpg|thumb|right]]
<u></u>Mechanical disorders are the cause in 90% of cases with the remaining 10% of cases being due to manifestation of systemic illness<ref>Nachemson AL. The lumbar spine an orthopaedic challenge. spine. 1976 Mar 1;1(1):59-71.</ref>. Despite a large number of pathological conditions that give rise to low back pain cases, 85% are without pathoanatomical or radiological abnormalities<ref name=":0" />. Most episodes of low back pain resolve quickly and are not incapacitating, nonetheless, pain and disability are often ongoing and recurrences are common<ref>Pengel LH, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: systematic review of its prognosis. Bmj. 2003 Aug 7;327(7410):323.</ref>. It is estimated 10 to 20% of affected adults develop symptoms of chronic low back painback-pain<ref>Diamond S, Borenstein D. Chronic low back pain in a working-age adult. Best practice & research Clinical rheumatology. 2006 Aug 1;20(4):707-20.</ref>.<br>


<u></u>
[[Image:LBP table.png|40]]
 
==== <u></u><u>Background</u>  ====
 
<u></u>Low back pain is an extremely common patient complaint with approximately 80% of the World population developing low back pain at some point (Deyo and Weinstein, 2001). 1/3 of the UK population will experience back pain each year (NICE 2009). It is the main cause of years lived with disability (Vos 2012). It is among 10 of the leading reasons for patient visits to medical facilities. (Patel and Ogle 2000). Non-specific low back pain is tension/soreness and or stiffness in the lower back region whereby it is not possible to find a cause for the pain (NICE 2009). Most cases resolve fairly quickly, but a significant number of patients develop chronic lower back pain. Patients experience unremitting pain and often become functionally impaired. Chronic LBP represents a greater financial burden in the form of direct costs resulting from loss of work and medical expenses, as well as indirect costs (Dagenais et al. 2008). Most patients on disability for more than 6 months will not return to work. The number of patients returning to work approaches zero at 2 years (Anderson 1997).
 
<br>
 
==== <u></u><u></u><u>Definition</u>  ====
 
<u></u><span style="line-height: 1.5em;">Generally there is a scarcity of information on the prevalence and incidence of CLBP, partly due to lack of agreement about it’s definition.  Chronic low back pain is mostly defined as persistent pain occurring on most days and lasting longer than 3 months (Maher 2004;Von Korff 1996; Waddell 2004) Others also define it as pain exceeding normal healing times and frequently reoccurring back pain over long periods.  Acute and chronic LBP warrant separate consideration as they may respond differently to the same interventions. (Sierpina 2002; van Tulder 1999)</span>
 
==== <u>Causes</u>  ====
 
<u></u>Mechanical disorders are the cause in 90% of cases with the remaining 10% of cases being due to manifestation of systemic illness (Nachemson 1976). Despite the large number of pathological conditions that give rise to low back pain cases 85% are without patho-anotomical or radiological abnormalities (Deyo and Weinsein, 2001). Most episodes of low back pain resolve quickly and are not incapacitating, nonetheless pain and disability are often ongoing and recurrences are common (Pengel et al. 2003). It is estimated 10% to 20% of effected adults develop symptoms of chronic low back-pain (Diamond and Borenstein, 2006)<br>
 
<br>
 
[[Image:LBP table.png|40]]  
 
<br>
 
<u></u>
 
==== <u>Risk Factors</u>  ====
 
<u></u>Many different patient characteristics have been described that predict who is at risk of developing chronic LBP. However, only a few have been replicated consistently in multiple studies. These include increasing age, previous back pain, job dissatisfaction, pain below the knee and depression. (Anderson 1999, Cherkin et al. 1999,Epping-Jordan et al. 1998) Depression has long been noted to be associated with various chronic pain syndromes, and several studies have reported it’s relationship with chronic back pain in particular in multiple studies (Epping-Jordan et al. 1998). Women are more commonly affected with LBP and some studies show increases in chronic LBP (Cherkin et al. 1999). Thomas et al. (1999) found that persistent back pain was associated with “premorbid factors” such as poor baseline functional status, high levels of psychological stress, poor self rated health, low levels of physical activity, smoking and obesity. Smoking has been found in multiple epidemiological studies to be a risk factor for the development of chronic low back pain. (Deyo and Bass, 1989)
 
<br>
 
==== <u>Prognosis</u>  ====
 
<u></u>
 
The longer the patient suffers from back pain the worse the prognosis. The chance of low back pain resolving is it’s highest during the first weeks (Anderson 1999). By the end of year one that chance diminishes significantly. In Van den Hoogen et al. 1998 study on the course of low back pain. 35% patients had pain at 12 weeks and 10% of patients had pain at 1 year. Thomas et al. 1999 reported similar outcomes at 1 year with 10% of patients complaining of the same back pain form the first episode. Carey et al. 2000 found that 2/3 of patients with chronic low back pain at 3 months still had functionally disabling symptoms at 22months and only 16% of patients became symptom free. Once established, chronic low back pain is persistent and achieving complete remission becomes less likely as time goes by. The question remains how to treat chronic low back pain, and can you prevent it from occurring in the first place?
 
= Core Stability  =
 
== Definition<br>  ==
 
Many authors have attempted to define core stability, which consequently means a globally accepted definition is yet to be confirmed (Huxel –Bliven and Anderson 2013). However, a widely accepted definition of core stability is:
 
<br>''“Comprises of the lumbopelvic-hip complex and is the capacity to maintain equilibrium of the vertebral column within its physiologic limits &nbsp;''
 
''&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; by reducing displacement from perturbations and maintaining structural integrity.”''
 
<br>
 
(Akuthota, Nadler 2004, Liemohn, Baumgartner, Gagnon 2005, Panjabi 2003, Panjabi 1992, Smith, Nyland, Caudill, Brosky, Caborn 2008, Willson, Dougherty, Ireland, Davis 2005)<br>
 
== <br>History  ==
 
<span>&nbsp;</span>
 
The first acknowledgment of core stability was by Henry and Florence Kendall who were both Physiotherapist's and first developed the idea of a “neutral pelvis” in 1940/1950’s (Kent 2012).
 
They initially suggested that the surrounding superficial muscle groups were responsible for the maintenance of alignment and of “neutral spine” . The muscles they were referring to were the erector spinae, hamstrings, abdominals and the hip flexors. Following on from this, it was suggested that pelvic tilt was pelvic movement deviating from the neutral position.
 
