1. Core Exercises: Current Treatment of Low Back Pain November 13, 2014
Monica Rho, MD
Assistant Professor
Director of Women’s Sports Medicine Program
Spine & Sports Rehabilitation
Rehabilitation Institute of Chicago
Northwestern University Feinberg School of Medicine

2. Overview Review the links of core strength to low back pain (LBP)
Highlight the evidence on core strengthening treatment for LBP

3. Core Muscles in Low Back Pain
Loss of anticipatory function
Transversus abdominus (TA) (Hodges 1996, Hodges 1997)
Weakness and decreased endurance
Multifidi and back extensor muscles (Hides 1994, Hides 1996, Jorgenson 1987)
Decreased spine proprioception
Motor control vs Motor strength
Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine 1996; 21:
Hodges PW, Richardson CA. Feedforward contraction of transversus abdominis is not influenced by the direction of arm movement. Exp Br Res 1997; 114:362-70
Jorgenson K, Nicolaisen T. Trunk extensor endurance: determination and relation to low back trouble. Ergonomics. 1987; 30(2)
Hides JA, Stokes M, Saide M, Jull GA, Cooper D. Evidence of lumbar multifidus wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine 1994;19:
Hides Richardson CA Julle GA. Multifidus muscle recovery is not automatic following acute first episode low back pain. Spine 1996;21:2763-9

4. Transversus Abdominus
TA is first muscle contracted during ventral trunk loading to prevent unwanted trunk movement with limb movement (Cresswell 1994)
TA is not the first responder in upper limb movements of patients with LBP (Cresswell 1994)
TA shows decreased ability to contract in patients with recurrent LBP during lower extremity tasks (Hodges 1997, Ferreira 2004)
Cresswell AG, Oddsson L, Thorstensson A: The influence of sudden perturbations on trunk muscle activity and intraabdominal
pressure while standing. Exp Brain Res 1994;98: 336–341
Hodges PW, Richardson CA: Contraction of the abdominal muscles associated with movement of the lower limb. Phys
Ther 1997;77:132–42; discussion, 142–34
Ferreira PH, Ferreira ML, Hodges PW: Changes in recruitment of the abdominal muscles in people with low back pain: Ultrasound measurement of muscle activity. Spine
2004;29:2560–6

5. Multifidi Multifidi atrophy in patients with chronic LBP
Post-op pt with unilateral LBP – 10-30% smaller paraspinals on affected side compared to unaffected (Laasonen 1984)
Unilateral acute/subacute LBP vs control : side to side difference was 3% in controls and 31% in LBP (Richardson 1999)
Laasonen EM: Atrophy of sacrospinal muscle groups in patients with chronic, diffusely radiating lumbar back pain.
Neuroradiology 1984;26:9–13
16. Richardson C, Jull G, Hodges P, et al: Traditional views of the function of the muscles of the local stabilizing system of
the spine, in: Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain: Scientific Basis and Clinical Approach. Edinburgh, Churchill Livingstone, 1999, pp
21–40
Rantanen J, Hurme M, Falck B, et al: The lumbar multifidus muscle five years after surgery for a lumbar intervertebral disc herniation. Spine 1993;18:568–74
Bogduk N: Clinical Anatomy of the Lumbar Spine and Sacrum. Edinburgh, Churchill Livingstone, 1997

6. Back Extensors
Decreased endurance of extensors compared with controls (Jorgensen 1987, Ebenbichler 2001)
Abnormal flexor to extensor strength ratios (McGill 2002, Siolie 2001)
Ebenbichler GR, Oddsson LI, Kollmitzer J, et al: Sensorymotor control of the lower back: Implications for rehabilitation. Med Sci Sports Exerc 2001;33:1889–98
Jorgensen K, Nicolaisen T: Trunk extensor endurance: Determination and relation to low-back trouble. Ergonomics 1987;30:259– male post men 3 groups – LBP affecting ability to work (1), LBP without affecting ability to work (2), no LBP (3). Couch method (upper body unsupported while horizontal off the side of a couch) and pulling test (60% of MVC). Time was measured. Group 1 Metod 2 (35s), Group 2 and 3 (61 and 54 seconds). Method 1 (148s, 194s, 184s) – close to significance
McGill S: Normal and injury mechanics of the lumbar spine, in: Low Back Disorders: Evidence-Based Prevention and Rehabilitation. Champaign, IL, Human Kinetics, 2002, pp 87–136
Sjolie AN, Ljunggren AE: The significance of high lumbar mobility and low lumbar strength for current and future low back pain in adolescents. Spine 2001;26:2629–36
Jorgensen 1987

