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Orthop Clin N Am 34 (2003) 245 – 254

Core stability exercise in chronic low back pain


Paul W. Hodges, BPhty (Hons), PhD
Department of Physiotherapy, The University of Queensland, Brisbane, Qld 4072, Australia

Exercise is commonly used in the management its implementation, and to review evidence for
of chronic musculoskeletal conditions, including efficacy of the approach.
chronic low back pain (CLBP). The focus of exer-
cise is varied and may include parameters ranging
from strength and endurance training, to specific
training of muscle coordination and control. The The rationale for core stability exercise
assumption underpinning these approaches is that
improved neuromuscular function will restore or Core stability exercise can be defined loosely as
augment the control and support of the spine and the restoration or augmentation of the ability of the
pelvis. In a biomechanical model of CLBP, which neuromuscular system to control and protect the spine
assumes that pain recurrence is caused by repeated from injury or reinjury. The term is variously used to
mechanical irritation of pain sensitive structures [1], describe a spectrum of exercise approaches that have
it is proposed that this improved control and stability the common goal to improve lumbopelvic control,
would reduce mechanical irritation and lead to pain with varied rationales. In general, strategies can be
relief [1]. Although this model provides explanation divided into two main groups: those that aim to
for the chronicity of LBP, perpetuation of pain is restore the coordination and control of the trunk
more complex, and contemporary neuroscience muscles to improve control of the lumbar spine and
holds the view that chronic pain is mediated by a pelvis [3,4], and those that aim to restore the capacity
range of changes including both peripheral (eg, (strength and endurance) of the trunk muscles to meet
peripheral sensitization) and central neuroplastic the demands of control [5,6]. Although both compo-
changes [2]. Although this does not exclude the role nents are necessary, it is useful to consider the
of improved control of the lumbar spine and pelvis rationales for each.
in management of CLBP, particularly when there is The ‘‘muscle capacity’’ model of core stability
peripheral sensitization, it highlights the need to exercise is based on the well-established premise that
look beyond outdated simplistic models. One factor stability of the spine is dependent on the contribution
that this information highlights is that the refinement of muscle. The contemporary view of spinal stability
of control and coordination may be more important is based on the Euler model that considers the control
than simple strength and endurance training for the of buckling forces [7 – 9]. This is based on the
trunk muscles. The objective of this article is to understanding that buckling failure of the lumbar
discuss the rationale for core stability exercise in the spine, devoid of muscle, occurs with compressive
management of CLBP, to consider critical factors for loading of as little as 90 N. This model argues that
muscle activity is required to act like guy wires to
stiffen intervertebral joints that they span to maintain
the lumbar spine in a mechanically stable equilibrium
Financial support was provided by the National Health [7 – 9]. This definition is relatively static and suggests
and Medical Research Council of Australia and The Swedish the maintenance of a set position of the spine. Few
Research Council. studies have considered this model in more dynamic
E-mail address: p.hodges@shrs.uq.edu.au terms [10]. Consistent with the proposal that muscle

0030-5898/03/$ – see front matter D 2003, Elsevier Inc. All rights reserved.
doi:10.1016/S0030-5898(03)00003-8
activity is required to control stability and restrict of the spine, as well as changes in this control when
trunk motion; studies have identified increased activ- people have LBP. As a result, many contemporary
ity [11,12] and coactivity of antagonist trunk muscles approaches to core stability exercise focus on reha-
[13], presumably to augment the control of the spine bilitation of the control of the trunk muscles. In many
in individuals with CLBP. On the basis of this cases, this focus has been on retraining the function
philosophy, a range of exercise strategies has been of the deep intrinsic muscles of the lumbar spine and
developed to overcome the buckling force and aug- pelvis (eg, transversus abdominis and lumbar multi-
ment the stability of the spine. In general, these fidus), and then on integration of the activity of the
strategies involve exercises that encourage mainte- deep and superficial trunk muscles in functional
nance of a stable lumbopelvic position, while forces tasks. The hypothesis here is that the coordinated
are applied with limb movements and loads. activity of the deep spinal muscles plays an important
The ‘‘control’’ model of core stability exercise is role in the fine-tuning of intersegmental motion of the
based on the premise that lumbopelvic function and spine and pelvis (eg, sacroiliac joints). Though these
health are dependent on the accurate interplay of the muscles may not provide the largest contribution
trunk muscles. Stability and control of the spine is to stability, their function is essential for optimal
dependent not only on the muscles but also on the spinal health.