<br>Over the years, the concept of core stability has changed and auhtors such as Paul Hodges have highlighted the significance and contribution of the Transverus Abdominus muscle, especialy in lumbo pelvic stability. Upon this basis, it has now become and important part in the management of spinal stability and e<span style="line-height: 1.5em;">xercises orientated upon the activation, recruitment and strengthening the core are a common avenue of treatment&nbsp;</span><span style="line-height: 1.5em;">(Hodges 1999).&nbsp;</span>
 
<br>
 
== Theories and Applications, How does it fit in to the wider picture ?<br> ==
 
In attempt to add some clarity to the phenomena of the stabilisng system of the spine, Panjabi proposed a classification model which offered an explaination into the functioning of the spine. His model consisted of three categories&nbsp;[[Lumbar Instability|(Panjabi 1992)]]<u>,&nbsp;</u><span style="line-height: 1.5em;">&nbsp;Active, Passive and Neural and the evident importance of core stability can be seen.</span>
 
==== <u>Passive</u>  ====
 
<u></u>
 
The passive category consists of the basic components of the spine which allow for soft tissue attachment (Panjabi 1992).
 
<br>• The lumbar vertebrae<br>• The joint capsules<br>• The intervertebral disc<br>• Ligaments surrounding the area
 
These structures of the spine do not contribute to any significant spinal stability in the neutral alignment. The skeletal structure does support the basic framework and the tensile properties in the various ligaments do start to resist end range movement, however do not have the capability to produce forces which initiate spinal movement is not caused by the passive structures.
 
==== <br><u>Active</u>  ====
 
<u></u>


The active structures hold responsibility for the initiation of gross spinal movement as well as providing contributing to spinal segmentation. <br>Bergmark (1989) further classified the active system into the local and global stabilising system.<br>  
== Risk Factors<u></u> ==
<u></u>Many different patient characteristics have been described that predict who is at risk of developing chronic LBP. However, only a few have been replicated consistently in multiple studies. These include increasing age, previous back pain, job dissatisfaction, pain below the knee and depression.<ref name=":2">Andersson GB. The epidemiology of spinal disorders. Frymoyer JW The adult spine: principles and practice. 1997. Philadelphia.</ref><ref name=":3">Cherkin DC, Deyo RA, Street JH, Barlow W. Predicting poor outcomes for back pain seen in primary care using patients' own criteria. Spine. 1996 Dec 15;21(24):2900-7.</ref><ref name=":4">Epping-Jordan JE, Wahlgren DR, Williams RA, Pruitt SD, Slater MA, Patterson TL, Grant I, Webster JS, Atkinson JH. Transition to chronic pain in men with low back pain: predictive relationships among pain intensity, disability, and depressive symptoms. Health Psychology. 1998 Sep;17(5):421.</ref> Depression has long been noted to be associated with various chronic pain syndromes, and several studies have reported it’s relationship with chronic back pain in particular in multiple studies<ref name=":4" />. Women are more commonly affected with LBP and some studies show increases in chronic LBP<ref name=":3" />. Thomas et al. (1999) found that persistent back pain was associated with “premorbid factors” such as poor baseline functional status, high levels of psychological stress, poor self-rated health, low levels of physical activity, smoking and obesity<ref name=":5">Thomas E, Silman AJ, Croft PR, Papageorgiou AC, Jayson MI, Macfarlane GJ. Predicting who develops chronic low back pain in primary care: a prospective study. Bmj. 1999 Jun 19;318(7199):1662-7.</ref>. Smoking has been found in multiple epidemiological studies to be a risk factor for the development of chronic low back pain<ref>Deyo RA, Bass JE. Lifestyle and low-back pain. The influence of smoking and obesity. Spine. 1989 May;14(5):501-6.</ref>.
== Prognosis  ==
<u></u>The longer the patient suffers from back pain the worse the prognosis. The chance of low back pain resolving is its highest during the first week<ref name=":2" />. By the end of year one that chance diminishes significantly. In Van den Hoogen et al. 1998's study on the course of low back pain, 35% patients had pain at 12 weeks and 10% of patients had pain at 1 year.<ref>van den Hoogen HJ, Koes BW, van Eijk JT, Bouter LM, Devillé W. On the course of low back pain in general practice: a one year follow up study. Annals of the rheumatic diseases. 1998 Jan 1;57(1):13-9.</ref> Thomas et al. 1999 reported similar outcomes at 1 year with 10% of patients complaining of the same back pain form the first episode<ref name=":5" />. Carey et al. 2000 found that 2/3 of patients with chronic low back pain at 3 months still had functionally disabling symptoms at 22months and only 16% of patients became symptom-free<ref>Carey TS, Garrett JM, Jackman AM. Beyond the good prognosis: examination of an inception cohort of patients with chronic low back pain. Spine. 2000 Jan 1;25(1):115.</ref>. Most patients on disability for more than 6 months will not return to work. The number of patients returning to work approaches zero at 2 years<ref name=":2" />. Once established, chronic low back pain is persistent and achieving complete remission becomes less likely as time goes by. The question remains how to treat chronic low back pain, and can you prevent it from occurring in the first place?


<span>&nbsp;</span><br>The '''<u>local globalising system</u>''' was slated to have a primary role in the mainatancence of <u>'''spinal segement stability and stiffness.'''</u><br>The '''<u>Global stabilising system</u>''' was stated to be more superficial and with a primary function to '''<u>generate force to control movement</u>''', there is often eccentric contractions to control motion segments throughout range
== Core Stability  ==


<br>  
Many authors have attempted to define core stability, which consequently means a globally accepted definition is yet to be confirmed<ref>Huxel Bliven KC, Anderson BE. Core stability training for injury prevention. Sports health. 2013 Nov;5(6):514-22.</ref>. However, a widely accepted definition of core stability is:


==== <u>Global mobilisers</u><u></u><br> ====
<br>''“Comprises of the lumbopelvic-hip complex and is the capacity to maintain the equilibrium of the vertebral column within its physiologic limits &nbsp; by reducing displacement from perturbations and maintaining structural integrity.”''<ref>Akuthota V, Nadler SF. Core strengthening. Archives of physical medicine and rehabilitation. 2004 Mar 1;85:86-92.</ref><ref>Liemohn WP, Baumgartner TA, Gagnon LH. Measuring core stability. Journal of Strength and Conditioning Research. 2005 Aug 1;19(3):583.</ref><ref>Panjabi MM. Clinical spinal instability and low back pain. Journal of electromyography and kinesiology. 2003 Aug 1;13(4):371-9.</ref><ref>Smith CE, Nyland J, Caudill P, Brosky J, Caborn DN. Dynamic trunk stabilization: a conceptual back injury prevention program for volleyball athletes. journal of orthopaedic & sports physical therapy. 2008 Nov;38(11):703-20.</ref><ref>Willson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its relationship to lower extremity function and injury. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2005 Sep 1;13(5):316-25.</ref>


<u></u>  
The first acknowledgment of core stability was by Henry and Florence Kendall who were both Physiotherapist's and first developed the idea of a “neutral pelvis” in 1940/1950’s<ref>Rockey AM. The relationship between anterior pelvic tilt, hamstring extensibility and hamstring strength. The University of North Carolina at Greensboro; 2008.</ref>


A further active functional classification was suggested by Comerford and Mottram (2001). They have proposed the idea of '''<u>“global mobilisers</u>'''<u></u>”. The primary role of these muscles is for shock absorption and to generate the gross spinal concentric contractions required for gross motor function.  
They initially suggested that the surrounding superficial muscle groups were responsible for the maintenance of alignment and of “neutral spine”. The muscles they were referring to were the erector spinae, hamstrings, abdominals, and the hip flexors. Following on from this, it was suggested that pelvic tilt was pelvic movement deviating from the neutral position.  


