The Empowered Beyond Pain Podcast

Episode 17

The myth of core stability, Peter O’Sullivan’s personal story for Low back pain fact 7

Low back pain is still the world’s most disabling health condition and costs more than cancer and diabetes combined. A scientific journal article covering 10 facts about low back pain was recently published in the British Journal of Sports Medicine ( The origins and motivations for that paper, as well as patient stories, were covered in episodes 4 and 5 of the podcast. In this episode, Professor Peter O’Sullivan discusses low back pain fact number 7: back pain is not caused by a ‘weak core’. Pete is well-positioned to talk about this topic;

  • he has the lived experience of trying to fix his debilitating back pain by doing core exercises,
  • as an early career researcher, he then researched core stabilising exercises for low back pain,
  • and now as an internationally-renowned, distinguished Professor of Musculoskeletal pain, and specialist clinician has a mountain of wisdom to share.

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Episode Show Notes:

O’Sullivan PBCaneiro JO’Sullivan K, et al
Back to basics: 10 facts every person should know about back pain

Lederman E. The myth of core stability. J Bodyw Mov Ther. 2010 Jan;14(1):84-98. doi: 10.1016/j.jbmt.2009.08.001. PMID: 20006294.

Augeard N, Carroll SP. Core stability and low-back pain: a causal fallacy. J Exerc Rehabil. 2019 Jun 30;15(3):493-495. doi: 10.12965/jer.1938198.099. PMID: 31316947; PMCID: PMC6614774.

Smith, B.E., Littlewood, C. & May, S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskelet Disord 15, 416 (2014).

May S, Johnson R. Stabilisation exercises for low back pain: a systematic review. 2008. In: Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. Available from:

Geisser, M. E., M. Ranavaya, A. J. Haig, R. S. Roth, R. Zucker, C. Ambroz and M. Caruso (2005). “A Meta-Analytic Review of Surface Electromyography Among Persons With Low Back Pain and Normal, Healthy Controls.” J Pain 6(11): 711-726.

Wong AY, Parent EC, Funabashi M, Kawchuk GN. Do changes in transversus abdominis and lumbar multifidus during conservative treatment explain changes in clinical outcomes related to nonspecific low back pain? A systematic review. J Pain. 2014 Apr;15(4):377.e1-35. doi: 10.1016/j.jpain.2013.10.008. Epub 2013 Nov 1. PMID: 24184573.

Mannion AF, Caporaso F, Pulkovski N, Sprott H. Spine stabilisation exercises in the treatment of chronic low back pain: a good clinical outcome is not associated with improved abdominal muscle function. Eur Spine J. 2012 Jul;21(7):1301-10. doi: 10.1007/s00586-012-2155-9. Epub 2012 Jan 24. PMID: 22270245; PMCID: PMC3389103.

Caneiro JP, Smith A, Rabey M, Moseley GL, O’Sullivan P. Process of Change in Pain-Related Fear: Clinical Insights From a Single Case Report of Persistent Back Pain Managed With Cognitive Functional Therapy. J Orthop Sports Phys Ther. 2017 Sep;47(9):637-651. doi: 10.2519/jospt.2017.7371. Epub 2017 Jul 13. PMID: 28704623.

Caneiro, J. P., A. Smith, S. J. Linton, G. L. Moseley and P. O’Sullivan (2019). “‘How does change unfold?’ an evaluation of the process of change in four people with chronic low back pain and high pain-related fear managed with Cognitive Functional Therapy: A replicated single-case experimental design study.” Behaviour Research and Therapy 117: 28-39.

Dankaerts W, O’Sullivan P, Burnett A, Straker L. Altered patterns of superficial trunk muscle activation during sitting in nonspecific chronic low back pain patients: importance of subclassification. Spine (Phila Pa 1976). 2006 Aug 1;31(17):2017-23. doi: 10.1097/01.brs.0000228728.11076.82. PMID: 16924221.

Dankaerts W, O’Sullivan P, Burnett A, Straker L, Davey P, Gupta R. Discriminating healthy controls and two clinical subgroups of nonspecific chronic low back pain patients using trunk muscle activation and lumbosacral kinematics of postures and movements: a statistical classification model. Spine (Phila Pa 1976). 2009 Jul 1;34(15):1610-8. doi: 10.1097/BRS.0b013e3181aa6175. PMID: 19564772.