central nervous system (CNS) which must determine It is impossible to separate these two rationales
the requirements of stability to plan and implement completely, but there are differences in focus that
strategies that meet these demands [1]. When the have lead to variations in the exercises incorporated
CNS can predict that the control of the spine will be into a core stability regime. The following section
challenged by an internal or external force (eg, as a addresses the neuromuscular control of stability to
result of the reactive forces from a moving limb), it provide greater insight into the clinical decisions for
has the capacity to plan strategies of muscle activity implementation of core stability exercise in the man-
in advance of the movement to prepare the spine (ie, agement of CLBP.
feedforward control). In other cases, when the per-
turbation is unexpected, the CNS can initiate a
response of the trunk muscles [14,15]. Thus, accurate Normal and abnormal control of the lumbar spine
control of the lumbar spine and pelvis is dependent and pelvis
not only on the capacity of muscle, but also on the
sensory system that provides information about the Many muscles span the lumbopelvic region and
status of stability, recognition of perturbation, and contribute to its control and stability. In fact, all
the development of the ‘‘internal model of body muscles are required for this function. There is
dynamics’’ that provides the CNS with the capacity considerable biomechanical and motor control evi-
to predict the outcome of mechanical events and dence, however, to argue that different muscles and
predict the interaction between body segments and different control strategies may be involved in the
the environment. Accurate control is also dependent control of different elements of stability, ie, interver-
on the capacity of the motor system to plan the tebral control, and the control or buckling forces and
appropriate strategy to meet the demands of stability. orientation of the lumbar spine and pelvis. The motor
This system is not only responsible for the control system has considerable redundancy, with many
of buckling forces, but also for the control of the muscles capable of performing similar functions.
overall orientation of the spine and pelvis, and
intervertebral translation and rotation during trunk
movement. Although the control of these two ele-
ments cannot be completely separated, particular
attention must be paid to control of translations and
rotations. For instance, during an arc of movement, it
is important to control the coordination between
translation and rotation at the intervertebral levels
[16]. It has been shown that, if the spine is modeled
with one segment with no muscle attachment, the
spine is as stable as having no muscle at all [8]. Thus,
segmental control is an essential component for
spinal stability. There is an increasing body of litera-
ture that has outlined the normal strategies for control
P.W. Hodges / Orthop Clin N Am 34 (2003) 245–254 247

or a few segments and that have a limited moment and attach caudally to the ilia and sacrum, whereas the
arm to move the joint, but an ideal anatomy to control deep fibers attach from the inferior border of a lamina
intervertebral motion. Bergmark included muscles and cross a minimum of two segments to attach on the
such as the lumbar multifidus in this group; however, mamillary process and facet joint capsule [30]. The
other muscles that satisfy these criteria are trans- superficial fibers are distant from the centers of rota-
versus abdominis (TrA), intertransversarii and inter- tion of the lumbar vertebrae, have an extension mo-
spinales, posterior fibers of psoas [19], and medial ment arm, and can control the lumbar lordosis [29]. By
fibers of quadratus lumborum [20]. Obliquus internus contrast, the deep fibers have a limited moment arm
has fibers that parallel the TrA and may contribute to and a minor ability to extend the spine [31].