<br>  
Over the years, the concept of core stability has changed and authors such as Paul Hodges have highlighted the significance and contribution of the Transverus Abdominus muscle, especially in lumbopelvic stability. Upon this basis, it has now become an important part of the management of spinal stability and e<span style="line-height: 1.5em;">xercises orientated upon the activation, recruitment, and strengthening of the core are a common avenue of treatment</span><ref>Hodges PW. Is there a role for transversus abdominis in lumbo-pelvic stability?. Manual therapy. 1999 May 1;4(2):74-86.</ref><span style="line-height: 1.5em;">.&nbsp;</span>  


==== <u>Neural</u><u></u><br>  ====
== Theories and Applications  ==


<u></u>  
In an attempt to add some clarity to the phenomena of the stabilisng system of the spine, Panjabi proposed a classification model that offered an explanation into the functioning of the spine. His model consisted of three categories<ref name=":6">Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. Journal of spinal disorders. 1992 Dec 1;5:390-.</ref><span style="line-height: 1.5em;">Active, Passive and Neural and the evident importance of core stability can be seen.</span>  


The neural component, according to Punjabi, is responsible for recieving information from the various transducers and relaying the relative signal onto the active system to achieve segmental stability. Until sufficient stability has been achieved, the neural components continue to control the active systems.<br>
=== Passive  ===
<u></u>The passive category consists of the basic components of the spine which allow for soft tissue attachment<ref name=":6" />.
* The lumbar vertebrae
* The joint capsules
* The intervertebral disc
* Ligaments surrounding the area
These structures of the spine do not contribute to any significant spinal stability in the neutral alignment. The skeletal structure does support the basic framework and the tensile properties in the various ligaments do start to resist end range movement, however, do not have the capability to produce forces that initiate spinal movement is not caused by the passive structures.  


<br>
===  Active  ===


===== Figure 1. &nbsp; =====
<u></u>The active structures hold responsibility for the initiation of gross spinal movement as well as providing contributing to spinal segmentation. <br>Bergmark (1989) further classified the active system into the local and global stabilising system<ref name=":7">Bergmark A. Stability of the lumbar spine: a study in mechanical engineering. Acta Orthopaedica Scandinavica. 1989 Jan 1;60(sup230):1-54.</ref>.  The '''local globalising system''' was slated to have a primary role in the maintenance of spinal segment stability and stiffness.  The '''global stabilising system''' was stated to be more superficial and with a primary function to generate force to control movement, there is often eccentric contractions to control motion segments throughout the range


A&nbsp;<span style="line-height: 1.5em;">model showing the relationship between the three models proposed by Punjabi (1992),&nbsp;Comerford and Mottram's (2001) and&nbsp;Bergmark (1989), which influecne "spinal stability".</span><br>  
=== Global Mobilisers<u></u>  ===
<u></u>A further active functional classification was suggested by Comerford and Mottram (2001)<ref name=":8">Comerford MJ, Mottram SL. Functional stability re-training: principles and strategies for managing mechanical dysfunction. Manual therapy. 2001 Feb 1;6(1):3-14.</ref>. They have proposed the idea of '''<u>“global mobilisers</u>'''<u></u>”. The primary role of these muscles is for shock absorption and to generate the gross spinal concentric contractions required for gross motor function.  
=== Neural<u></u>  ===
<u></u>The neural component, according to Punjabi, is responsible for receiving information from the various transducers and relaying the relative signal onto the active system to achieve segmental stability. Until sufficient stability has been achieved, the neural components continue to control the active systems.<br>


[[Image:Spinal assessment types.jpg]]
Figure 1. &nbsp;
 
===== Figure 2.  =====
 
A table proposed by Norris (2008), identifying the different characteristics between the stablisers and mobilisers.  
 
<br>
 
<br>


[[Image:Spinal assessment 2.png]]
A&nbsp;<span style="line-height: 1.5em;">model showing the relationship between the three models proposed by Punjabi (1992),&nbsp;Comerford and Mottram's (2001) and&nbsp;Bergmark (1989), which influence "spinal stability"</span><ref name=":8" /><ref name=":7" /><span style="line-height: 1.5em;">.</span>


(Norris 2008)
[[Image:Spinal assessment types.jpg]]


== <br>Relevant anatomy<br>  ==
Figure 2.


<br>
A table proposed by Norris (2008), identifying the different characteristics between the stablisers and mobilisers<ref name=":9">Norris CM. Back stability: integrating science and therapy. Human Kinetics; 2008.</ref>.


[[Image:Spinal assessment 2.png]]<ref name=":9" />
==  Relevant Anatomy  ==
<br>  
<br>  


[[Image:Spinal assessment 4.png]]
[[Image:Spinal assessment 4.png]]  
 
<span style="line-height: 1.5em;">(Kibler, Press and Sciascia 2006)</span>
 
== <br>Physiology  ==
 
<br>PICTUE TO BE PUT IN OF A PRIME MOVER MUSCLE – MOSEY DOINT A TENNIS SERVE OR SOMETHING
 
 
 
It has been stated that core is characterised by “Proximal stability for distal mobility” (Putnam 1993, Zattara and Bouisset 1988)
 
<br>When contracting, the primary role of the core stability muscles is to raise the intra-abdominal pressure and to increase the tension in the thoracolumbar fascia.
 
