Strengthening The Core Will Not Always Work

Tuesday, 29 June 2010 11:00

CORE MUSCLES AREN'T ALWAYS GOING TO CREATE A HEALTHY SPINE

Often it is heard that in order to bullet proof our back we need to create a strong "core." However, as strong as this information is, it may not be relevant for all individuals. Clinically, an individual that has a weak core will no doubt be benefited from strengthening the core; however, often the individual will present with a strong core and still be troubled by disabling lower back pain. Body builders are a great example of this. I see many as patients and let me be the first to say, they don't have perfect spines.
The research shows that strength may in fact, have little to do with the quality of the lower back. What may be more important, regarding the muscles of the core, is endurance and speed. Even more important is the fact that the spine is highly unstable (on its own) and must be placed into an optimum position or posture to reduce load; compression, shear, and distraction. Lumbar spine trouble is multi-faceted and needs to be analyzed systematically to arrive at a successful conclusion for care.

So this leaves us in a position of determining what the client may actually need. Do they need to improve some component of the muscular system or do they need to improve some component of their neurological capability (i.e. movement). This is an enormous notion because it makes the problem approachable in a systematic manner. Often the problem of lower back pain is showered with a core strengthening approaches as a solution. Time and time again, trainers are discouraged because the pain levels remain the same or worsen as core strength increases. The problem usually lies in the understanding of the mechanism of injury surrounding the lower back.

There are many clinicians that have had multiple patients in attendance clinically which have had surgery, rehabilitation, pain management and every other treatment under the sun with little or no result. Often they find all that is needed is an organized look at all the systems in operation. What I mean is, often the patient has areas peripheral to the site of injury that may be culprit to the pain generator. Also, there may be many other factors not apparent affecting the injury. For instance, I recently had a patient that had undergone two discectomies in the course of a couple months. His pain levels were around 7-8 upon specific movements and he was in a constant state of discomfort. He was also taking morphine on a regular basis to cope with the pain. In his case, the physiotherapist had worked immensely on re-grooving motor patterns, strengthening the core and lengthening muscles but had failed to get lasting results. The pain management specialist and clinical psychologist were both futile in their approach as well.

When the patient presented to me we spent about an hour just talking about him and his problem. We discussed many areas of his life and I came to the conclusion that I may be able to help facilitate his healing. Long story short, I figured much of the problem was spawning from multiple adhesions around the surgery site. These were internal but it appeared to be affecting his hamstring strength and coordination; which is what tipped me off. 4 weeks of intensive care (3x per week for 30 minutes) we mobilized nerve tissue and lengthened only the hamstrings. In addition, we also worked on shutting down his overly energetic spinal extensors. After two weeks he was off the morphine and after 4 weeks his pain was minimal. Nearly a year has passed and he remains stable and strong. What caused the need for the initial surgery? Most likely, given his history and the activity of his spinal extensors, it was improper movement leading to unjustified compression which damaged the disc.

The moral of that case is sometimes the solution is simple but not apparent. Core strengthening in his case, proved to be detrimental. It increased his strength, but in the long run increased his pain. The scar tissue from the excessive surgery was most likely the culprit but had been missed. Often technology and procedures conceal us from the solution and the solution is only as complicated as the problem itself.
The following flow chart is a simple ideology that I use when deciding what to do with chronic lower back pain. Please understand that I use this AFTER I screen for any serious red/yellow flag category sources. Also, some clients that have been in excessive pain for years or are in excessive present pain, require slight modifications to the flowchart. There is no absolute science.

The bracing ability plays an important role in the patient's initial success because it will show the patient's ability to react to dynamic situations. I will take my whole hand and rake across the stomach and instruct the patient to brace or tighten the abdomen. There should be no bulging of the stomach; they should only be contracting the abdomen. If the patient is able to do this well and quickly it is assumed they are capable of doing this involuntarily. If they cannot do it consciously, then I know they probably cannot do it involuntarily, which means they cannot protect their spine under dynamic conditions. Please refer to elementary anatomy text or pictures to understand why this is.

If the patient/client is able to brace, I then begin examining their movement strategies. This begins (for me as a physician) in the waiting room. How do they get out of their chair? How do they walk into the exam room? If they are flexed or antalgic then I know we may have a problem. If they use their spine predominantly to stand and sit, then I also know this is a problem. Think of the spinal tissues as a credit card. The credit card is resilient but if bent back and forth so many times, will yield to the stress and ultimately break. The same goes with the spinal tissues. A constant barrage of these movements over years or decades will result in a lowered threshold or tolerance. However, this doesn't mean that flexing is always bad. I will use another analogy. Imagine someone who eats brownies now and then but is healthy otherwise; not so bad. Now imagine someone who consumes brownies day in and day out, is overweight and struggling with their health. The brownies aren't the problem, the habit is the problem. Fix the habit and the problem is solved.

If the clients habits are intact and they are able to load and unload without compromise of their posture or movement then I can begin examining the muscular ability. I do this by testing endurance of the lateral walls and anterior walls. There are multitudes of ways to do this but the least likely to contribute to undue pressure/compression is the side bridge and the 45 degree static sit up. Each patient has a different ideal time that they can statically hold these. For instance a 65 year old male is different from a 25 year old male. Moreover, there are obvious differences male to female (see here for more information). This seems obvious but it is important to make sure you are on track with this information. Moreover, if I need to be more detailed, which clinically may be the case; I can look at the extensors as well and then find the ratio of the side bridge tests to the extensor tests (see here for more information). Specific findings here may lead me to believe there is other forces suspect in causing trouble in the lower back. If all testing proves to be a success then I am confident that strengthening or improving endurance of the core will not be of benefit. From this point on I can begin to look at a multitude of factors that may also be culprit. In addition, many of these suspects may be detected during the simple analysis of their movement and habits.

So what I am saying is that, at any time, other ideas may be tested. I just use the previous flow chart as a guideline, not a set of concrete rules.
This methodology has proven consistent to me both clinically and in the fitness centre, time and time again. As with anything, it is important that you adapt it to your own methodology. If you fail to do so, then you will fail to understand for yourself, why or why not, something is working.

SUMMARY

Strengthening the core won't always fix a problematic spine
Look at the global picture before attacking the local problem
Look at movement habits secretly when working with or meeting a client for the first time.
Rule out other culprits such as shoulder, hip or ankle involvement
Test endurance, not strength, when initially screening the client/patient
Observe lumbar and hip strategies during complex or dynamic loading tasks
Make any system your own, understand it for yourself.

-Dr. Anthony Close
www.anthonyclose.com
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