the force closure of the sacroiliac joint (SIJ) [21]. By Multifidus can control intervertebral motion by
contrast, the global muscles cross several joints with generation of intervertebral compression [32]. The
attachments to the pelvis and the thorax. These proximity of deep multifidus to the center of rotation
muscles have a larger moment arm (ie, greater results in compression with minimal extension
torque-generating capacity) and are suited to the moment. In addition, multifidus may contribute to
control of orientation and external forces. Examples the control of intervertebral motion by control of
of the global muscles include: rectus abdominis, anterior rotation and translation of the vertebrae
obliquus externus and internus abdominis, thoracic [29], or by tensioning the thoracolumbar fascia as it
portions of the longissimus and iliocostalis, lateral expands on contraction [33]. Several studies have
fibers of quadratus lumborum, anterior fibers of provided in vitro and in vivo evidence of the ability
psoas, and latissimus dorsi. There is overlap between of multifidus to control intervertebral motion [32,34].
these systems, and some muscles share features of The contribution of the superficial global muscles
both, such as the lumbar longissimus and iliocostalis, to lumbopelvic movement and stability generally is
and the superficial fibers of multifidus having one predictable based on the moment arm and the di-
attachment to the lumbar vertebrae and sharing some rection of force provided by the muscles [17,35]. That
features of the local system. is, flexors generate flexion torque and oppose exten-
Two local or deep intrinsic lumbopelvic muscles sion. In addition, it generally has been considered that
have received attention specifically in the literature: antagonist trunk muscles are coactivated to stiffen the
the TrA and the lumbar multifidus. TrA is a broad spine and prevent buckling [36]. For example, greater
sheet-like muscle with extensive attachments to the activity of the superficial abdominal muscles has
lumbar vertebrae via the thoracolumbar fascia, and to been demonstrated during isometric trunk tasks than
the pelvis and rib cage. The muscle fibers have a predicted by a biomechanic model [35], and antago-
relatively horizontal orientation and, therefore, min- nistic activity of obliquus externus (OE) and internus
imal ability to move the spine, although they may abdominus (OI) has been recorded during lifting and
contribute to rotation [22,23]. Contribution to spinal isometric trunk efforts [35].
control is likely to involve modulation of intra- Optimal function of both systems is required to
abdominal pressure (IAP) and tensioning the thora- maintain spinal function. The local system has only a
columbar fascia. TrA has been shown to be associated limited ability to influence the control of orientation,
closely with control of IAP [22,24], and recent data and the global system has only a limited ability to
confirm that spinal stiffness is increased by IAP control intervertebral motion. It is important to con-
[25,26]. Fascial tension may restrict intervertebral sider how these muscles are coordinated in function.
motion directly or provide gentle segmental compres- Studies of feedforward and feedback control of the
sion via the posterior layer of the thoracolumbar trunk suggest that the CNS uses separate strategies for
fascia [27]. Recent porcine studies confirm that the the control of intervertebral motion and orientation of
combined effect of IAP and fascial tension is required the spine. Initial studies of the deep muscles inves-
for TrA to increase intervertebral stiffness, and the tigated locomotion and trunk movements [22,37]. In
mechanical effect of its contraction is reduced if the these tasks, the superficial abdominal and extensor
fascial attachments are cut [25]. For sacroiliac sup- muscles were active in a manner that was specific to
port, TrA acts via the ilia to compress the SIJ direction. TrA was tonically active, however, and not
anteriorly [21], and this finding has been confirmed influenced by the direction of movement [22,37].
in vivo [28]. Precise evidence of this differential control has come
The lumbar multifidus has five fascicles that arise from investigation of predictable challenges to spinal
from the spinous process and lamina of each lumbar stability caused by rapid limb movements. Early
vertebra and descend in a caudo-lateral direction [29]. studies of arm movements showed activity of leg
The most superficial fibers cross up to five segments muscles and erector spinae before flexion of the arm
248 P.W. Hodges / Orthop Clin N Am 34 (2003) 245–254

[38]. More recently, studies have confirmed that TrA reduced during experimental pain [47], and relative
and the deep fibers multifidus are activated as a EMG activity of the rectus abdominis and the infero-
component of this anticipatory response [39 – 41]. lateral abdominal wall is altered in CLBP [40].
