Core Stabilization Versus Education for Low Back Pain

A new study just came out comparing different methods of back pain prevention in a military setting. The headline is that back pain education was more effective than core stabilization exercise. Is that what it really shows? Does that mean I should put down that swiss ball and pick up a book instead? Here’s a little more detail on the study.

The subjects were soldiers entering a 16 week training program to become combat medics in the U.S. Army. They were between the ages of 18 and 35 years old and had no prior history of low back pain. The soldiers were doing divided into 4 groups: traditional exercise; traditional exercise with “psychosocial education”; core stabilization exercise; and core stabilization exercise with psychosocial education.

“Traditional exercises” basically meant situps, rotating situps and crunches. “Core stabilization exercise” was designed to target the notorious transversus abdominis and multifidus, and was comprised of abdominal draw ins, side planks, flexor squats, bridges and quadruped “bird dogs.” Both groups did 5-6 exercises for one minute each, every day for 12 weeks. It should be noted that in addition to these exercises, all the groups did the daily physical work that is part of the training and assessment of the soldiers. Which included situps. Hey, it’s the army.

The “psychosocial education program” was one 45 minute session providing evidence-based information on low back pain designed to reduce its threat value and encourage active coping strategies.

After the program, the soldiers were off to Afghanistan, Iraq and elsewhere. And two years later researchers measured who sought healthcare for low back pain and for how long.

Of all the soldiers, 17% sought healthcare for low back pain. Core stabilization exercise had no protective effect. But the groups that received education had 3.3% less low back incidence over the years.

So what can we conclude? That education rules and core stabilization drools? Well maybe so but I don’t see this study as any great proof of that fact. The education group had only a small protective effect, meaning that you would need to educate 30 people before expecting even one less to seek healthcare for low back pain.

And, we need to remember that the study didn’t measure low back pain, but visits to the doctor for low back pain. There’s a big difference, particularly in light of the fact that one of the very things the education group learned was that doctors aren’t very good at finding a cause for back pain, and that they should employ active coping strategies. Of course these guys went to the doctor less, they were told doctors can’t help. Did they also have less pain? Maybe, but we don’t know.

Further, before we decide that this study provides strong evidence that core stabilization exercise is useless, we need to consider the context in which the exercise was used – in a sea of situps, pushups and other activities that would be expected to have a large effect on low back mechanics good or bad. For example, maybe all those situps made their backs as resistant to back pain as they could get, so that core stabilization could add no further benefit. Or maybe the sit ups were bad, and the core stabilization would have worked much better if those recruits didn’t have to do so many repeated spinal flexions, like some pig spine in Stu McGill’s lab.

Finally, one of the primary justifications in favor of core stabilization exercise is that it useful to activate muscles that  have somehow become sleepy with the onset of low back pain. But this group did not have a previous history of back pain, so there was no opportunity to test the purported merits of core stabilization training in this context.

So what can we conclude from this? At a minimum, that pain education is probably a good thing. And, in a group that is already healthy and getting a good dose of general exercise, maybe it’s the best thing we have. Or maybe not.

What do you think? What did I miss? Let me know in the comments.

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16 Responses to Core Stabilization Versus Education for Low Back Pain

  1. Yes, basically I thought this study didn’t tell us much.

    When you factor in the fact that these are military folk, it would be astonishing if you didn’t get reduction in medical visits once they knew (as they would likely interpret it) that going to the doctor for back pain was frowned upon.

    If the core exercises had had a notable effect, *that* would have been interesting. But to me, the only notable number here is that 17%. That’s not just people with back pain, that’s people seeking care for it, in a young and active population. Crikey. We’re talking a lot of pain.

    • Dale,

      I agree. 17% seems high for healthy people, but for healthy people fighting in Afghanistan? Maybe not so surprising.

  2. Good summary, Todd. Good point about the reporting problem: I missed that. Will reconsider. But do bear in mind that the results here are strongly consistent with a lot of other convergent evidence about core strength.

    • Thanks Paul. I agree that the results here are part of a pattern showing poor results for core stabilization. But as a single piece of evidence it doesn’t do any damage IMO. And, I think the exercises were selected to improve motor control, as opposed to build strength, so studies about core strength are not part of the pattern.

