If you’ve ever had back pain, you’ve probably noticed that people are likely to attribute it to a weak core. Finding core work in one’s programming today is as common as Bench and Biceps on Monday programming. We see core exercises in gyms all around the world, where people hammer away at crunches, planks, pikes on gym balls, toes to bar, or GHD sit ups, to name just a few.  Some people instead migrate to Pilates or yoga classes, with the best intention of properly rehabilitating their spine pain.
 
If you have back pain and attribute it to a weak core, perhaps the question you need to be ask is, “When did my core become weak in my training process?” The answer is never. You did not pass some threshold where your core strength was so poor for your training tasks that you developed back pain.
 
Maybe we should look at low back pain with a different set of lenses.
 
Here’s a little history. Core stability training really became a thing in the late 90s following a study on the transverse abdominis or  TvA  by Paul Hodges, et al. The study looked at subjects with low back pain and those without it. It found that the TvA and multifidi had a delayed activation in those with low back pain and was active prior to a task in those without low back pain. The researchers postulated that the low back pain was due to delayed TvA onset rather than an effect in response to pain. This led to rehab therapists and later, fitness professional showing abdominal hollowing to every patient with back pain, and they were told to draw their belly button to their spine (seen here).
 
Another study in 2012 by Vassaljen, et al. looked at low load core exercises, sling-based higher threshold exercises, and general exercises among people with chronic back pain, and found that there were no significant changes in pain among any of the groups.
 
So what does this mean? What are we to do to address this epidemic of low back pain, and how do we treat it? Everywhere we look, the studies contradict themselves, which is why we have the evidenced-based practitioners saying just load it and build capacity and the back will be better, just like this study by Moreside in 2013 indicates. Other practitioners utilize motor control training (DNS, PRI, etc.) or teach spinal stiffness using the McGill method, getting the same results—improved function and reduction in pain.
 
The Real Reason For Your Back Pain
 
What if the primary cause of pain was not due to weakness or delayed activation of your TvA or inhibition of glutes, but rather it was your habitual movement patterns surrounding your spine that eventually led to your pain? You sit in a flexed position at work all day and as you drive in a car, and then you head to the gym and your coach has you squatting and deadlifting. What if you have some flexion in your spine, but are unaware of this position, because it is natural? What if you were a gymnast or dancer in the past, and the art of the sport began to transition into daily aspects of your life? We have all seen how gymnast and ballerinas move. External rotation of the feet is demanded in the daily training of foot positions, and you see hyperlordotic positions of gymnasts at the end of their routines. Additionally, abdominal surgery like an appendectomy or C-section may change your stability stereotype due to previous pain.

As someone who utilizes all of these previously mentioned methods of spinal rehabilitation (except TvA hollowing, because it’s just wrong), here are some things that would be beneficial in determining to help guide your recovery.

1. There is always a trigger to your pain. As Stu McGill says, “there is no such thing as non-specific low back pain.” The practitioner you are working with should be able to evaluate you well enough to determine a trigger for your pain, whether your spine is painful when flexed, extended or when load is added either statically or dynamically, etc. This is the first thing that must be determined so that the person in pain can learn how to stop hurting themselves.

Yes. training may have to be modified, but never does it need to stop. For example, if you are experiencing low back pain with your back squat because you have flexion in the spine or what we hear people refer to as the “butt wink,” maybe we would have you box squat in a decreased range of motion that does not exacerbate your symptoms. Or it may be as simple as pulling your deadlifts off blocks, or doing rack pulls instead of pulling from the floor.

2. Is the stabilization stereotype you are using adequate for the task at hand?

As someone who is a practitioner of DNS and the neurodevelopmental acquisition of postural system it is founded on, I am reminded of a quote by the great Gray Cook, PT who says we should “never put strength on top of dysfunction.” As a practitioner of DNS principles, we assess the function of the diaphragm and its role in stabilizing the lumbar spine through assessment or breathing patterns as well as the bracing stereotype.What was found in the study done by Pavel Kolar, et al. in 2010 was that the diaphragm, when working appropriately in both stability and respiration, created a barrel through the abdomen by increasing intra-abdominal pressure. When we have convexities and concavities of the core when bracing, we tend to indicate a pattern of rectus abdominus dominance. This is what we see at times when we continually train with concentric core activities like crunches, toes to bar, GHD sit ups, etc. This is why addressing stabilization patterns/stereotypes is important and when not addressed may hinder an athlete from returning to full pain-free activities without fear of reinjury.
 
When we discuss this, we need to look into pain science. Pain is an output of the brain. It is not a damage indicator, but rather a perceived threat indicator. Your brain has one main job running in the background and that is self- preservation. If you have low back pain, your body is telling you that you have a real or perceived threat to the area. Working on DNS, PRI, McGill or any other stability strategies you are essentially saying, the habit which I am currently using to stabilize my spine continues to lead to sensitization of the structures involved. When we work on changing the stereotype of how we stabilize or move around our spine, we are trying to uncouple movement from pain, or as Lorimer Moseley would call it, “neurotags.”
 
When we have shown that we have improved these motor control strategies of bracing and the drills have become easy, we need to start moving in the direction of higher threshold activities. Which brings me to my third point in addressing spine rehabilitation.
 

3.  Load the tissue, and build resilience and robustness. In the PT world where many say that they are exercise and movement specialists, they sit in a stagnant world of deadbugs, bird-dogs, clam shells and monster walks. This is actually shitty care, and the field could learn a lot from the strength and conditioning world of how to load up a spine and how to build capacity through graded exposure. As we know, adaptation and change only occur if the stressor is dosed appropriately. This is how we build new neural pathways and motor strategies, whether it’s learning how to throw a curve ball or how to properly deadlift. If we do not add weight to our rehab process, and at times heavy weight, we will never get the full specific adaptation to the imposed demands we are wanting.

 
Weight can be a great teacher, and you can get the reflexive stability you are looking for if you just understand your limitation of movement to protect against exacerbation and add enough load that the strategy necessary to move the weight is appropriate. Take for example a Pallof press in squat stance. If you have too light of a load, you can pretty much use any strategy to achieve the exercise. But if we increase the load or we place you in a narrow base half -kneeling position, you will be required to utilize the proper bracing reactively to allow you to move the weight. This is what is referred to as a self-limiting exercise, and if it is not done correctly, you will not be able to do it.
 
If you are a physical therapist or a coach, the greatest thing you can do for your patients and clients is to understand why they have back pain. You are already better than most in your field by searching out these types of articles. Understand that although strength fixes many things, increasing core strength may actually worsen the issue—not because of your intent to get the core stronger, but because of the specific exercises you are choosing to achieve the goal. You need to ask, “what’s the cost of doing business?”  Do your methods match the findings, and is the exercise appropriate?
 
Always remember in fitness and rehab: “Simple is sexy and more is not better, better is better.”