Though the response of the superficial muscles is There is preliminary evidence that the deep para-
linked to the direction of force [40,42], the activity of spinal muscles show similar changes in activity. Dur-
TrA and deep multifidus is independent of the ing functional tasks, there is reduced amplitude of
direction of force [40 – 42]. That is, the superficial activity of the multifidus in CLBP [50], and altered
muscles control the orientation of the spine, whereas responses have been observed during loading of the
the deep muscles provide control of intersegmental trunk. For example, when a load is unexpectedly
motion that is not specific to the direction of force. dropped into the hands, there is normally a short-
An important additional finding of these studies is latency response of the paraspinal muscles [15,51];
that the CNS does not make the spine rigid by in healthy control subjects, when the loading can be
coactivation of the superficial muscles but, instead, anticipated, the response of the deep fibers of multi-
uses controlled movement to help counteract the ap- fidus occurs earlier [15]. When people with sciatica
plied forces [42]. The differential control of the deep catch a load that is predictable, however, the earlier
and superficial muscles has been confirmed in exper- response of the paraspinal muscles does not occur [51].
iments that have manipulated task expectation [43]. Others, using an unexpected loading paradigm, report
Thus, feedforward studies indicate that the CNS both delayed response [44] and no change [12] in
uses specialized strategies for each element of spinal paraspinal muscle activity. These changes in activity
control (ie, nondirection specific, early, tonic coac- are consistent with changes in the morphology and
tivation of the deep muscles and direction specific, fatigability of the muscle, which could be explained by
phasic activation of the superficial muscles). This is altered use of the muscle. For example, studies report
supported by studies of feedback-mediated control. changes in muscle fiber composition [52], increased
Many studies have investigated activity of the super- fatigability [53], and a reduced cross-sectional area
ficial muscles in response to external perturbations that occurs as little as 24 hours after the onset of acute,
such as a load dropped into a box held in the hands in unilateral LBP [54]. In CLBP, there is evidence of fatty
front of the body [44], translation of the support infiltration into the paraspinal muscles [55].
surface [45], or trunk loading [24]. These studies There is a large body of literature that investigates
report direction-specific activity of the superficial changes in the superficial trunk muscles in LBP.
muscles to maintain spinal orientation. By contrast, Although the changes have been studied extensively,
studies of TrA report activity irrespective of the there is considerable disagreement as to whether the
direction of force [24]. Recent data indicate that the superficial muscles have reduced endurance and
deep and superficial fibers of multifidus are differ- strength capacity [56,57]. It has been suggested that
entially activity in response to trunk loading [15]. these changes may be more related to inactivity than
This was only apparent, however, when the loading to pain [57]. Likewise, studies of superficial para-
was predictable. spinal muscle activity have had variable results, with
Many studies report changes in motor control in some reporting increased activity [58], others report-
people with acute and chronic LBP. Though there is ing decreased [50] or asymmetrical activity [59], and
considerable variability in results, differential changes still others reporting no change in activity [60]. One
in activity of deep and superficial muscles have been finding that has been observed consistently in people
relatively consistent. In terms of deep muscle activity, with LBP is sustained activity of the erector spinae
there is evidence of delayed activity of TrA in asso- muscles at the end of the range of spinal flexion—
ciation with rapid limb movements in CLBP [46]. The a point at which the erector spinae muscles are
changes in TrA have been replicated when pain is normally inactive (the so-called flexion-relaxation
induced by intramuscular injection of hypertonic sa- response) [61]. This finding has been replicated by
line into the longissimus muscle [47]. Notably in experimental pain [12] and has been shown to limit
studies of CLBP the changes were identified in people intervertebral motion [62]. The normal periods of
who had a history of LBP but were in remission from silence in erector spinae activity between heel con-
their symptoms. Although these studies have reported tacts are reduced, furthermore, in LBP patients and in
a delay in activation, it is likely that the change is not otherwise asymptomatic participants given experi-
confined to this parameter but, instead, may be reflec- mentally induced LBP [11], which may serve to
tive of a general change in control. For example, tonic splint the area during this period. Others have iden-
activity of TrA, which is normally observed during tified delayed reduction of activity and increased
repetitive trunk [22] and limb movements [48], is coactivation of superficial muscles in response to
P.W. Hodges / Orthop Clin N Am 34 (2003) 245–254 249

removal of a load from the trunk in a subset of CLBP Clinical factors in the implementation of core
[13]. Experimentally induced pain caused variable stability exercise
responses of the superficial trunk muscles in asso-