7. Spine Proprioception
Postural control is altered in patients with chronic LBP (Ebenbichler 2001)
Single leg stance balance
Postural stability tests (Mok 2004)
Unexpected balance challenges
Trunk perturbation (Wilder 1996)
Difficult repositioning back to neutral spine posture (O’Sullivan 2003)
Proprioception comes from deep fibers of Z joint capsules and multifidi (Bogduk 1997, Hides 2004)
Ebenbichler GR, Oddsson LI, Kollmitzer J, et al: Sensorymotor control of the lower back: Implications for rehabilitation. Med Sci Sports Exerc 2001;33:1889–98
Mok NW, Brauer SG, Hodges PW: Hip strategy for balance control in quiet standing is reduced in people with low back pain. Spine 2004;29:E107– Bilateral standing on short base with eyes closed – LBP failed 4 times more than controls
Wilder DG, Aleksiev AR, Magnusson ML, et al: Muscular response to sudden load: A tool to evaluate fatigue and rehabilitation. Spine 1996;21:2628–39– able to correct wtih2 weeks of back extensor exercises
O’Sullivan PB, Burnett A, Floyd AN, et al: Lumbar repositioning deficit in a specific low back pain population. Spine 2003;28:1074–9
Symptomatic control compared with lumbar HNP tested postural control and rotation proprioception. Decreased in both in herniation group. After surgery there was no correlation with painrelief and postural control or proprioception – but position sense improved post op but postural control did not. This mechnism thought to be due to multifidi
Bogduk N: Clinical Anatomy of the Lumbar Spine and Sacrum. Edinburgh, Churchill Livingstone, 1997
Hides J: Paraspinal mechanism and support of the lumbar spine, in: Richardson C (ed): Therapeutic Exercise for Lumbopelvic Stabilization, ed 2. Edinburgh, Churchill Livingstone, 2004, pp 59–74

8. How do we treat low back pain with core exercises?

9. Abdominal Hollowing/Abdominal Draw-in
Contemporary culprit of low back pain
Activity of TA contributes to spinal control (Cresswell 1992, Hodges 1999)
Dysfunction of the muscle occurs in people with LBP (Hodges 1996, 1998, 2001)
Activated by abdominal draw-in maneuver (Richardson 1999, Jull 1995, Hodges 1996, Urquhart 2005)
“Breath in and out. Gently and slowly draw in your lower abdomen below your navel without moving your upper stomach, back or pelvis” (Urquhart 2005)
ADM is the greatest most independent activity of TrA. Greater activation in lower and middle regions of TrA compared with upper region.
Cresswell AG, Grundstrom H, Thorstensson A. Observations on intraabdominal pressure and patterns ofabdominal intra-muscular activity in man. Acta Physiologica Scandinavica 1992;144(4): 409–18.
Hodges PW, Richardson CA, Jull GA. Evaluation ofthe relationship between laboratory and clinical tests oftransversus abdominis function. Physiotherapy Research International 1996a;1(1): 30–40.
Hodges PW, Richardson CA. Inefficient muscular stabilization ofthe lumbar spine associated with low back pain. A motor control evaluation oftransversus abdominis. Spine 1996b;21(22): 2640–50.
Hodges PW, Richardson CA. Feedforward contraction of transversus abdominis is not influenced by the direction ofarm movement. Experimental Brain Research 1997;114(2):362–70.
Hodges PW, Richardson CA. Delayed postural contraction of transversus abdominis in low back pain associated with movement ofthe lower limb. Journal ofSpinal Disorders 1998;11(1):46–56.
Hodges PW, Cresswell A, Thorstensson A. Preparatory trunk motion accompanies rapid upper limb movement. Experimental Brain Research 1999;124(1):69–79.
Hodges PW. Changes in motor planning of feedforward postural responses ofthe trunk muscles in low back pain. Experimental Brain Research 2001;141(2):261–6.
Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine 1996;21(23):2763–9.
O’Sullivan PB, Twomey L, Allison G, Sinclair J, Miller K, Knox J. Altered patterns ofabdominal muscle activation in patients with chronic low back pain. Australian Journal ofPhysioth erapy 1997a;43(2):91–8.
O’Sullivan PB, Twomey L, Allison G, Taylor JR. Specific stabilising exercise in the treatment ofchronic low back pain with a clinical and radiological diagnosis oflumbar segmental ‘instability’. In: Proceedings ofManipulative Physiotherapists Association of Australia Tenth Biennial Conference, Melbourne, Australia, 1997b. p. 139.
O’Sullivan PB, Twomey LT, Allison GT. Evaluation ofspecific stabilizing exercise in the treatment ofchronic low back pain with radiologic diagnosis ofspondylolys is or spondylolisthesis. Spine 1997c;22(24):2959–67.
O’Sullivan PB, Twomey L, Allison GT. Altered abdominal muscle recruitment in patients with chronic back pain following a specific
exercise intervention. Journal
Urquhart DM et al. Manual Therapy 10(2005)