Kevin WernliJay-Shian TanPeter O’SullivanAnne SmithAmity Campbell, and Peter Kent. Journal of Orthopaedic & Sports Physical Therapy 2020 0:01-48

From this paper: 

Slater D, Korakakis V, O’Sullivan P, Nolan D, O’Sullivan K. “Sit Up Straight”: Time to Re-evaluate. J Orthop Sports Phys Ther. 2019 Aug;49(8):562-564. doi: 10.2519/jospt.2019.0610. PMID: 31366294.

Other Supporting references:

Nic SaraceniPeter KentLeo NgAmity CampbellLeon Straker, and Peter O’Sullivan

Journal of Orthopaedic & Sports Physical Therapy 2020 50:3121-130

Nolan D, O’Sullivan K, Newton C, Singh G, Smith BE. Are there differences in lifting technique between those with and without low back pain? A systematic review. Scand J Pain. 2020 Apr 28;20(2):215-227. doi: 10.1515/sjpain-2019-0089. PMID: 31730537.

Heneweer, H., Staes, F., Aufdemkampe, G., van Rijn, M., & Vanhees, L. (2011). Physical activity and low back pain: a systematic review of recent literature. Eur Spine J, 20(6), 826-845. doi:10.1007/s00586-010-1680-7

Mitchell, T., O’Sullivan, P. B., Burnett, A., Straker, L., Smith, A., Thornton, J., & Rudd, C. J. (2010). Identification of modifiable personal factors that predict new-onset low back pain: a prospective study of female nursing students. Clin J Pain, 26(4), 275-283. doi:10.1097/AJP.0b013e3181cd16e1

Machado, G. C., et al. (2016). “Transient physical and psychosocial activities increase the risk of nonpersistent and persistent low back pain: a case-crossover study with 12 months follow-up.” Spine Journal 16(12): 1445-1452.

Inability to perform because of pain/injury in elite adult Irish dance: A prospective investigation of contributing factors.

Cahalan R, O’Sullivan P, Purtill H, Bargary N, Ni Bhriain O, O’Sullivan K.Scand J Med Sci Sports. 2016 Jun;26(6):694-702. doi: 10.1111/sms.12492. Epub 2015 Jun 3.PMID: 26040202
Coenen, P., et al. (2017). “Abdominal bracing during lifting alters trunk muscle activity and body kinematics.” Appl Ergon 63: 91-98.
Wernli, KO’Sullivan, PSmith, ACampbell, AKent, PMovement, posture and low back pain. How do they relate? A replicated single‐case design in 12 people with persistent, disabling low back painEur J Pain2020241831– 1849



Peter O’Sullivan:            I looked at myself in the mirror and I thought you know what I am holding myself awkwardly. I was holding myself very stiff and rigid and contracted and I was really fortunate one day that someone said to me why are you holding yourself so awkwardly and I kind of stopped and I looked in the mirror and I kind of gave myself permission to just stop doing it and almost at that point I became not just aware of my pain but I became aware of all this protective guarding that I was doing for myself so I kind of over a period of time I just unravelled where I just broke those rules of like train myself to relax my back and not brace my core and just talk myself back to being normal again and as that happened the whole pain system of obviously my concerns the pain reduced my levels of concern and distress reduced and my capacity to function improved and so did my sleep and a whole lot of things so it just unravelled basically that whole process