The increase in intra-abdominal pressure stiffens and strengthens the relevant structural support around the spine,&nbsp;compacts the arthrogenic structures and in combination with abdominal contraction, it can encourage a rigid cyclinder and stiffness to occur around the spine&nbsp;<span style="line-height: 1.5em;">&nbsp;</span><span style="line-height: 1.5em;">(McGill and Norman 1987).</span>
 
<br>This gives the spine a relative degree of stability which is needed to facilitate superficial muscle activation and gross motor action.<br>
 
==== <u>Core stability functions</u>  ====
<div><u><br></u></div><div><u></u></div>
<u></u>


<u></u>  
<ref name=":10">Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports medicine. 2006 Mar 1;36(3):189-98.</ref>  


• Anticipatory postural adjustments – pre-programmed muscle activation which helps the body to anticipate the subsequent force
==  Physiology  ==
It has been stated that core is characterised by “Proximal stability for distal mobility” <ref>Putnam CA. Sequential motions of body segments in striking and throwing skills: descriptions and explanations. Journal of biomechanics. 1993 Jan 1;26:125-35.</ref><ref>Zattara M, Bouisset S. Posturo-kinetic organisation during the early phase of voluntary upper limb movement. 1. Normal subjects. Journal of Neurology, Neurosurgery & Psychiatry. 1988 Jul 1;51(7):956-65.</ref>.  When contracting, the primary role of the core stability muscles is to raise the intra-abdominal pressure and to increase the tension in the thoracolumbar fascia.  The increase in intra-abdominal pressure stiffens and strengthens the relevant structural support around the spine,&nbsp;compacts the arthrogenic structures and in combination with abdominal contraction, it can encourage a rigid cylinder and stiffness to occur around the spine<ref>McGill SM, Norman RW. Reassessment of the role of intra-abdominal pressure in spinal compression. Ergonomics. 1987 Nov 1;30(11):1565-88.</ref>.  This gives the spine a relative degree of stability which is needed to facilitate superficial muscle activation and gross motor action.[[Image:Timothy 4.JPG|thumb|right]][[Image:Timothy 2.JPG|thumb|left]]


• To create interactive moments that help to control the exposure of force and loading that is applied to a joint&nbsp;
[[Image:Timothy 1.JPG|thumb|center]] 


• To help in force control throughout the various locations in the body  
=== Core Stability Functions  ===
* <u></u><u></u><u></u>Anticipatory postural adjustments – pre-programmed muscle activation which helps the body to anticipate the subsequent force
* To create interactive moments that help to control the exposure of force and loading that is applied to a joint&nbsp;
* To help in force control throughout the various locations in the body  
<ref name=":10" /><span style="line-height: 1.5em;"></span>
== Typical Core Exercises  ==


<span style="line-height: 1.5em;">(Kibler, Press and Sciascia 2006)</span>  
A lumbopelivic stability programme is constructed in three sections<ref>Richardson C, Hodges P, Hides J. Therapeutic exercise for lumbopelvic stabilization. Edinburgh: Churchill Livingstone; 2004 May.</ref>.
<div><span style="line-height: 1.5em;">
* Section 1 - Entails segmental control and active recruitment over global mobilisers - specifically transversus abdominus, pelvic floor, and diaphragm
</span></div>
* Section 2 - Whilst maintaining segmental control and activation, introducing closed chain exercises, with low velocity and low load.&nbsp;  
* Section 3 - Whilst maintaining segmental control, introducing open-chain exercises with high velocity and load. Movement of adjacent body segments can be used to stress the core structures<br>  
Many of the specific exercises listed below have been proven to significantly increase general health, sports functioning, and significantly decrease in pain<ref>Gladwell V, Head S, Haggar M, Beneke R. Does a program of Pilates improve chronic non-specific low back pain?. Journal of sport rehabilitation. 2006 Nov 1;15(4):338-50.</ref>.{{#ev:youtube|Cwy5KhHYJYs|300}} 


== Typical core exercises ==
{{#ev:youtube|mYgNq9pCBE8|300}}  


<span>&nbsp;</span>
{{#ev:youtube|RMoZji7yW40|300}}


A lumbo-pelivic stability programme is constructed in three sections&nbsp;<span style="line-height: 1.5em;">(Richardson, Hodges and Hides (2004)</span>.
===  Phase 2  ===


Section 1 - Entails segmental control and active recruitment over global mobilisers - specifically transversus abdominus, pelvic floor and diaphragm
==== Bridging ====
<u></u>{{#ev:youtube|RMoZji7yW40|300}}


Section 2 - Whislt maintianing segmental control and activation, introducing closed chain exercises, with low velocity and low load.&nbsp;
==== <u></u>Single Leg Fall Out<u></u> ====
{{#ev:youtube|82qq1gV-Jt8|300}}


Section 3 - Whilst maintaining segmental control, introducing open chain exercises with high velocity and load. Movement of adjacent body segements can be used to stress the core structures<br>
==== Single Leg Extension in Supine<u></u> ====
 
{{#ev:youtube|bjR0SczylUg|300}}
 
 
Many of the specific exercises listed below have been proven to significantly increase &nbsp;general health, sports functioning, and significantly decrease in pain.<span style="line-height: 1.5em;">(Gladwell, Head, Haggar et al 2006)</span>
 
<br> {{#ev:youtube|Cwy5KhHYJYs|300}}
 
<br>
 
{{#ev:youtube|mYgNq9pCBE8|300}}
 
<br>
 
{{#ev:youtube|RMoZji7yW40|300}}
 
== <br>Phase 2  ==
 
<u>Bridging&nbsp;</u>
 
<u></u>{{#ev:youtube|RMoZji7yW40|300}}<br>
 
<u></u>
 
<u>Single leg fall out</u><u></u>
 
{{#ev:youtube|82qq1gV-Jt8|300}}
 
<br>
 
<u>Single leg extension in supine</u><u></u><br>
 
{{#ev:youtube|bjR0SczylUg|300}}<br>
 
<br>
 
<u>Basic 4 point Kneeling</u>


==== Basic 4 Point Kneeling ====
{{#ev:youtube|VdJchjWg63w|300}}  
{{#ev:youtube|VdJchjWg63w|300}}  


<br>
==== Advanced 4 Point Kneeling ====
 
<u>Advanced 4 point Kneeling</u>
 
{{#ev:youtube|u8FHp3ef-bw|300}}  
{{#ev:youtube|u8FHp3ef-bw|300}}  


<br> <br> <br>The modified one leg stretch: Crook lying, slide one leg away as far as possible and then return to start position. <br>The modified shoulder bridge: Crook lying, “peeling” the bottom off the mat. Progression: Increase the range of movement (more of the spine away from the mat).<br>Swimming (a modification from a four point base): Box position, slide one foot along the floor behind, return to the start position. Repeat on other leg.<br>
<br><br>The modified one leg stretch: Crook lying, slide one leg away as far as possible and then return to start position. <br>The modified shoulder bridge: Crook lying, “peeling” the bottom off the mat. Progression: Increase the range of movement (more of the spine away from the mat).<br>Swimming (a modification from a four point base): Box position, slide one foot along the floor behind, return to the start position. Repeat on other leg.  


