This article is written by Dr. John Neal who practices in Woodstock, NB and Fredericton.
When it comes to treating mechanical low back pain (pain attributed to the muscles, joints, or nerves of the lumbar spine), it is likely that you’ve tried stretches and exercises to help fix the problem. If you haven’t yet, then you’ve been missing out! Contact us as soon as possible if that’s the case as the right exercise approach is the best long term solution to back pain.
Getting back to my point.
When putting low back exercises together for back pain, it is crucial that the solution is matched with the problem. All too often I see people coming in with a history of back pain and they’ve tried exercises that just didn’t work. Sometimes it was a list of exercises that were missing an important piece of the puzzle such as mobility work or strengthening. However, sometimes the strengthening work was the wrong approach! This is what we are going to talk about! There are 2 main approaches to engaging the core muscles. I find that some therapists can get stuck on using one or the other. The key to proper spine rehabilitation and performance training is ensuring that we use the approach that works for the individual case. Follow along as I explain the 2 main approaches, their applicability, and how they could help you get through some serious episodes of back pain.
Stabilization exercises are very popular in the treatment of mechanical low back pain (LBP). The goal of this type of exercise is to optimize the muscle activation and coordination around the spine while minimizing compressive or aggravating stress to spinal tissues. Stabilization exercise in combination with daily activity modifications have been shown to be effective in the treatment of LBP. The 2 main approaches to do this form of exercise are Abdominal Hollowing and Abdominal Bracing.
Abdominal Hollowing
Abdominal Hollowing is a spine stabilization exercise that targets the activation of the intrinsic core muscles transverse abdominus (TrA) and multifidus. This technique is performed by actively “drawing in” your belly button to your spine without the use of “sucking in”. If you have your fingers on the inside of your front pelvic bones, you’ll feel the muscle contraction if you do this correctly. The theory behind this technique is that is activates the deep fascial system that creates a “corset” which provides lumbopelvic support.
Previous research from the Queensland Australia group (Hides, Richardson, Jull etc.) showed that the transverse abdominus (TrA) is recruited later in patients with low back pain, which led to speculation that it was related to an unstable or unhealthy spine. This led to the creation to this approach to rehabilitation with attempts to exclusively activate and rehabilitate the TrA. However, most existing evidence to support this concept has been indirect or qualitative. In fact, it has been shown that the TrA can only be isolated at very low levels of activation (1-2% maximum voluntary contraction or MVC).
At higher activation levels, such as during normal daily activities or athletic tasks, the TrA has been shown to be a synergist to the internal oblique (IO). In light of this, what the original research on TrA did suggest is that a motor control deficit exists in LBP patients, not necessarily that the TrA is the most important factor in this relationship. Subsequent research has demonstrated that LBP patients not only have delayed TrA activation, but other motor control deficits as well, including delays in other trunk muscles when the torso is moved quickly, inhibited knee extensors, perturbed gluteal firing patterns during walking, and an inability to breathe heavily and maintain spinal stability. This indicates a global deficit in muscle coordination, rather than a specific deficit in one muscle.
Abdominal Bracing
As the research on TrA was emerging from Australia, the biomechanics lab at the University of Waterloo (McGill and his PhD students – Grenier etc.) developed an advanced and validated method of modeling the spine and calculating how muscles contribute to spinal motion and stability. Abdominal Bracing is performed by placing the tips of your fingers into the musculature of your abdomen between the ribcage and the pelvis. Then push out your fingers by stiffening your core as if someone was going to punch you in the stomach. This technique involves activation of the abdominal muscles all around the spinal column to a level that increases torso stiffness, rather than targeting specific deep muscles as per the hollowing technique.
In a study by Grenier and McGill in 2007, they studied Bracing vs Hollowing and found that abdominal bracing was superior to abdominal hollowing in terms or increasing spinal stability with lower compression bracing increased spinal stability an additional 32% compared to hollowing, while only increasing compression 15%. Other studies on Abdominal Bracing have found that this type of training can be effective in increasing torso stiffness which can be preventative in low back pain patients. The results of this study indicate that abdominal bracing is a superior strategy for increasing spinal stability and sparing spinal load compared to abdominal hollowing. The authors were quick to point out that these results should not diminish the potential benefit of hollowing for retraining a TrA deficit from a motor control perspective, as it is still part of the abdominal wall. However, the common advice from therapists and exercise professionals to “draw in” in an effort to increase stability seems to be misdirected.
It may also be relevant that this study indicated that any attempt to hollow seemed to recruit other abdominal muscles, and thus represented a low-level brace. The authors speculate that during muscle activation, the layers of the abdominal wall may bind together, resulting in increased stiffness of the spinal column. If this is true, the TrA would still be important as a member of the “muscle orchestra” rather than a solo contributor.
Clinical Application
As a chiropractor, I ensure that when I’m assessing low back pain patients, I assess the function of their abdominal and/or core muscles. Realistically, each of these approaches are best for the patient they are best for. One is not inherently superior to the other but can be superior based on the individual patient. By teaching the patient to perform each of these approaches, seeing how that effects their pain, gives great insight into the approach to rehab and management. In addition to the therapy given to the specific diagnosis and functional limitations of the specific patient, using either or both of these approaches in the low back pain patient is important to produce the recovery and performance outcomes.
Are you struggling with back pain? Give these approaches a try? Better yet, contact us to help assess and guide you on the path of knowing what is best for your low back and spinal health!
If you enjoyed this article and you’d like to book an appointment with Dr. John in Woodstock, NB click HERE or in Fredericton, book HERE