Stability TL;DR

By Dr Austin Rees

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Does your core strength actually decrease the likelihood that you’ll have lower back pain? Many people come into the clinic with various back complaints and admit to having a subjectively weak core. The term neutral spine has become the victim of misinterpretation, people tend to view a spinal extension bias as neutral. 

No spinal movement is innately bad, spines like to move and were engineered to do so. Reliance on the passive structures of the spine — ligaments, joint capsules, discs — for support is silly, we should train our core muscles to support the spine. Positioning of the abdomen is the first movement pattern I try and solve. The goal is to relatively align the diaphragms(the pelvic floor and the diaphragm) in parallel. This balances the tension on the front and the back of the abdomen. The next thing I care about is breathing while they maintain this tension. Many lose tension when instructed to breathe, which is a problem given we breathe … all the time. Lastly, rehabbing only in the sagittal plane is a wee bit silly. Our limbs are not located midline, therefore, any unilateral challenge we place on ourselves involves a rotational action and rotational reaction - guess what provides the rotational reaction?

If we can not stabilize against all the demands placed on our core where does this leave us? The movement will likely occur at the weakest point in the chain — the path of least resistance. The excessive motion and accumulation of forces in that one area can result in a build-up of tension in the surrounding musculature.

Ever heard of recurrent lower back pain? We have an initial flare-up of low back discomfort, we give it time, symptoms may decrease, and we forget about it — until it rears its ugly head again. It’s like scraping a scab off over and over, it gets a little better but we never resolve the underlying issue. You’re going to make me say it — how about we take the opportunity to optimize movement so that forces are shared as equally as possible throughout the system! 

*We know that low back pain has a high likelihood to reoccur in a person’s lifetime, but we can use rehab and education to make a person more resilient to reoccurrence and aware of management strategies*

Stability

Does your core strength actually decrease the likelihood that you’ll have lower back pain? I find it comedic when patients come into the clinic with back pain and elude to the fact that they know their core is not strong enough. I’m a curious cat so I typically prod, “how do you know?” and typically the answer is well my back gets sore after I do an activity. I find it interesting that the average patient understands the fundamental role of the core musculature, they can associate a weak core with the risk of developing discomfort, but they do not prioritize its training. As practitioners, we can get … lazy … simply prescribing McGill’s “large and in-charge” 3 exercises — bird dogs, side planks, and crunches. I think these exercises have value, but they are not the only exercises that should be prescribed! Obviously, other practitioners think their value is monumental given the amount of “Try these 3 exercises to forever rid yourself of any back pain for the rest of your life” videos on social media. So we know the importance of core strength and stability, but do we train it to be functional?

This is where I am at: 

More often than not we are fixated on where the spine is in space. Practitioners hold on to the term neutral spine like Smeagle held on to The One Ring. Neutral spine has been misinterpreted, the common neutral spine assumption is an anti-flexed spine. I was guilty of having this view. No spinal movement is innately bad — flexion, extension, rotation, and lateral flexion are all okay. Yes, repetitive flexion of a porcine spine can cause disc herniations. These porcine spines were stripped of their active contractile components, therefore, we understand that repetitive flexion of an unsupported spinal column can be detrimental to the structural integrity of spinal tissue. We can manage the stress on the passive components of the spine by offloading them with the active tissue (muscle), this is not a mind-blowing statement. I suppose someone could read this bad blog and scoff at the fact that I don’t talk about tissue creep. Tissue creep occurs when people stay in sustained postures for an extended period of time. A big problem with tissue creep is the change in the tissue stiffness of the area that has experienced creep and the change in the proprioception of the area (how the brain perceives that area). You can see how a reduction in tissue stiffness and position sense could predispose you to injury. My solution is the same solution I have for all posture-related questions. What is a good posture in my opinion? A good posture is a variable posture. If a variable posture can not be achieved a proper warmup (this should be done anyway) will be required to stimulate the mechanoreceptors to improve position sense.

As we have established, reliance on passive structures in the spine may predispose you to injury. I think a fair place to start is to observe how someone adds tension to their core. I would say many people simply pressurize their abdomen (the feeling of pushing your belly out). If we are thinking about how we can adequately add tension to the abdomen both dorsally(back) and ventrally(front) we need to think about how to properly position the two diaphragms — the diaphragm … diaphragm and the pelvic floor. Proper parallel alignment of the two diaphragms makes it much easier to adequately apply tension throughout the entirety of the core. Rehab guru Dr. S. Sharmann’s approach might focus more on balancing the positional and functional demands of the core musculature. Nevertheless, the objective remains the same — get the muscles in their best position to perform and coordinate, thus increasing our potential to stabilize. Maybe an easier way to think about this is — I am an Instagram influencer attempting to influence you to look at my glutes. I know a little cheat code, if I extend my lumbar spine I can create the illusion that my badonkadonk is much larger than it truly is. Funny enough, this position is often regarded as one of the safest positions for the spine. If we then think about the length-tension relationship of the core muscles in this extended position. The muscles on the back or dorsum of the person are basically maximally shortened. In contrast, the muscles on the ventral surface or the front are maximally lengthened. The result is that we have little tension on the front of the abdomen, and here is the kicker — force production of muscles is reduced at their maximal ranges of motion, therefore, the capacity for the muscles on the ventral surface of the abdomen to contract is compromised — but(t) I still managed to catch your eye.

Oh, before I forget. We should know how to breathe. An interesting takeaway from working with patients this last year and a half (internship and practice), is the amount of people who simply hold their breath when doing core exercises. Even when I work with patients on very simple core-setting exercises and ask them to take 3–5 breaths they struggle to maintain core tension while breathing. What you may see is a flaring of the ribs as they attempt to inhale. My mentorship and the Integrated Seminar Series were great for highlighting the importance of being able to breathe with core tension. I’m paraphrasing here but, you don’t want to be an asshole and breathe with your rib cage! If tension can not be maintained while breathing we have a problem. At a minimum, your patient should be able to breathe and stabilize at the same time. If these two actions can not happen in conjunction it suggests they will have to sacrifice one to achieve the other. In the office with their practitioner breathing goes bye-bye, elsewhere breathing might take more precedence.

Hopefully, all of this yappa-yappa has not scared you away, because this is why I think all this mumbo-jumbo is important. A spine that is being held at end-range extension is probably pretty good at resisting pure flexion. The tricky thing is that our limbs are not located perfectly in line with our spine, thus, when loading our limbs biomechanically we insert a rotational demand and require a rotational reaction. In the words of Gary Ward, “Joints act, muscles react”. This is where those sleepy muscles on the front(ventral surface) of the abdomen come into play. The obliques play an important role in controlling the rotational demands placed on the core. There are two challenges now: the suboptimal balancing of the core musculature and the lack of emphasis traditional rehab/prehab/training programs place on rotational control.

My approach is:

1. Can you actually move your spine?
2. Can you actively recruit your abdominal muscles?
3. Can you breathe while those abdominal muscles are turned on?
4. Add the context of movement … Do you fall apart when doing various movements (capacity issue)?

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