<br>
=== Phase 3.  ===
 
<u></u>
== Phase 3.  ==
 
<u></u>
 
<u><span>&nbsp;Bridging progression onto a pilates ball</span></u>  


==== <span>&nbsp;Bridging Progression Onto a Pilates Ball</span> ====
{{#ev:youtube|hHkMOpI_P6c|300}}  
{{#ev:youtube|hHkMOpI_P6c|300}}  


<br>
==== Pilates Ball Plank ====
 
<u>Pilates ball plank</u>
 
{{#ev:youtube|0LaYE5S2DUo|300}}  
{{#ev:youtube|0LaYE5S2DUo|300}}  


= Recent Evidence  =
== Recent Evidence  ==


This chapter will look at the evidence which shows postitive effects and ambiguity of core stability for chronic low back pain. The European Guidelines have stated that the following are recommended in the management of chronic non-specific low back pain: cognitive behavioural therapy, exercise therapy and educational therapy (Airaksinen el al, 2006). When searching the literature, studies only compared core stabililty exercise with general exerise therapy out of the European Guidelines recommendations.  
The European Guidelines have stated that the following are recommended in the management of chronic non-specific low back pain: cognitive behavioural therapy, exercise therapy and educational therapy<ref>Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, Mannion AF, Reis S, Staal JB, Ursin H, Zanoli G. European guidelines for the management of chronic nonspecific low back pain. European spine journal. 2006 Mar;15(Suppl 2):s192.</ref>. When searching the literature, studies only compared core stability exercise with general exercise therapy out of the European Guidelines recommendations.  


Pain and function were selected as outcome measures to determine the effectiveness of core stability exercises as these were the consistent outcome measures in the evidence and have been shown to be major factor of psychosocial well-being of patients &nbsp;(Gureje et al, 1998; Stevens et al, 1996).&nbsp;  
Pain and function were selected as outcome measures to determine the effectiveness of core stability exercises as these were the consistent outcome measures in the evidence and have been shown to be a major factor of the psychosocial well-being of patients<ref>Gureje O, Von Korff M, Simon GE, Gater R. Persistent pain and well-being: a World Health Organization study in primary care. Jama. 1998 Jul 8;280(2):147-51.</ref> <ref>Stevens SE, Steele CA, Jutai JW, Kalnins IV, Bortolussi JA, Biggar WD. Adolescents with physical disabilities: some psychosocial aspects of health. Journal of adolescent health. 1996 Aug 1;19(2):157-64.</ref>.&nbsp;  


== Evidence For<br>  ==
=== Evidence For   ===


[[Image:Table 1 Core Stability.png|860x480px]]  
[[Image:Table 1 Core Stability.png|860x480px]]  


== <br>  ==
=== <span>Evidence Against</span>  ===
 
== <span>Evidence Against</span>  ==


== [[Image:Core exercises for clbp 1.png|860x480px]]<br><br>[[Image:Core exercises for clbp 2.png|860x480px]]  ==
== [[Image:Core exercises for clbp 1.png|860x480px]] [[Image:Core exercises for clbp 2.png|860x480px]]  ==


== Conclusion  ==
== Conclusion  ==


The meta-analysis showed core stability exercise has signficant improvement in both pain and function compared to general exercise for patients with chronic low back pain. However these findings were only significant in the short term. In contrast, evidence published since this meta-analysis has found no significant difference between core stability and general exercises neither short term nor long term even though both interventions did improve pain and function. It should be noted though that no study reported adverse effects from core stability exercise when compared to general exercise with respect to pain and function.&nbsp;  
The meta-analysis showed core stability exercise has significant improvement in both pain and function compared to general exercise for patients with chronic low back pain. However, these findings were only significant in the short term. In contrast, evidence published since this meta-analysis has found no significant difference between core stability and general exercises neither short term nor long term even though both interventions did improve pain and function. It should be noted though that no study reported adverse effects from core stability exercise when compared to general exercise with respect to pain and function.&nbsp;  
 
<br>
 
In conclusion these findings show that clinicians have a choice to either administer core stability exercise or general exercise when a patient has chronic non-specific low back pain. Core stability exercise can be used as an alternative to general strengthening and stretching if patient is more suitable and if it would encourage compliance. However clinicians should not expect a significant improvement by choosing core stability in regards to pain and function especially in the long term.<br>
 
= Limitations<br>  =
 
The wealth of literature available compared core stability exercises to general exercise. Although there is literature to support the use of other therapies e.g. CBT, mobilisations and pharmacology they have not been compared directly to core stability exercises. Therfore further research is required into these areas. &nbsp;
 
= References  =
 
Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, Mannion AF, Reis S, Staal JB, Ursin H, Zanoli G. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006 Mar;15 Suppl 2:S192-300.
 
<span style="line-height: 1.5em;">Akuthota, V, SF Nadler. Core strengthening, Archives of Physical Medical Rehabilitation, 2004, 85(3)(suppl 1):S86-S92.</span><span style="line-height: 1.5em;">&nbsp;</span>
 
Andersson, G. B. J. (1997). The epidemiology of spinal disorders. The adult spine: Principles and practice.
 
Bergmark, Anders. Stability of the lumbar spine:A study in mechanical engineering. Acta Orthopaedica Scandinavica Supplementum, 1989, VOL. 60, NO. 230
 
Carey, T. S., Garrett, J. M., &amp; Jackman, A. M. (2000). Beyond the good prognosis: examination of an inception cohort of patients with chronic low back pain. Spine, 25(1), 115.
 
Cherkin, D. C., Deyo, R. A., Street, J. H., &amp; Barlow, W. (1996). Predicting poor outcomes for back pain seen in primary care using patients' own criteria. Spine, 21(24), 2900-2907.
 
Comerford, M. J, S. L. Mottram. Functional stability re-training: principles and strategies for managing mechanical dysfunction, Manual Therapy, 2001, 6(1), 3±14
 
Dagenais, S., Caro, J., &amp; Haldeman, S. (2008). A systematic review of low back pain cost of illness studies in the United States and internationally. The Spine Journal, 8(1), 8-20.
 
Deyo, R. A., &amp; Bass, J. E. (1989). Lifestyle and low-back pain: the influence of smoking and obesity. Spine, 14(5), 501-506.
 
Deyo, R.A., Weinstein, J.N.(2001)Low back pain. New England Journal of Medicine;344(5):363–70.
 
Diamond, S., &amp; Borenstein, D. (2006). Chronic low back pain in a working-age adult. Best Practice &amp; Research Clinical Rheumatology, 20(4), 707-720.
 
Epping-Jordan, J. E., Wahlgren, D. R., Williams, R. A., Pruitt, S. D., Slater, M. A., Patterson, T. L., ... &amp; Atkinson, J. H. (1998). Transition to chronic pain in men with low back pain: predictive relationships among pain intensity, disability, and depressive symptoms. Health Psychology, 17(5), 421.
 
Gladwell ,Valerie, Samantha Head, Martin Haggar And Ralph Beneke. Does a Program of Pilates Improve Chronic Non-Specific Low Back Pain? Journal of sports rehabilitation, 2006, 15, 338-350
 
Gureje O, Von Korff M, Simon GE, Gater R. Persistent pain and well-being: a World Health Organization Study in Primary Care. JAMA. 1998 Jul 8;280(2):147-51.
 
Hodges, P.W. Is there a role for transverus abdominus in lumbo-pelvic stability? Manual therapy, 1999, 4 (2), 74±86.
 