10. Abdominal bracing Lateral flaring of abdominal wall (Kennedy 1980)
Increase of intrabdominal pressure (Kennedy 1980)
Greater external oblique activity than other abdominal muscles (Urquhart 2005)
“Breath in and out. Gently and slowly swell out your waist without drawing your abdomen inwards or moving your back or pelvis” (Urquhart 2005)
Kennedy B. An Australian programme for management of back problems. Physiotherapy 1980;66(4):108–11.

11. Posterior pelvic tilting
Reduction of lumbar lordosis (Vezina 2000)
Muscle activation patterns are not clearly defined with or without LBP (Vezina 1998)
Great activity of internal oblique than rectus abdominus (RA) and external oblique (EO) (Urquhart 2005)
Greater RA activity compared to lateral abdominals (Richardson 2005)
Greater EO than RA (Vezina 2000)
Similar IO and RA (Flint 1965, Carman 1972)
“Breath in and out. Gently and rock your pelvis backwards” (Urquhart 2005)
Vezina MJ, Hubley-Kozey CL, Egan DA. A review ofthe muscle activation patterns associated with the pelvic tilt exercise used in the treatment oflow back pain. The Journal of Manual and Manipulative Therapy 1998;6(4):191–201.
Vezina MJ, Hubley-Kozey CL. Muscle activation in therapeutic exercises to improve trunk stability. Archives of Physical Medicine and Rehabilitation 2000;81(10):1370–9.
Carman DJ, Blanton PL, Biggs NL. Electromyographic study of the anterolateral abdominal musculature utilising indwelling electrodes. American Journal of Physical Medicine 1972;51(3):113–29.
Flint MM, Gudgell J. Electromyographic study ofabdominal muscular activity during exercise. The Research Quarterly 1965;36(1): 29–37.

12. Can we change low back pain with stabilization exercises?
Improvement in the activation multifidi improves pain in acute and chronic LBP (Hides 1996, O’Sullivan 1997)
Inconclusive evidence that proprioception can improve with lumbar stabilization program (Kavcic 2004)
Spinal Segmental Stabilization Training (Richardson 1999)
Re-training the co-contraction of the transversus abdominis and lumbar multifidus
Drawing in the abdominal wall – causes activation of deep transversus abdominis in co contraction of the deep fascicles of lumbar multifidis (Jull 1999)
Eventual incorporation of these skills into functional task
Abdominal bracing training
Stiffens the spine and improves stability (Grenier 2007)
Immediately more functional maneuver
Hides JA, Richardson CA, Jull GA: Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine 1996;21:2763–9
Multifidi: RCT 39 first time unilateral back pain with multifidi atrophy – education and regular care vs specific exercise training of multifidi (Hides 1996)
Both group had near resolution of LBP at 4 weeks
Exercise group was able to show normal mulitifidi muscle at 4 weeks
Control group had continued mulitifidi atrophy at 4 weeks
At 3 yr follow up control group was 9 times more likely to have a recurrent flare of pain vs. treatment group
Kavcic N, Grenier S, McGill SM: Quantifying tissue loads and spine stability while performing commonly prescribed low back stabilization exercises. Spine 2004;29:2319–29.
Richardson CA, Jull GA, Hodges PW, Hides JA. Therapeutic exercise for spinal segemental stabilization in low back pain. Scientific basis and clinical approache. Ediburgh: Churchill Livingston 1999
Jull GA, Richardson CA. Motor control problems in patients with spinal pain: a new direction for therapeutic exercise. J Manip Phys Thera. 2000;23(2)
Grenier SG, McGill SM. Quantification of lumbar stability by using 2 different abdominal activation strategies. Arch Phys Med Rehabil Jan; 88(1): 54-62