      If I was a proponent of the core stability exercises used in the study (which I am not) I definitely would not use this study as a way to test their efficacy. There is nothing here to test their ability to treat pain, only prevent it. And the context was unusual – army recruits in the middle of a training process that involves tons of core work that might have been either redundant or counterproductive. That’s like trying to test whether a certain medicine works by giving it to healthy patients with lots of other medicine at the same time.

  3. Interesting debate, do strong core muscles not automatically translate in a well balanced, effortless to maintain posture or does good posture not prevent the occurrence of back pain or other pains?

    In the light of the overwhelming amount of stress these men undoubtedly have gone through, this study will not provide the answer.

  4. I agree that this study is obscure and ambiguous.

    Plus how effective is 25 minutes of core stabilization when you spend the rest of the day succumbing to old patterns and habits (especially while doing PT).

    I have recently started a pilates regiment, and one of the main keys is subtlety in core muscle activation, and bringing awareness of your core throughout the day.

    Maybe that would be a harder thing to study.

    • Ritvik,

      “Plus how effective is 25 minutes of core stabilization when you spend the rest of the day succumbing to old patterns and habits (especially while doing PT).”

      Exactly. The whole point of these exercises (regardless of their ability to do so) is to change a coordination pattern, not to build strength. Making a change is going to be very hard to do in the middle of basic training.

  5. Ritvik,

    Why on earth should you be aware of your core all day? Sounds nuts. Is that really how the body should work?

  6. Has anyone noted that the core training involved “drawing in” or hollowing, something that Pr.McGill says detracts from stabiliy?

  7. Hi, Todd. The largest problem I see with the study: the Soldiers only participated in the modified exercises during the 12-week training program at the beginning of the study. I have never ever heard of any research paper — or any exercise program at all — claiming that 12 week’s worth of exercise would have any impact on LBP 2.5 years later. The authors did not note anyone who had ever made that claim. If you look at the way the results cris-cross over the span of the study, it’s pretty clear that ascribing any causality 5 minutes’ worth of exercise a day over 12 weeks at the program’s beginning is problematic.

    I think it’s great if the program actually reduced LBP in the participants. You note obvious problems in the methodology. I believe a separate paper was published on the design of this study; I plan to read that and see why they made the choices they did. A follow-up study/questionnaire could have cleared up some of the confusion that their metrics created.

    One nit: the training program was reported as 12 weeks and not 16.

  8. In addition to the problems you mention, I have a few other concerns with the core strength program – firstly, it doesn’t appear that the loads involved in the core strength exercises were closely matched to those the recruits would experience during training and subsequent job demands. The basic exercises listed are just the very basics of “core strength” work – athletes or those with demanding jobs then should surely progress to more advanced exercises with higher loads that more closely mimic demands of work (such as lifting, for example. My favourite core strength exercise for preventing back injuries in people who do significant amounts of heavy lifting? The deadlift, of course!).

    My second query is with the amount of individual coaching and supervision the recruits received with the exercises. Several of those listed are actually fairly sophisticated exercises that are commonly performed (and in my experience regularly taught) badly. If they aren’t being performed correctly, they can be worse than useless.

    • Hi Rosie,

      I agree that the deadlift would be a very logical way to prepare someone for the demands of heavy lifting. Makes me curious whether the soldiers in question actually did do a lot of lifting, and if so, whether these demands were a factor in their rate of back injury. Would they have been better served by a program that had some deadlfiting? Maybe. And their program would have been more fun too.

      I totally agree with your second point. In my own experience, the devil is in the details when it comes to corrective movement. Worse than useless is a good term for exercises done the wrong way.

  9. You said “pig spine” …..uhh huh huh:) Do you think all of Stu’s stuff is rubbish? Just curious, thanks!

    • Eric,

      No I have both of Stu’s books and they are useful. But I do some have some problems with some of what has been extrapolated from his work. Bret Contreras discusses some of this overreaching a little in an article called To Crunch or not to Crunch.

  10. You already know maybe, it could be a good lecture;

    Therapeutic Neuroscience Education,
    Adriaan Louw
    Emilio Puentedera

    Based on Butler, Moseley and many other researcher.

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