Core Stabilization Versus Education for Low Back Pain

A new study just came out comparing different methods of back pain prevention in a military setting. The headline is that back pain education was more effective than core stabilization exercise. Is that what it really shows? Does that mean I should put down that swiss ball and pick up a book instead? Here’s a little more detail on the study. The subjects were soldiers entering a 16 week training program to become combat medics in the U.S. Army. They were between the ages of 18 and 35 years old and had no prior history of low back pain. The soldiers were doing divided into 4 groups: traditional exercise; traditional exercise with “psychosocial education”; core stabilization exercise; and core stabilization exercise with psychosocial education.

“Traditional exercises” basically meant situps, rotating situps and crunches. “Core stabilization exercise” was designed to target the notorious transversus abdominis and multifidus, and was comprised of abdominal draw ins, side planks, flexor squats, bridges and quadruped “bird dogs.” Both groups did 5-6 exercises for one minute each, every day for 12 weeks. It should be noted that in addition to these exercises, all the groups did the daily physical work that is part of the training and assessment of the soldiers. Which included situps. Hey, it’s the army.

The “psychosocial education program” was one 45 minute session providing evidence-based information on low back pain designed to reduce its threat value and encourage active coping strategies.

After the program, the soldiers were off to Afghanistan, Iraq and elsewhere. And two years later researchers measured who sought healthcare for low back pain and for how long.

Of all the soldiers, 17% sought healthcare for low back pain. Core stabilization exercise had no protective effect. But the groups that received education had 3.3% less low back incidence over the years.

So what can we conclude? That education rules and core stabilization drools? Well maybe so but I don’t see this study as any great proof of that fact. The education group had only a small protective effect, meaning that you would need to educate 30 people before expecting even one less to seek healthcare for low back pain.

And, we need to remember that the study didn't measure low back pain, but visits to the doctor for low back pain. There's a big difference, particularly in light of the fact that one of the very things the education group learned was that doctors aren’t very good at finding a cause for back pain, and that they should employ active coping strategies. Of course these guys went to the doctor less, they were told doctors can't help. Did they also have less pain? Maybe, but we don't know.

Further, before we decide that this study provides strong evidence that core stabilization exercise is useless, we need to consider the context in which the exercise was used - in a sea of situps, pushups and other activities that would be expected to have a large effect on low back mechanics good or bad. For example, maybe all those situps made their backs as resistant to back pain as they could get, so that core stabilization could add no further benefit. Or maybe the sit ups were bad, and the core stabilization would have worked much better if those recruits didn't have to do so many repeated spinal flexions, like some pig spine in Stu McGill's lab.

Finally, one of the primary justifications in favor of core stabilization exercise is that it useful to activate muscles that  have somehow become sleepy with the onset of low back pain. But this group did not have a previous history of back pain, so there was no opportunity to test the purported merits of core stabilization training in this context.

So what can we conclude from this? At a minimum, that pain education is probably a good thing. And, in a group that is already healthy and getting a good dose of general exercise, maybe it's the best thing we have. Or maybe not.

What do you think? What did I miss? Let me know in the comments.