Huxel Bliven, Kellie C, Barton E Anderson. Core stability training for injury prevention, Sports Health: A Multidisciplinary Approach, 2013, Volume 5, 514.
 
Kent, Christine. The end of the “neutral pelvis” – part 1[online]. Albuquerque, 2012 [ 10/01/14]. Available from: http://wholewoman.com/blog/?p=1074
 
Kibler, Ben W, Joel Press and Aaron Sciascia. The role of core stability in athletic function, Sports medicine, 2006, 36(3): 189-98
 
Lee, T., Kim, Y., Sung, P. (2011) A comparison of pain level and entropy changes following core stability exercise intervention. International medical journal of experimental and clinical research. 17(7): pp.362-368
 
Liemohn, Wp, Ta Baumgartner, Lh Gagnon. Measuring core stability. Journal of Strength abd Conditioning Research/ National strength and conditioning association, 2005, 19(3):583-586.
 
Maher, C. G. (2004). Effective physical treatment for chronic low back pain. Orthopedic Clinics of North America, 35(1), 57-64.
 
Mcgill, SM and RW Norman. Reassessment of the role of intra-abdominal pressure in spinal compression. Ergonomics, 1987, 30(11):1565-88
 
Norris, CM. Back Stability. Human Kinetics. Champaign, 2008,
 
Patel, A. T., &amp; Ogle, A. A. (2000). Diagnosis and management of acute low back pain. American family physician, 61(6), 1779.
 
Panjabi, MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. Journal of Spinal Disorders. 1992, 5:390-396
 
Panjabi, MM. Clinical spinal instability and low back pain. Journal of Electromyography and Kinesiology. 2003, 13:371-379.<br>
 
Pengel, L. H., Herbert, R. D., Maher, C. G., &amp; Refshauge, K. M. (2003). Acute low back pain: systematic review of its prognosis. Bmj, 327(7410), 323.
 
Putnam, CA. Sequential motions of body segments in striking and throwing skills: descriptions and explanations. Journal of Biomechanics, 1993, 26 (1):125-35
 
Richardson CA, PW Hodges, J Hides. Therapeutic Exercise for Lumbo-pelvic Stabilization: A Motor Control Approach for the Treatment and Prevention of Low Back Pain. 2 edition. Edinburgh: Churchill Livingstone; 2004.
 
Savigny, P., Watson, P., &amp; Underwood, M. (2009). Early management of persistent non-specific low back pain: summary of NICE guidance. BMJ, 338.
 
Sierpina, V. S., Curtis, P., &amp; Doering, J. (2002). An integrative approach to low back pain. Clinics in Family Practice, 4(4), 817-831.
 
Smith, CE, J Nyland, P Caudill, J Brosky, DN Caborn. Dynamic trunk stabilization: a conceptual back injury prevention program for volleyball athletes. Journal of Orthopaedic Sports Physical Therapy. 2008,38:703-720.
 
Stevens SE, Steele CA, Jutai JW, Kalnins IV, Bortolussi JA, Biggar WD. Adolescents with physical disabilities: some psychosocial aspects of health. J Adolesc Health. 1996 Aug;19(2):157-64.
 
Thomas, E., Silman, A. J., Croft, P. R., Papageorgiou, A. C., Jayson IV, M., &amp; Macfarlane, G. J. (1999). Predicting who develops chronic low back pain in primary care: a prospective study. Bmj, 318(7199), 1662-1667.
 
van den Hoogen, H. J., Koes, B. W., van Eijk, J. T. M., Bouter, L. M., &amp; Devillé, W. (1998). On the course of low back pain in general practice: a one year follow up study. Annals of the rheumatic diseases, 57(1), 13-19.
 
Van Tulder, M. W., Koes, B. W., &amp; Bouter, L. M. (1997). Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions. Spine, 22(18), 2128-2156.
 
Von Korff, M., &amp; Saunders, K. (1996). The course of back pain in primary care. Spine, 21(24), 2833-2837.
 
Vos, T., Flaxman, A. D., Naghavi, M., Lozano, R., Michaud, C., Ezzati, M., ... &amp; Brooks, P. (2013). Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet, 380(9859), 2163-2196.


Waddell, G. (2004). The back pain revolution (Vol. 265482). Edinburgh: Churchill Livingstone.<br>
In conclusion, these findings show that clinicians have a choice to either administer core stability exercise or general exercise when a patient has chronic non-specific low back pain. Core stability exercise can be used as an alternative to general strengthening and stretching if the patient is more suitable and if it would encourage compliance. However, clinicians should not expect a significant improvement by choosing core stability in regards to pain and function, especially in the long term.  


Wajswelner, H., Metcalf, B., Bennell, K. (2012). Clinical pilates versus general exercise for chronic low back pain: randomized trial. Medicine and science in sports and exercise. 44(7): pp.1197-1205
== Limitations  ==


Wang XQ, Zheng JJ, Yu ZW, Bi X, Lou SJ, Liu J, Cai B, Hua YH, Wu M, Wei ML, Shen HM, Chen Y, Pan YJ, Xu GH, Chen PJ. A meta-analysis of core stability exercise versus general exercise for chronic low back pain.PLoS One. 2012;7(12):e52082.
The wealth of literature available compared core stability exercises to general exercise. Although there is literature to support the use of other therapies e.g. CBT, mobilisations, and pharmacology they have not been compared directly to core stability exercises. Therefore further research is required in these areas. &nbsp;  


Willson, JD, CP Dougherty, ML Ireland, IM Davis. Core stability and its relationship to lower extremity function and injury. Journal of American Academy of orthopaedic Surgeons, 2005, 13:316-32
== References  ==
<references />
[[Category:Nottingham University Spinal Rehabilitation Project]]
[[Category:Lumbar Spine]]
[[Category:Lumbar Spine - Interventions]]
[[Category:Interventions]]
[[Category:Exercise Therapy]]

Latest revision as of 23:53, 19 November 2020

Original Editor - Yann Moysey, Josh Plail, Timothy Sheehy and Samuel Soroya, as part of the Nottingham University Spinal Rehabilitation Project

Top Contributors - Josh Plail, Yann Moysey, Timothy Sheehy, Samuel Soroya, Kim Jackson, Rachael Lowe and Admin  

Introduction[edit | edit source]

lowerleftbackpain.info/wp-content/uploads/2012/09/lower-back-pain.jpg

Low back pain is an extremely common patient complaint with approximately 80% of the World population developing low back pain at some point[1]. 1/3 of the UK population will experience back pain each year[2]. It is the main cause of years lived with disability[3]. It is among 10 of the leading reasons for patient visits to medical facilities.[4] Non-specific low back pain is tension/soreness and or stiffness in the lower back region whereby it is not possible to find a cause for the pain[2]. Most cases resolve fairly quickly, but a significant number of patients develop chronic lower back pain. Patients experience unremitting pain and often become functionally impaired. Chronic LBP represents a greater financial burden in the form of direct costs resulting from loss of work and medical expenses, as well as indirect costs[5]. 