Kevin Wernli: hello and welcome to episode 17 of the empowered beyond pain podcast proudly brought to you by body logic physiotherapy today’s episode addresses arguably one of the most common misconceptions in the spinal health space both prevention and treatment this topic is often heavily misunderstood by fitness professionals personal trainers physiotherapists surgeons doctors osteopaths chiropractors and well the whole of society really but that’s okay because knowledge evolves and is fluid we see our role as both researchers and clinicians to make sense of modern science for you and empower you on the road to growth in many ways Pete is the perfect guest for this topic as you’ll hear he has a lived experience of trying to fix his debilitating back pain by doing core exercises as an early career researcher he then researched core stabilizing exercises for low back pain and now as an internationally renowned distinguished professor of musculoskeletal pain and a specialist clinician has a mountain of wisdom to share we need more research is often a sentiment for many research topics but thankfully for our benefit and yours the area of core stability is one that has been extensively researched each episode we share the supporting references for the evidence we bring to your eardrums and we do this in as balanced a way as possible preferring to cite high quality systematic reviews randomized control trials and studies with robust research methods that minimize bias and this week is no exception in fact it is probably the most robust and trustworthy bibliography that we’ve had to date and if you’ve seen some of the previous reference lists that’s saying something if you value the podcast and the information we share each fortnight we’d really value your feedback review the podcast on iTunes reach out to us on social media at podcast and share this with your colleagues as always the show notes for this episode can be found at forward slash podcast we’ll start today’s conversation by sharing fact 7 from the 10 facts every person should know about back pain scientific paper shared by patient voice Anthony and remember to ask is there more to pain than damage [Music] back pain is not caused by a weak core weak core muscles do not cause back pain in fact people with back pain often tense their cores as a protective response this is like clenching your fist after you sprained your wrist being strong is important when you need the muscles to switch on but being tense all the time isn’t helpful learning to relax their core muscles during everyday tasks can be helpful welcome to the back to the podcast everyone we’re sitting down today with peter Sullivan we get to sort of I suppose hear a little bit of his story um both as a personal experience for low backpack with his low back pain but also his early research and then um the you know the contemporary research around core stability and it’s kind of a topic that I’m pretty excited to share with you guys all I think this is a really common thing that we see in the clinic this idea that you know because my core is weak I’ve got back pain or I need to get my core strong to get rid of my back pain and that’s something that I really want to delve into today with yourself Pete um so I think we kind of ended the last episode about this with this crane story so if anyone hasn’t heard that listen back to that that sort of talks about it briefly touches on this idea around is the core helpful to tense when we’re lifting um but like I said let’s I think start with your personal story with back pain Pete um so I think that kind of summarizes that nicely yeah so my first um I’d never really thought about the core until I went to physiotherapy school it certainly hadn’t ever been discussed in my early you know my growing up at school or um in my home at all um and neither had posture for that matter but um I had an event uh pretty early on after I just graduated where I had a ski injury and I’ve been going down a hill way too fast and out of control and I went off a ledge and I landed heavily on my back up and I was in a huge amount of pain I thought I’d fractured my spine actually and um luckily I hadn’t but that kind of created it was the beginning of kind of like the catalyst of my first major episode of back pain and I’ve had a few from different incidents across my life um interestingly one from being manipulated had my spine manipulated as a postgraduate manual therapy student which is my another second episode um having a spinal fracture from mountain biking was another episode um so I’ve had a few but this first one was um probably my first major episode and um and it made me realize that across my training there’d been this major emphasis on um on posture and core and so one up until that time I hadn’t thought about it for myself but once I developed pain I started kicking in all this attention to my body that I hadn’t had before because it hurt and so I had pain through my thoracic spine neck and into my back so it was quite widespread pain which was consistent with the injury that I had and I started became whole but holding myself very upright and guarded and bracing my core um and I started doing that when I was working so I was first year out as a physio and I found that at the end of the day I was completely exhausted and a lot of pain in fact I was worse towards the end of the day than the beginning of the day and the more pain I got the more I tried to adjust my posture and hold my core thinking that was a good thing and I got myself into a complete pickle to a point where I started getting pain radiating down my arms and I was disrupting my sleep and it was limiting my ability to function and it became really quite concerning for me because I was thinking god I’m first you’re out I’m involved in this job which was predominantly you know more manual therapy based work at that stage because that’s what my training had predominantly been where I was spending time leaning over patients and working on patients trying to hold these postures that presumably were good for me while bracing my core and I developed this whole widespread sensitivity um that was just got me into a position where I thought maybe I won’t better do this job um and it was a kind of interesting um experience of feeling like I was getting stuck in a cycle which is such a common thing we hear patients do um and I was really fortunate one day that someone said to me why are you holding yourself so awkwardly and I kind of stopped and I looked in the mirror um I looked at myself in the mirror and I thought you know what I am holding myself awkwardly I was holding myself very stiff and rigid and contracted uh and