ciation with rapid limb movements [47]. Importantly, From the preceding discussion, it is clear that the
however, although there was considerable intersub- specific nature of the core stability exercise program
ject variability in the pattern of superficial trunk can vary depending on whether the focus is on control
muscle activity, at least one superficial muscle was or muscle capacity. In reality all components require
augmented during pain in every subject. Notably, consideration, and a specific intervention must be
despite the variation in superficial muscle activity, tailored to the individual patient’s presentation. This
hypoactivity of the intrinsic spinal muscle, TrA, was section addresses factors to consider in the imple-
a consistent finding across the group in that study. mentation of the spectrum of exercise interventions
In addition to changes in muscle recruitment, that fall under the umbrella of core stability exercise.
impairment of other elements of the sensorimotor In terms of retraining the control of core stability,
system has been identified in CLBP that may affect evidence thus far suggests that there are specific
the normal control of the lumbar spine and pelvis. For changes in the strategies used by the CNS to control
example, studies have reported reduced acuity [63] the spine, and that this consistently involves impaired
and impaired ability to perform repositioning tasks activity of the deep muscle system, often in asso-
[64]. Because both feedforward- and feedback-medi- ciation with overactivity of one or more superficial
ated components of motor control are dependent on muscles. It is unlikely that general exercise for the
sensory input, any change in sensory input is likely to trunk such as sit-ups and back extension exercises
be important. would restore the coordination between the trunk
In summary, the evidence suggests that, with LBP, muscles, and a strategy based on the principles of
the activity of the deep and superficial muscles are motor relearning and skill acquisition is required.
affected differentially. Although the results are vari- This approach aims to train the skilled activation of
able, there is evidence for augmented activity of at the deep muscles, to train the integration of the deep
least one of the superficial muscles in CLBP, whereas and superficial systems, and to progress through a
the control of the deep intrinsic spinal muscles is program of tailored functional exercises in varying
invariably impaired irrespective of the pathology. environments and contexts to ensure transfer to
Although the increase in superficial trunk muscle normal activity [4].
activity can prevent lumbar spine buckling and The nervous system has considerable potential for
increase spinal stiffness [9,17], it is also associated plasticity and learning. A key strategy described in
with increased compressive loading of the spine [36], the literature to retrain motor function involves prac-
which has long been considered a risk factor for tice of ‘‘parts’’ of movement rather than the ‘‘whole’’
spinal degeneration and pain. It is known, moreover, movement [66]. When a skill is trained in parts, the
that the CNS uses movement rather than stiffening of attention demand is reduced to allow attention to be
the spine to overcome challenges to stability [42] and focused on a single element. Several techniques have
reduce energy expenditure. A strategy of trunk stiff- been described for part-task training. These include
ening, although requiring less complex neural con- segmentation and simplification [66]. For segmenta-
trol, may compromise optimal spinal loading. Finally, tion, the task is divided into smaller parts, to be
the response to pain of stiffening the spine appears to practiced as an independent unit, and then the prac-
be at the ‘‘cost’’ of a loss of the fine tuning of ticed elements are integrated together progressively to
intersegmental motion of the spine provided by the practice the complete skill. A key feature of this
deep muscles. strategy is selection of the specific features of a
The mechanism of these changes is not com- movement that are impaired or dysfunctional (ie,
pletely understood, nor whether the changes precede ‘‘essential components’’), and then implementation
the pain or are a result of the painful episode. Though of strategies that optimize the performance of that
it is not possible to exclude the possibility that motor component using cognitive strategies. At a later stage,
control changes may predispose an individual to pain, it is important to perform the interdependent parts of
recent evidence argues that pain may replicate the a task together, and to integrate the trained compo-
changes seen in clinical populations [36]. The mech- nents in a functional context [67]. From the evidence
anism for the effect of pain may involve factors such presented above, the component of movement that is
as changes in excitability along the motor pathway or impaired in normal function is the activity of the deep
more complex changes caused by fear-avoidance muscle system (the activity of this system is delayed,
behaviors. This topic is reviewed elsewhere [65]. more phasic, and no longer independent of the
250 P.W. Hodges / Orthop Clin N Am 34 (2003) 245–254

superficial muscles). Thus, the focus of initial stages (naturally occurring), or augmented in some way, and
of rehabilitation is to train this component, indepen- may involve any of the senses including tactile
dently from the superficial muscles. Simplification (palpation) visual (ultrasound imaging) [74], and
refers to strategies to increase the ease of movement auditory (EMG biofeedback) information.
