Low Back Pain – getting to the “Core “of the problem
by Dr Brian Nicholls
Over the years, there have been many “magic bullet” interventions touted as being the way to solve the epidemic of lower back pain, and it’s nearly 20 years since the introduction of one of the best known of these – the theory of core stabilisation. This theory has become so much a staple of back pain therapy that we frequently hear it referred to by everyone from GPs to sports commentators – saying things like “Oh yes, it’s so important to have a strong core in this sport.” Also, we’ve lost count of the number of our patients who go to personal trainers and are told that the first thing they need to do is strengthen their core.
However, 20 years on it has become apparent that the emphasis on core strengthening hasn’t really succeeded in denting the figures for back pain. In fact, its incidence continues to rise. So what’s the story? Is core strengthening a waste of time, or does it have a value?The research evidence is confusing. Initial trials appeared promising, with decreases in pain, and more rapid return to work times resulting from core strengthening exercises. Later studies, though, questioned this. It was pointed out that many people with strong core muscles still had back pain, and there were plenty of people with weak cores who had never had bad backs. More recent
research, including a number of comparative reviews of studies, has suggested that, although there may be short term benefits, the long-term benefits of core stabilisation are not proven. In addition, over recent years, studies have been carried out comparing core stabilisation exercise with other forms of exercise to see if core stabilisation works better than other exercise regimes. At the end of 2014 a systematic review was published which concluded that ”There is strong evidence stabilisation exercises are not more effective than any other form of active exercise in the long term.”So where does this leave us? Should our patients all start abandoning their core programmes at the gym or with their personal trainers? Probably not. None of the studies have suggested that core stabilisation is a complete waste of time. In fact many have suggested that it does have some benefit, albeit more in the short term. What all this research does tell us, however, is that “magic bullets” rarely, if ever turn out to be the instant fix we are all hoping for. Back pain remains a complicated thing, and is affected by multiple factors. Specific exercises do influence back pain, but so do general activity levels, obesity, ergonomics, past injury history and a whole range of other factors, including psycho-social. A recent study indicated, for instance, that our risk of suffering a back injury increases if we are tired, distracted or have been drinking alcohol.
What all of the research tells us is that there is no easy solution to the back pain epidemic. The management of back pain needs to encompass a number of approaches. Risk factors such as occupational strain need to be reduced. There is good evidence that manual therapies such as osteopathy are beneficial. A wide range of exercises – not just core stabilisation – can help. Pain relieving medications, back supports and even surgery all have their place in some cases. There is also evidence of benefit from other therapies such as the Alexander Technique. We all love the idea that there may be a magic bullet, but current evidence tells us that a multifactorial approach is most likely to be the best, and that is the way we try to work here at Bayside. We have a multi-disciplinary approach in which our osteopaths can work together with Shirl, our Exercise Physiologist, Jenny, our Massage Therapist, and with the patient’s GPs and other specialists where required.