I kind of gave myself permission to just stop doing it and almost at that point I became not just aware of my pain but I became aware of all this protective guarding that I was doing for myself so I kind of over a period of time it just unravelled where I just broke those rules of like train myself to relax my back and not brace my core and just talk myself back to being normal again and as that happened the whole pain system of obviously my concerns the pain reduced my levels of concern and distress reduced and my capacity to function improved and so did my sleep and a whole lot of things so it just unravelled basically that whole process so that was my kind of early personal journey um and I’ve had you know a few subsequent ones of that and then so the second part of that was um of that kind of journey for me was in the early 90s where I’d done my manual therapy training and then I was starting to be involved in research and it was just around the time there was a lot of focus on you know the transverse ab and you know multifidus training idea and ironically I kind of got kind of caught into that space uh where there was this view of um kind of common belief that back pain was um you know maybe caused by this lack of stability the spine that needed to be protected with these muscles like the transverse abs and the multifidus and um so part of our research and well my PhD research at that point was looking at um using that model as a means of treating people with chronic back pain and I can remember I can still remember a number of key patients that we saw that I saw in that process of people who we were doing this work of trying to train them to activate these muscles and in one sense a number of them said look you’re asking me to do something I don’t understand it’s really hard I don’t it doesn’t make sense to me why I’m doing this I can’t do it and others were saying you know what not when I’m doing this it’s making my pain worse and I can’t breathe properly and it’s making me look making me feel stiff and when I was watching these people I was going they were looking robotic in the way they were moving and I was going this doesn’t this can’t be right there was part of my brain going this isn’t right you know I’m teaching people to do stuff that’s not normal and I think that allowed me to reflect back on my own experience of going you know it is not normal to walk around pulling your tummy in all the time it’s not normal to be constantly contracting muscles and the other thing that struck me in that process was that some people became more and more hyper vigilant around their body which seemed to distress them more and it kind of makes sense now when we with a greater understanding around pain and that high pain body hyper vigilance and pain hyper vigilance isn’t probably not a very healthy thing for a human being you know engaging in activities that they value and love and having your attention outside your body and trusting your body to me is something that we want to attain I felt like in that process of teaching people to have this very focused attention to contracting muscles around their pelvis and abdomen and back was creating a kind of pain hyper vigilance for some people and like without a doubt some people appeared to benefit from it where others it actually you know they were telling us it was making them worse or making them more distressed or they were losing confidence in their body because they weren’t sure if they were doing it right and for others it was making them move abnormally which you know triggered these alarm bells in my brain to go hang on this is not right the other part of that research that we then kind of triggered onto which kind of moved more towards when vacant work was then to look at patients with back pain and measure their muscle activity when they were doing normal activities that were provocative for them things like sitting standing bending and what we what when found in that research was actually these muscles that we thought needed targeting were actually overactive that then the likes of these multifidus muscles were oh and you know admittedly we were measuring the superficial part of multifidus but it’s part of that group um the abdominal wall and that we saw the same thing in um Darren beadle’s work looking at pelvic girdle pain is that we had this model that said oh if you’ve got pain around the pelvis it means the pelvis is unstable we need to stabilize it they were already overworking these muscles so what we were finding and this was is consistent with some of your work Kev is that um that people with pain protect the area that hurts is a common scenario so actually they were already over acted activating these muscles so typically we see people over guard the core when they’re in pain and this idea of doing more when they’re already protecting something just obviously doesn’t make a lot of sense um similar to that we did other studies looking at what people without pain do and we realize that they people without pain don’t engage their core when they bend they don’t engage their core when they lift it’s people with pain that do that and if you think about it logically it makes sense like why would you sit there contracting your stomach when you’re sitting and standing or bending forward when those muscles are flexors so they’re actually those muscles should relax as you bend forward they should relax as you lift because you’re generating extension motor makes no sense to create a flexion moment as you create an extension moment because it creates a handbrake on the movement so I realized that um we were training people to do stuff that probably wasn’t normal it certainly didn’t seem to be helpful for some people and in some we from what they were telling us it was probably making them worse creating a degree of hyper vigilance and I think often um uh this this sense of the body my body’s vulnerable I need to protect it which you know is clearly not something that we want to promote now it’s really interesting you sort of had that personal experience of being really protective with your movement and then someone pointed out to you like what are you doing Pete that looks ridiculous um stop moving like a robot and then and then by not moving like a robot your pain like reduced and you got back to doing all the things that you that you valued and then yet again you were kind of pulled into that research space and then yeah it sounds like you sort of had that that conflict yeah that international conflict exactly and I think I think I’ve had that a number of times in my career when uh this this this deep sense of what is right and yet my beliefs have overridden it