13. Role of Breathing

14. Summary
Muscles of the core are affected in patients with low back pain
Re-training these muscles does improve function and outcome in low back pain
Methods of re-training these muscles are varied and there is controversy as to which is the “best” method
Breathing patterns has an affect on the activation of core muscles

15. Laughter is the Best Medicine

16. References
Laasonen EM: Atrophy of sacrospinal muscle groups in patients with chronic, diffusely radiating lumbar back pain. Neuroradiology 1984;26:9–13
Richardson C, Jull G, Hodges P, et al: Traditional views of the function of the muscles of the local stabilizing system of the spine, in: Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain: Scientific Basis and Clinical Approach. Edinburgh, Churchill Livingstone, 1999, pp 21–40
Rantanen J, Hurme M, Falck B, et al: The lumbar multifidus muscle five years after surgery for a lumbar intervertebral disc herniation. Spine 1993;18:568–74
Cresswell AG, Oddsson L, Thorstensson A: The influence of sudden perturbations on trunk muscle activity and intraabdominal pressure while standing. Exp Brain Res 1994;98: 336–341
Hodges PW, Richardson CA: Contraction of the abdominal muscles associated with movement of the lower limb. Phys Ther 1997;77:132–42; discussion, 142–34
Ferreira PH, Ferreira ML, Hodges PW: Changes in recruitment of the abdominal muscles in people with low back pain: Ultrasound measurement of muscle activity. Spine 2004;29:2560–6
Ebenbichler GR, Oddsson LI, Kollmitzer J, et al: Sensorymotor control of the lower back: Implications for rehabilitation. Med Sci Sports Exerc 2001;33:1889–98
Jorgensen K, Nicolaisen T: Trunk extensor endurance: Determination and relation to low-back trouble. Ergonomics 1987;30:259–67
McGill S: Normal and injury mechanics of the lumbar spine, in: Low Back Disorders: Evidence-Based Prevention and Rehabilitation. Champaign, IL, Human Kinetics, 2002, pp 87–136
Sjolie AN, Ljunggren AE: The significance of high lumbar mobility and low lumbar strength for current and future low back pain in adolescents. Spine 2001;26:2629–36
Mok NW, Brauer SG, Hodges PW: Hip strategy for balance control in quiet standing is reduced in people with low back pain. Spine 2004;29:E107–12

17. References
Bogduk N: Clinical Anatomy of the Lumbar Spine and Sacrum. Edinburgh, Churchill Livingstone, 1997
Hides J: Paraspinal mechanism and support of the lumbar spine, in: Richardson C (ed): Therapeutic Exercise for Lumbopelvic Stabilization, ed 2. Edinburgh, Churchill Livingstone, 2004, pp 59–74
Hides JA, Richardson CA, Jull GA: Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine 1996;21:2763–9
Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine 1996; 21:
Hodges PW, Richardson CA. Feedforward contraction of transversus abdominis is not influenced by the direction of arm movement. Exp Br Res 1997; 114:362-70
Wilder DG, Aleksiev AR, Magnusson ML, et al: Muscular response to sudden load: A tool to evaluate fatigue and rehabilitation. Spine 1996;21:2628–39
O’Sullivan PB, Burnett A, Floyd AN, et al: Lumbar repositioning deficit in a specific low back pain population. Spine 2003;28:1074–9

18. Thank You