performance and may be achieved by changing A critical component of skill learning is that the
parameters such as postural load (eg, training in performance of the skill can be transferred to different
supported positions), reduction of attention demands, conditions in which the environment, personal char-
reduction of speed, or additional strategies to aug- acteristics, or predictability are changed. To optimize
ment performance (eg, improved accuracy of feed- transfer, it is considered essential to progress the task
back with ultrasound imaging). sequentially from easy to more complex situations. If
Motor learning occurs in three main phases: the aim is to transfer a skilled movement to functional
cognitive, associative, and autonomous [68]. In the tasks, then it is necessary to progress to function.
cognitive phase, the focus is on cognitively oriented More specifically, it may be necessary to replicate
problems. All elements of the movement performance sensory characteristics (eg, limitation of visual feed-
are organized consciously with attention to feedback, back), environmental contexts (eg, unstable surfaces,
movement sequence, performance, and instruction distractions), and personal contexts (eg, anxiety,
during repetition and practice. In motor relearning fatigue) [75] to ensure that the elements of the skill
for LBP, the goal of the initial phase of motor can be transferred to specific contexts [66].
relearning is to contract the deep muscles cognitively Another issue to consider is the importance of the
to increase the precision and skill of the contraction neutral position of the spine, which is variously
of the local muscles. Once mastered, the goal shifts to described as being the normal lumbar, cervical lor-
increased precision, increased number of repetitions dosis, and thoracic kyphosis. Around the neutral
and holding time, and decreased feedback. In the position, the spine exhibits the least stiffness [1].
associative phase, the fundamentals of the skill have This region is important to consider because stability
been acquired, and the cognitive demands reduced. is dependent on the contribution of the trunk muscles.
The focus moves from simple elements of task In addition, it has been argued that loading through
performance to consistency of performance, success, the spine is optimal in neutral positions [5]. Clin-
and refinement. In this stage, many repetitions are ically, training trunk-muscle control in neutral posi-
required in a variety of contexts to reduce the tions has been argued to be important for effective
cognitive demand of the task. In terms of trunk management of CLBP [4,6].
muscle training, this phase involves performance of In summary, in a motor control model to progress
the task in increasingly challenging positions (eg, a patient with LBP through the normal phases of
sitting and standing) and integration of deep and motor learning, the basic sequence that needs to be
superficial muscle function, eg, using leg-loading undertaken is: (1) skill learning, (2) precision train-
tasks [18], proprioceptive neuromuscular facilitation ing, (3) activation in a variety of contexts (including a
techniques [69], and postural challenges [3]. The final variety of postures and positions), (4) integration of
stage of motor learning, the autonomous phase, is the skill into tasks that includes activation of the
achieved after considerable practice and experience. superficial trunk muscles, and (5) specific functional
The task becomes habitual or automatic, and the retraining to ensure that the appropriate coordination
requirement for conscious intervention is reduced. of deep and superficial trunk muscles is maintained in
Importantly, there is preliminary evidence that train- a functional context.