Prevalence[edit | edit source]

Generally there is a scarcity of information on the prevalence and incidence of chronic low back pain, partly due to lack of agreement about its definition. Chronic low back pain is mostly defined as persistent pain occurring on most days and lasting longer than 3 months[6][7][8]. Others also define it as pain exceeding normal healing times and frequently reoccurring back pain over long periods. Acute and chronic LBP warrant separate consideration as they may respond differently to the same interventions[9][10].

Causes[edit | edit source]

Mechanical disorders are the cause in 90% of cases with the remaining 10% of cases being due to manifestation of systemic illness[11]. Despite a large number of pathological conditions that give rise to low back pain cases, 85% are without pathoanatomical or radiological abnormalities[1]. Most episodes of low back pain resolve quickly and are not incapacitating, nonetheless, pain and disability are often ongoing and recurrences are common[12]. It is estimated 10 to 20% of affected adults develop symptoms of chronic low back painback-pain[13].

40

Risk Factors[edit | edit source]

Many different patient characteristics have been described that predict who is at risk of developing chronic LBP. However, only a few have been replicated consistently in multiple studies. These include increasing age, previous back pain, job dissatisfaction, pain below the knee and depression.[14][15][16] Depression has long been noted to be associated with various chronic pain syndromes, and several studies have reported it’s relationship with chronic back pain in particular in multiple studies[16]. Women are more commonly affected with LBP and some studies show increases in chronic LBP[15]. Thomas et al. (1999) found that persistent back pain was associated with “premorbid factors” such as poor baseline functional status, high levels of psychological stress, poor self-rated health, low levels of physical activity, smoking and obesity[17]. Smoking has been found in multiple epidemiological studies to be a risk factor for the development of chronic low back pain[18].

Prognosis[edit | edit source]

The longer the patient suffers from back pain the worse the prognosis. The chance of low back pain resolving is its highest during the first week[14]. By the end of year one that chance diminishes significantly. In Van den Hoogen et al. 1998's study on the course of low back pain, 35% patients had pain at 12 weeks and 10% of patients had pain at 1 year.[19] Thomas et al. 1999 reported similar outcomes at 1 year with 10% of patients complaining of the same back pain form the first episode[17]. Carey et al. 2000 found that 2/3 of patients with chronic low back pain at 3 months still had functionally disabling symptoms at 22months and only 16% of patients became symptom-free[20]. Most patients on disability for more than 6 months will not return to work. The number of patients returning to work approaches zero at 2 years[14]. Once established, chronic low back pain is persistent and achieving complete remission becomes less likely as time goes by. The question remains how to treat chronic low back pain, and can you prevent it from occurring in the first place?

Core Stability[edit | edit source]

Many authors have attempted to define core stability, which consequently means a globally accepted definition is yet to be confirmed[21]. However, a widely accepted definition of core stability is:


“Comprises of the lumbopelvic-hip complex and is the capacity to maintain the equilibrium of the vertebral column within its physiologic limits   by reducing displacement from perturbations and maintaining structural integrity.”[22][23][24][25][26]

The first acknowledgment of core stability was by Henry and Florence Kendall who were both Physiotherapist's and first developed the idea of a “neutral pelvis” in 1940/1950’s[27]

They initially suggested that the surrounding superficial muscle groups were responsible for the maintenance of alignment and of “neutral spine”. The muscles they were referring to were the erector spinae, hamstrings, abdominals, and the hip flexors. Following on from this, it was suggested that pelvic tilt was pelvic movement deviating from the neutral position.

Over the years, the concept of core stability has changed and authors such as Paul Hodges have highlighted the significance and contribution of the Transverus Abdominus muscle, especially in lumbopelvic stability. Upon this basis, it has now become an important part of the management of spinal stability and exercises orientated upon the activation, recruitment, and strengthening of the core are a common avenue of treatment[28]. 

Theories and Applications[edit | edit source]

In an attempt to add some clarity to the phenomena of the stabilisng system of the spine, Panjabi proposed a classification model that offered an explanation into the functioning of the spine. His model consisted of three categories[29]Active, Passive and Neural and the evident importance of core stability can be seen.

Passive[edit | edit source]

The passive category consists of the basic components of the spine which allow for soft tissue attachment[29].

  • The lumbar vertebrae
  • The joint capsules
  • The intervertebral disc
  • Ligaments surrounding the area

These structures of the spine do not contribute to any significant spinal stability in the neutral alignment. The skeletal structure does support the basic framework and the tensile properties in the various ligaments do start to resist end range movement, however, do not have the capability to produce forces that initiate spinal movement is not caused by the passive structures.

Active[edit | edit source]

The active structures hold responsibility for the initiation of gross spinal movement as well as providing contributing to spinal segmentation.
Bergmark (1989) further classified the active system into the local and global stabilising system[30]. The local globalising system was slated to have a primary role in the maintenance of spinal segment stability and stiffness. The global stabilising system was stated to be more superficial and with a primary function to generate force to control movement, there is often eccentric contractions to control motion segments throughout the range

Global Mobilisers[edit | edit source]

A further active functional classification was suggested by Comerford and Mottram (2001)[31]. They have proposed the idea of “global mobilisers”. The primary role of these muscles is for shock absorption and to generate the gross spinal concentric contractions required for gross motor function.

Neural[edit | edit source]

The neural component, according to Punjabi, is responsible for receiving information from the various transducers and relaying the relative signal onto the active system to achieve segmental stability. Until sufficient stability has been achieved, the neural components continue to control the active systems.

Figure 1.  

A model showing the relationship between the three models proposed by Punjabi (1992), Comerford and Mottram's (2001) and Bergmark (1989), which influence "spinal stability"[31][30].

Spinal assessment types.jpg

Figure 2.

A table proposed by Norris (2008), identifying the different characteristics between the stablisers and mobilisers[32].

Spinal assessment 2.png[32]

Relevant Anatomy[edit | edit source]


Spinal assessment 4.png

[33]

Physiology[edit | edit source]

It has been stated that core is characterised by “Proximal stability for distal mobility” [34][35]. When contracting, the primary role of the core stability muscles is to raise the intra-abdominal pressure and to increase the tension in the thoracolumbar fascia. The increase in intra-abdominal pressure stiffens and strengthens the relevant structural support around the spine, compacts the arthrogenic structures and in combination with abdominal contraction, it can encourage a rigid cylinder and stiffness to occur around the spine[36]. This gives the spine a relative degree of stability which is needed to facilitate superficial muscle activation and gross motor action.