and then I’ve come to this point of reflection of going hang on a second this doesn’t make sense and I can remember times where you know like I don’t know if anyone does this anymore but there was a time where people were meant to lie in their belly and suck their belly in to try and reduce pressure under pressure by a feedback device I remember lying there going I can’t even breathe when I’m doing this this cannot be normal like this idea we’re asking the people to do stuff that’s just not normal um and look I think the other thing that’s important here is to differentiate the importance of being strong so having a strong core having being fit and strong is very different between being tense and guarded and we often see people who are tense and guarded who are actually quite weak and not well conditioned but they’re guarding their back to protect it so often um this idea of core is also linked to other things like a belief like I’ve got to protect my vulnerable back therefore I need to protect my core which is linked to hyper vigilance and so we don’t really know how much this kind of focus on core is like a local biomechanical stress or how much of it’s just linked to this negative pain schemer with these beliefs and um and vigilance and kind of lack of confidence is driving a process that kind of activates the pain system to protect the vulnerable back if that makes sense yeah um and certainly the there’s trials that have trained patients with back pain to work their core um any benefits gained from those interventions don’t look like they’re related to a change in the muscle itself they’re more late related to things like you know I’ve got more confidence in my body so uh or improve self-efficacy so um you know even if you do see a benefit from those kinds of interventions it looks like the reason for it is not the is not related to the thing you do and it’s more other processes or cognitive processes that that probably mediate the change yeah I think that’s important to highlight because lots of people do get better with core exercises and I think what we’re highlighting here is that the reason why they get better is not because their core you know measures of their core stability have changed and that’s been highlighted in several studies which we’ll link to in the resources there’s loads of great resources around these there’s some videos there’s some articles that will link you to in the show notes page um just on that Kev though I think when we say people get better they don’t get better a lot um there was a study looking at training the likes of you know transverse abs and um and multifidous comparing it to placebo like I think it was detuned ultrasound and the benefits were marginally better and they weren’t clinically important differences so it’s not it’s not a cure for back pain by any means and in fact the systematic reviews have compared um the benefit from stabilization training to other forms of exercise via walking road bike you know general stuff which has probably got better health benefits generally for a person showing that there’s no greater benefit certainly in the moderate to long term from those exercises exercise is good for people with back pain but the effects at this stage around that kind of approach is pretty small and what we’re interested in is you know we’ve got to do better with back pain than little effects is what we’re interested in and you know that’s part of our ongoing research to look at that yeah it’s true yeah it’s true and I suppose the important thing is it’s not like you said it’s not better than you know just general exercise going for a walk or strengthening or anything like that I want to highlight the conclusion to one of those systematic reviews there’s an update of a systematic review by ben smith and this is a quote there is strong evidence stabilization exercises are not more effective than any other form of active exercises in the long term the low levels of heterogeneity which basically just means all the studies were the same so we can compare them and large number of higher methodological quality studies which just means that they’re studied of high quality at long term follow up strengthen our current findings and further research is unlikely to considerably alter this conclusion and I think we don’t see that in research very often that that um further research is unlikely to change it you have seen it in something like the arthroscopy versus because there are a number of trials that just show they don’t work and it’s like we don’t need to do those studies anymore because we know that um and I suppose the big question is can we do something different can we offer something different and I think the highlight here is that movement and physical activity is a really potent um intervention for people with back pain as long as pain isn’t a barrier for them engaging with that and often what we see with people who are really disabled is that um movement and activity is a massive provoker of their pain and so that becomes a barrier for engaging with that so um whilst we know that movement activity and at the moment it doesn’t look like one that is more superior than the other but engaging in something regularly is really important for a lot of people with back pain they would say to us well that’s all very well but I’ve tried that and it makes me worse or my pain stopped me from doing it and that’s our big challenge I think as healthcare practitioners is how we build people’s confidence and capacity to engage in physical activity that is linked to the things that they enjoy um as an alternative than just saying look you know you need to embrace your core and I had a case yesterday who just fit so perfectly in this who’d had he’s had four years of back man he’s seen multiple uh people and he’s completely frustrated because his pain has just got worse over time and he is someone who was guarding his abdominal wall holding his posture doing exactly what I was and he’d been you know he had scans showing disc bulges and you know all the unusual stuff that we see in people with um you know as around the age of 40 and had just got stuck and was really quite distressed and then we’re starting to avoid a whole lot of stuff normal activities that he was doing previously and part of his belief was on damage therefore I need to guard my back using my core and by doing it he pre he was pre-loading his spine and within that first session just teaching him to relax his belly relax his posture breathe learn to move in a more normal way he could immediately sense a reduction in his pain which allowed him to realize that he had been protecting his back and when I asked him whether