ing in this manner can result in a change in the In contrast with the motor relearning approach to
automatic control of the spine [70,71] and peripheral retraining the control and coordination of the trunk
joints [72]. muscles, at the other end of the spectrum of core
An important element of motor learning is the stability exercise are tasks aimed at restoring the
provision of augmented feedback. Feedback can be ability of the trunk muscles themselves to meet the
divided generally into two main types: knowledge of demands for spinal stability. Notably, as the mag-
performance and knowledge of results [73]. Put nitude of force acting on the trunk is increased, the
simply, feedback that provides knowledge of per- relative contribution of the superficial trunk muscles
formance relates to ongoing information provided is increased [5]. Thus, the system must be trained to
during movement, whereas knowledge of results is meet the demands of high-level activities. The strat-
feedback of the outcome of the task. In the cognitive egies employed overlap with those described above.
phase, it is critical to provide accurate feedback of Though these tasks form the central component of
contraction quality. This feedback may be intrinsic some core stability exercise programs, they may be
P.W. Hodges / Orthop Clin N Am 34 (2003) 245–254 251

used in a motor control model as progressive training population, they are important to consider here
to rehabilitate the integration of the local and global because recurrence of pain is a major factor in CLBP.
systems for higher-level activities. Many exercise Other studies of chronic headache [70] and patellofe-
strategies have been developed for this component moral pain [72], using a similar clinical paradigm,
of core stability exercise. Strategies that are consistent have shown positive clinical outcomes. Additional
with this approach include Pilates exercise, dissoci- studies of CLBP [82] and pelvic pain [83] have
ation exercises [18], limb movements with a neutral promising early results.
lumbar spine and pelvis [4], Swiss ball programs Another focus of clinical studies has been to
[76], McGill’s stability exercises [5], rhythmic stabili- identify the mechanism of efficacy of the clinical
zation exercises from proprioceptive neuromuscular approach. In general, studies of muscle size [84],
facilitation [69], balance board and balance shoe muscle strength, muscle endurance, and muscle fiber
training [77], floor exercise programs [6], and so composition [85] have failed to find improvement or a
on. The key features of exercise vary between relationship with the clinical outcome. Improvements
approaches but include features such as control of in motor control parameters such as muscle activation
the lumbopelvic position (particularly in neutral) patterns [49,71,72] and performance of specific
during movement of the limbs [4,6,18,76], and on skilled activities [70] have found a positive relation-
unstable surfaces [76,77], closed chain tasks [4], and ship, however. Thus, there is increasing evidence of
resisted movements [78]. efficacy of core stability exercise, particularly from a
motor-control perspective, and there is evidence that
the improvements are related to the factor being
Efficacy of core stability exercise in the addressed in the intervention, not a tertiary cause.
management of chronic LBP

There are an increasing number of clinical studies Summary


that have investigated the efficacy of core stability
exercise in the management of CLBP. Although early In conclusion, core stability exercise is an evolv-
studies were based on audits of clinical outcome [6], ing process, and refinement of the clinical rehabili-
more recently, high quality randomized controlled tation strategies is ongoing. Two major foci are
clinical trials have been conducted. The first study addressed in contemporary core stability programs:
investigated core stability exercise, from a motor motor control and muscle capacity. Both of these
control perspective, in people with CLBP associated factors have considerable foundation in the literature
with spondylolisthesis [79]. In this study, subjects and can be seen as a progression of exercise rather
were allocated randomly to either participate in a than conflicting approaches. Importantly, the clinical
motor-relearning program or a nontreatment group. efficacy of these approaches is being realized in
The training period lasted for 10 weeks. At the clinical trials. Further work is required, however, to
completion of training and at follow-up at 30 months, refine and validate the approach, particularly with
there was a significant reduction in pain and disability reference to contemporary understanding of the neu-
in the motor-relearning group. There was no signifi- robiology of chronic pain.
cant change in the nontreatment group. The second
study involved training in acute first-episode unilat-
eral LBP [80]. This group was selected because they References
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