Core Training For Low Back Pain

Does it work?

Training your core is one of the most discussed topics in health and wellness. Physical Therapist, personal trainers, medical doctors etc. have programmed or prescribed core training to cure back problems, enhance sports performance, improve movement and posture and to just plain look good. A quick YouTube search finds core training to include isometric exercises (planks) to isolated exercises (crunches) to compound movements (squats) to exercises purported to come from different regions or the world (Russian twists or Turkish Get Ups). As a physical therapist, my job intersects with the core generally in the context of low back pain and getting athletes and weekend warriors back after it. To that end, I try to incorporate a didactic approach, explaining what the core is and how we should go about training it.

What is the core? Fitness professionals, physical therapists, doctors and exercise scientists will all give you a different answer to this question. There is absolutely no consensus on exactly what specifically defines the core. Physical therapists tend to define the core as system of muscles around our torso that control inter-vertebral movement, or segmental stability of our spine. That is to say, the core is a system of muscles that control the relative movement of our spinal vertebrae. This definition is derived from a bio-mechanical model of low back pain that posits that the origin of back pain is from the dysfunctional movement of our spinal vertebrae negatively impacting nearby nerve and muscle tissue.

What is core training? Again, there is no consensus amongst clinical disciplines. Physical Therapists tend to focus on strengthening deep muscles like the transverse abdominis and multifidus to better control the inter-vertebral movement of our spine, eliminating our dysfunctional movement and the pain associated with it. The goal is to train our patients to consciously activate these muscles with specific exercises compelling a spill over to when we need to subconsciously activate these muscle to stabilize our spine. In this model, only once the deep muscles have been adequately trained do we move on to the prime movers, recuts abdominis and obliques.

Does core training help relieve low back pain? Yes it does and this is where it gets interesting. Core training does relieve back pain, but probably not for the reasons most clinicians think. There really is no good scientific studies that can establish a causal relationship between any specific core exercises and a reduction in back pain. A causal link has not been established because it is impossible to activate muscles of the core in isolation. So, while we can give you exercises to activate your transverse abdominis and multifidus we are also activating a host of other muscles in the core. So we can’t attribute the strengthening of any particular muscle with a reduction of low back pain, but Physical Therapy do exercises tend to work on low back pain.

That’s right, our exercises work and so do a a ton of other exercises, both very specific and general movements. Why is that? Movement is medicinal, especially when it pertains to back pain. Our scientific studies may not be able to point to a causal relationship between specific core training and reduced back pain, but they show a causal relationship between exercise and a reduction in back pain.

Given the murky evidence linking core strengthening to a reduction in back pain, I focus on improving a patient’s low back (I also look at the mid-back and hips) range of motion first. As we age, the intervertebral discs tend to start to shrink, bringing the spinal vertebrae closer together. The loss of disc height contributes to the stiff and achy spine many of us north of 40 years old begin to feel. A stiff and achy spine does not move well and we tend to lose the ability to rotate to either side and bend forward. The loss of range of motion in the spine is a good predictor of chronic back pain.

Specifically, I start with flexion or bending forward. A simple and easy exercise to reduce low back pain is to sit in a chair and slowly and repeatedly bend forward towards the ground. Pause briefly when you feel a stretch in the low back and then slowly sit back up. Repeat this 10-15 times, 3 times per day or as need for pain. This exercise promotes spinal flexion, creating more space between the vertebrae as well as promoting increased flexion range of motion.

Seated Flexion

Once you have been working of flexion for a few weeks, add in rotation. Again, find a chair and have a seat. Cross your arms across your chest, now slowly and repeatedly rotate to your right and pause when you feel the stretch. Slowly return to the starting position and repeat the rotation to the right 10-15 times. Then rotate to the left 10-15 times.

Seated Rotation

I like to spend a few weeks re-establishing age-appropriate range of motion. But, as you can imagine, these movements are only the tip of the iceberg. If my patient is a runner or a hiker, we start working on isometric core exercises (planks, hollow position) to promote core stabilization before more dynamic core movements (cable or medicine ball rotations). If my patient plays pickle ball or golf, my focus is going to be on strengthening their core for more dynamic rotational movements. If my patient is just wants to look good, we isolate recuts abdominis for more muscle definition.

The core is really a nebulous region of our body that is defined by different clinicians in different ways. But, as clinicians our intuition about the importance of the core when it comes to back pain, sports performance, aesthetics, etc. is correct. However, it seems to be at this point that ideas around core training diverge into an unapproachable morass of advice. I try to take a simpler approach, but an approach that mirrors the success I have had treating other parts of the musculoskeletal system. First, establish appropriate range of motion. Second, layer on general strength with functional movements. Last, specify your exercises to your sport.

Isometric Core Exercise - The Plank

Dynamic Core Exercise - Step Through

Compound Movement Core Exercise - Goblet Squat