Timothy 4.JPG
Timothy 2.JPG
Timothy 1.JPG

Core Stability Functions[edit | edit source]

  • Anticipatory postural adjustments – pre-programmed muscle activation which helps the body to anticipate the subsequent force
  • To create interactive moments that help to control the exposure of force and loading that is applied to a joint 
  • To help in force control throughout the various locations in the body

[33]

Typical Core Exercises[edit | edit source]

A lumbopelivic stability programme is constructed in three sections[37].

  • Section 1 - Entails segmental control and active recruitment over global mobilisers - specifically transversus abdominus, pelvic floor, and diaphragm
  • Section 2 - Whilst maintaining segmental control and activation, introducing closed chain exercises, with low velocity and low load. 
  • Section 3 - Whilst maintaining segmental control, introducing open-chain exercises with high velocity and load. Movement of adjacent body segments can be used to stress the core structures

Many of the specific exercises listed below have been proven to significantly increase general health, sports functioning, and significantly decrease in pain[38].

Phase 2[edit | edit source]

Bridging[edit | edit source]

Single Leg Fall Out[edit | edit source]

Single Leg Extension in Supine[edit | edit source]

Basic 4 Point Kneeling[edit | edit source]

Advanced 4 Point Kneeling[edit | edit source]



The modified one leg stretch: Crook lying, slide one leg away as far as possible and then return to start position.
The modified shoulder bridge: Crook lying, “peeling” the bottom off the mat. Progression: Increase the range of movement (more of the spine away from the mat).
Swimming (a modification from a four point base): Box position, slide one foot along the floor behind, return to the start position. Repeat on other leg.

Phase 3.[edit | edit source]

 Bridging Progression Onto a Pilates Ball[edit | edit source]

Pilates Ball Plank[edit | edit source]

Recent Evidence[edit | edit source]

The European Guidelines have stated that the following are recommended in the management of chronic non-specific low back pain: cognitive behavioural therapy, exercise therapy and educational therapy[39]. When searching the literature, studies only compared core stability exercise with general exercise therapy out of the European Guidelines recommendations.

Pain and function were selected as outcome measures to determine the effectiveness of core stability exercises as these were the consistent outcome measures in the evidence and have been shown to be a major factor of the psychosocial well-being of patients[40] [41]. 

Evidence For[edit | edit source]

Table 1 Core Stability.png

Evidence Against[edit | edit source]

Core exercises for clbp 1.png Core exercises for clbp 2.png[edit | edit source]

Conclusion[edit | edit source]

The meta-analysis showed core stability exercise has significant improvement in both pain and function compared to general exercise for patients with chronic low back pain. However, these findings were only significant in the short term. In contrast, evidence published since this meta-analysis has found no significant difference between core stability and general exercises neither short term nor long term even though both interventions did improve pain and function. It should be noted though that no study reported adverse effects from core stability exercise when compared to general exercise with respect to pain and function. 

In conclusion, these findings show that clinicians have a choice to either administer core stability exercise or general exercise when a patient has chronic non-specific low back pain. Core stability exercise can be used as an alternative to general strengthening and stretching if the patient is more suitable and if it would encourage compliance. However, clinicians should not expect a significant improvement by choosing core stability in regards to pain and function, especially in the long term.

Limitations[edit | edit source]

The wealth of literature available compared core stability exercises to general exercise. Although there is literature to support the use of other therapies e.g. CBT, mobilisations, and pharmacology they have not been compared directly to core stability exercises. Therefore further research is required in these areas.  

References[edit | edit source]

  1. ↑ 1.0 1.1 Deyo RA, Weinstein JN. New England Journal of Medicine. NEJM. 2001;344(5)):363-70.
  2. ↑ 2.0 2.1 Savigny P, Watson P, Underwood M. Early management of persistent non-specific low back pain: summary of NICE guidance. Bmj. 2009 Jun 4;338:b1805.
  3. ↑ Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V, Abraham J. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The lancet. 2012 Dec 15;380(9859):2163-96.
  4. ↑ Patel AT, Ogle AA. Diagnosis and management of acute low back pain. American family physician. 2000 Mar;61(6):1779-86.
  5. ↑ Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. The spine journal. 2008 Jan 1;8(1):8-20.
  6. ↑ Maher CG. Effective physical treatment for chronic low back pain. Orthopedic Clinics. 2004 Jan 1;35(1):57-64.
  7. ↑ Von Korff M, Saunders K. The course of back pain in primary care. Spine. 1996 Dec 15;21(24):2833-7.
  8. ↑ Waddell G, Schoene M. The back pain revolution. Elsevier Health Sciences; 2004.
  9. ↑ Sierpina V, Curtis P, Doering J. An integrative approach to low back pain. Clinics in Family Practice. 2002 Dec;4(4):817-31.
  10. ↑ Van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions. Spine. 1997 Sep 15;22(18):2128-56.
  11. ↑ Nachemson AL. The lumbar spine an orthopaedic challenge. spine. 1976 Mar 1;1(1):59-71.
  12. ↑ Pengel LH, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: systematic review of its prognosis. Bmj. 2003 Aug 7;327(7410):323.
  13. ↑ Diamond S, Borenstein D. Chronic low back pain in a working-age adult. Best practice & research Clinical rheumatology. 2006 Aug 1;20(4):707-20.
  14. ↑ 14.0 14.1 14.2 Andersson GB. The epidemiology of spinal disorders. Frymoyer JW The adult spine: principles and practice. 1997. Philadelphia.
  15. ↑ 15.0 15.1 Cherkin DC, Deyo RA, Street JH, Barlow W. Predicting poor outcomes for back pain seen in primary care using patients' own criteria. Spine. 1996 Dec 15;21(24):2900-7.
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  17. ↑ 17.0 17.1 Thomas E, Silman AJ, Croft PR, Papageorgiou AC, Jayson MI, Macfarlane GJ. Predicting who develops chronic low back pain in primary care: a prospective study. Bmj. 1999 Jun 19;318(7199):1662-7.
  18. ↑ Deyo RA, Bass JE. Lifestyle and low-back pain. The influence of smoking and obesity. Spine. 1989 May;14(5):501-6.
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  21. ↑ Huxel Bliven KC, Anderson BE. Core stability training for injury prevention. Sports health. 2013 Nov;5(6):514-22.
  22. ↑ Akuthota V, Nadler SF. Core strengthening. Archives of physical medicine and rehabilitation. 2004 Mar 1;85:86-92.
  23. ↑ Liemohn WP, Baumgartner TA, Gagnon LH. Measuring core stability. Journal of Strength and Conditioning Research. 2005 Aug 1;19(3):583.
  24. ↑ Panjabi MM. Clinical spinal instability and low back pain. Journal of electromyography and kinesiology. 2003 Aug 1;13(4):371-9.
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  41. ↑ Stevens SE, Steele CA, Jutai JW, Kalnins IV, Bortolussi JA, Biggar WD. Adolescents with physical disabilities: some psychosocial aspects of health. Journal of adolescent health. 1996 Aug 1;19(2):157-64.
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