this is something he had done previous to his background he said no this is what I’ve been taught to do this is what’s normal for people with back pain so there’s a sense that people in the population have this generalized belief that good posture is very finally linked to the core is something you need to do but it’s a bit like walking around clenching your pistol day uh wondering why you got a sore wrist there’s nothing wrong with clenching your fists but it’s not normal to do that when you’re writing a letter or writing your notes or you know sitting down at rest because you’re going to end up with that sauron the clenching itself is normal if you’re going to pick something heavy up or you know um push something really hard but to do that all the time is probably what we know is not healthy for the body and in fact it’s not healthy for the spine structures to be constantly under guard all the time yeah absolutely and I I think um it’s probably important to to highlight that often when people feel like they’re not getting better with these exercises the blame often comes on themselves like I’m not doing exercises right my core’s not strong enough and and I think as therapists when when an intervention doesn’t work we are quick to blame the patient and say oh look you must not be doing it right you’re not getting the right activation or the lateral slide or whatever it is whatever measure we’re using and I think that’s unfair I think um it’s the cause of a lot of frustration for patients um and like he said it’s actually not that helpful and we know that you know there’s been countless studies that demonstrate these people with pain have far more activation or unable to relax their back muscles when they’re bending um and doing functional tasks as well yeah and their core muscles and I think it’s maybe helpful to define the core you sort of mentioned moment arms and things like that before I just wanted to kind of um talk about that maybe the you know the cause obviously or it’s made up of the transverse abdominis internal oblique and external obliques are sort of the big three uh which which all sit in front of the spine so if you’re making the spine actually yeah it’s around the side and into the front of the spine it’s like a corset and when you brace those muscles you pressurize your abdomen you also contract your diaphragm and your pelvic floor so it’s like a pressure container that kind of tightens up and when that happens you also activate your back muscles but it the the net effect of those muscle groups is tends to be to compress or to flex or decide for forward bending or so yeah so you know you engage you call when you twist your spine when you side bend your spine where you flick when you flex your spine against gravity um that in activates those that abdominal kind of network muscle network which is linked in with the the back and the diaphragm your breathing muscle and your pelvic floor which is you know your muscles that control continence and interestingly um you know we see this whole interconnection between breathing control control of bladder you know bladder control and pain is kind of linked with that whole network and and so when you engage your abdominal wall muscles for example which again is very normal if you get cough sneeze um pass a bowel motion um you know push a heavy weight list twist under load you naturally activate that system it’s normal but if you’re constantly doing it that is not normal um and that can compromise other things such as issues around continents uh you know those muscles attach up to your ribcage it can change your breathing system so you know it can have quite widespread influence in terms of shifting tension up into your neck because you end up using your your accessory or your upper chest breathing muscles because you can’t engage diaphragm so we see a whole cluster of clinical presentations with people who are over engaging that muscle group or those muscle groups um and so you know people who work in the pelvic pain space or say the pelvic floor space with incontinence issues often spend time teaching people to both be strong but also to relax their pelvic floor muscles in a similar way healthy abdominal wall muscles should be able to relax when you don’t need them to rapidly engage when you do and and that’s the key of a healthy motor system is a system that can be relaxed when you don’t need it and engage when you do unfortunately with pain you often see the systems activated when you don’t need it and then it can’t respond naturally or normally when you do need it so the the core stability idea has is absolutely exploded um in the fitness industry in you know the injury management injury prevention prevention of pain and then also the treatment of pain um across everywhere where has it come from I reckon well my my view on this and this came out on the um set up straight um posture yeah um a paper that wasn’t just um that I think it’s it’s one of those one of those um concepts that has tapped into um what we see as desirable as human beings so I think as human beings we have an idea of what looks desirable and if you ask most people is it desirable for your belly to be hanging out or is it desirable to have a flat belly and so we often see this kind of social desirability of what body should look like is like you know shoulders up chest up belly in you know it’s everywhere just gets taught my daughter um you know spent years doing dance and that was a message that was strongly promoted within that industry and I think women get a lot of those messages but even now males are getting them as well and particularly when we see you know I can think of many young women who I’ve seen over the years who are constantly pulling in their bellies because they perceive that they’re fat or overweight or they don’t like their bellies I hear that a lot and so teaching women or and guys as well are constantly pulling their tongue muscles in uh to hide their tummy because this social desirability issue I reckon that’s one of the reasons it’s become such a it’s kind of hooked into it and then the pilates interest rates hooked into it so it’s almost like there’s there was this latent belief that you know you want what what looks good is you know upright posture flat belly and then this whole um kind of core belief kind of hooked into that industry around social desirability that then it’s kind of exploded to then kind of link into this belief that pain is linked to damage and if it’s damaged you need to protect it and so what do you use to protect it where you’ve got to use your core and so it’s all it’s complex but it’s all kind of missed mashed into that space I reckon and so there’s this this you know we often hear this and people go oh my god that’ll look terrible if I relax my core I thought well actually if you look in the mirror it doesn’t really look very different at all like oh it feels terrible you know I feel terrible when I do that but when we say well how does it feel for your back like it actually feels quite nice of course it’s quite relaxing um so there becomes this conflict around actually it’s relaxing um it feels better often to relax those muscles but actually I feel like I shouldn’t do it because it doesn’t look good and well if I don’t and the other thing that is fascinating with that is people go I pull on my core to hold myself up straight which is a complete oxymoron because chronically the core muscles are pulling you down so they don’t hold you up straight at all so you see these beliefs that people hold where they think yeah I’m really locking it in to keep myself straight and it doesn’t keep you straight at all it pulls you down so they’re just you know kind of myths that are just so embedded as you say at so many levels of our society around what we teach kids to do social desirability um linkedin to dance fashion you know all kinds of stuff that has just kind of made this such a powerful um uh kind of talking point a focus point which I would say almost every patient comes in with I believe that almost everybody is so english people yeah yeah and I want one thing you highlight is they don’t want to let their stomach go because obviously there’s that social stuff but I think the other side of it is because they’re worried that well if I relax then what’s going to protect my back and I’m going to cause my back pain to be worse and I think that social side is one big area that’s that’s driven this this um overwhelming dogmatic I suppose almost belief and the other side I guess is the research side and there’s a couple of studies in the late 1990s that that looked at um you know the transverse abdominis and and how quickly it fired when people lifted their arms and that was on on 15 people at a single point in time well one was twelve one was fifteen um and and it showed that that um people with back pain um who didn’t have much back pain at that time of testing had um slightly delayed twenty milliseconds delay which is one fiftieth of a second one five 500th of a second um and 150th I think and then from that it’s it’s sort of like exploded in terms of well transverse abdominis is this magic muscle that’s going to stop back pain which is not what the original original authors intended but that’s kind of where it’s all sort of started from um so so what should people do then if they’ve got um you know we have some listeners that have pain and and certainly I’ve sort of highlighted uh mandy’s story who’s one of our listeners I think in the last week’s episode of the week week before where she um she’s been practicing relaxing her core and and of a you know I think a 20-year history of pain and and it’s actually helped reduce her pain which is like the same sort of story that happened with your patient you saw yesterday and that’s not going to happen for everyone of course you know there’s uh we’re all humans sorry it is a very common story um and and even you know in in my systematic review this this idea that people become less protective that’s um as they improve is is so um common in in the single case series that I’ve done as well that’s been really common um that people get less protective as they improve yeah so so what what uh what advice would you give what tips would you give to people who have got um back pain or who treat people with back pain and um and they’re now starting to think okay you know we’ve got these people telling us that maybe the cause not that important and to yeah so I kind of have a number of thoughts around that Kev one of them was I remember when gwen dankins was doing his PhD and he had these patients who were and people without pain who had 16 um emg electro so these are electrodes that measure muscle activity around the trunk uh um across all the abdominal wall and the back muscles and he got to do really simple things like get out of a chair bend over and you know come back up etc uh and when you looked at like that’s just 16 muscles right like the complexity of it like no one was the same everyone’s muscles fired in a different way and and the complexity made me realize what are we thinking when we can teach people we think we can teach people to contract our muscle and control it during function what are we thinking it’s a bit like saying we’ve got an orchestra of 16 different instruments and we’re going to control one of those instruments you know just one it’s not how the brain works the brain doesn’t think in terms of muscle thinks in terms of function it thinks in terms of safety or danger or threat or what is the meaning of the pain and so i think for our clinicians um the important thing is to listen to the person’s story and understand what the the key barriers are for that person of course the first thing is to make sure there’s no serious diagnosis going on for that pain problem but um for the majority of people back and we know that’s not the case and then the key is to build confidence back in the back so that backs we know love to move they love to bend and twist and move in a normal way they they respond well to loading and to activation they love they’d love to be engaged in activity um and so building that confident relaxed movement that then you can build into strength and conditioning and and get people back to doing stuff that they love to me that’s the key around good care um getting focused on individual muscles to me is a bit of a side route um which can be a massive distraction or a distraction for not engaging people to get back to living again and i would encourage people to go down the easier road than the more complicated roads i spent years torturing myself and patients to try and find muscles that they just couldn’t easily activate and and i can remember as a you know younger physio being in courses where a room of 120 people couldn’t have physios couldn’t activate isolate the activation of these muscles so if if the healthcare practitioner can’t do it what are we expecting our patients to do so this idea that um that that out the human brain can isolate these things in this degree is not how the brain controls movement in my mind um that’s not my understanding of how movement is controlled and so at a very basic level it’s like you know we’d say to someone with pain you know can you release are you are you confident to move are there movements or activities that you’re not confident with what are you doing when you engage with them are you breath holding are you holding your body tense are you guarding yourself and if you can’t change that find someone who can coach you through a process of learning to do that again because often in going through that process you realize that the guarding actually was hindering your progress not helping it um and that could be quite a journey as we know from a number of studies for people for others can be incredibly hard to learn to relax and build confidence back in the body because we know pain can be really scary for people and when you’re front you tend to guard yourself and so you know some of jp canero’s work has shown that as people develop control over their pain and reduce their fear often their pain levels and their disability shifts and so some of those processes around perceptions of confidence or control ability of pain and levels of confidence versus levels of fear are critical targets to shift around just getting people back to living again yeah but but i think the other thing to highlight as well is often people go oh well you know you’re anti-core no way i mean i i personally do sit-ups i i do push-ups i do planks i would do side planks you know i believe in being strong because that helps me with the things that i love to do but there’s no way i’m sitting around pulling my belly in or trying to hold my core all day because i did it it didn’t work it wasn’t helpful for me being strong and fit is really important and and we need to separate that out from this idea of protecting the vulnerable back and and i think joe um sort of highlighted it nicely patient story joe i think from episode 14 we don’t do it with any other part of our body we don’t guard our ankle we don’t guard our wrist you know certainly if we injure it certainly then yeah for a short period of time we want to limit further injury of course um and that’s sort of the same applies for for backs as well but we don’t we don’t continue then tensing the muscles around there or trying to switch on certain muscles um to in order to heal or or get better it’s not a normal thing to do yeah exactly is there any final uh remarks pete that you want to talk about with regards to the core no but i i think um i think i think people who might listen to this you often you’ll get a backfire effect when when people hear the stuff going on you know that’s ridiculous and i know um i did an interview a number of years ago um that was put on youtube around core stability and if you look at the comments there are some people going this guy’s thinking about he’s dangerous he’s like you know this is really strong you get people who hold we hold these views about the body very strongly and um and uh often it can be quite threatening when people question that so and i’ve often encounter i wouldn’t tell patients you mustn’t do that i’d say how is can let’s just explore how that experiences for you so um you know that’s probably the most important part is it’s not like you must do this or this it’s like is that helpful for you you know are you living again are you back doing the stuff do you have confidence in your body that are the things that really are the important questions and if if you don’t have that then there may be other things that you can do um that is beyond the course we see lots of people doing a lot of cool work who are still in pain and are disabled and not doing stuff they love exac exactly like joe was or um so the young man i saw yesterday yeah and and certainly you know if those people on youtube um or those people making comments if they’ve done you know if they’ve had disabling back pain and then they’ve done core training and core exercises and they’ve improved then of course then you know that that’s like their identity or their pathway to improvement and i would never want to take that away from them ever so the bottom line for me is you know what what are the things that build confidence that you know get people back to doing the stuff in life that they that they value that’s the bottom line the way you get there you know we can have a discussion around that because they’re probably a few different parts to getting to that point but over focusing and over protecting may not be the easiest part and for something and we know it’s not an effective path for some uh and so that’s where you have to start questioning beyond the kind of paradigm again yeah absolutely and and you know certain industries might sort of find this conversation a little bit confronting especially if their identity or their their job or their life is tied up in teaching people um core stability or or trunk strength which is again we’re we’re all for strength and confidence um but yeah as we’ve discussed today there’s some nuances in that as well yeah cool awesome thanks so much for your time again pete thank you mate it’ll be a pretty popular episode and um yeah we look forward to chatting to you again next time yo thanks kim so there you have it the end of another episode many patients often say how liberating it is to hear that they don’t have to worry about tensing their core every instant of every day and how doing this can reduce their pain as you’re gathering from this podcast pain is an individual and not necessarily a simple process and as we say at the end of every podcast this information is for educational purposes only and should not substitute an individualized assessment from a trusted healthcare practitioner i guess my take home would be that while core exercises can help they don’t help more than any other exercises or manual therapy and the results on average aren’t that great and the reason behind why they work doesn’t appear to be because any measures of core stability improve it may be more to do with confidence and a sense of safety plus the potential vigilance and worrying thoughts around a perceived fragile or vulnerable spine that needs stabilizing is almost invariably unhelpful what were your take homes share them with us on social media via ebp podcast as always show notes are available at forward slash podcast and we look forward to bringing evidence to your eardrums making sense of science to close the research to real-world practice gap next fortnight until then remember to ask is there more to pain than damage [Music] please note what you heard on this episode of empowered beyond pain is strictly for information purposes only and does not substitute personalised high-value care from a licensed and trusted healthcare practitioner we are all individuals and need to be assessed and managed as such theme music generously provided by ferven and cash

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