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Core values

Huge leap forward or passing fad? Jennifer Trueland looks at the different takes on a popular theory

As a specialist physiotherapist with an NHS pain management service, Pete Gladwell sees patients who have often been through many modes of treatment, including physiotherapy.

It puzzles him, however, that so many patients seem obsessed with their core muscles. ‘I was seeing patients whose only experience of physiotherapy was core stability,’ he says. ‘They had no idea about other forms of rehabilitation. My view is different. I believe that rehabilitation is a core part of physiotherapy and there’s more than one way to do it.’

Core stability – the idea that some muscles in the trunk and pelvic area help stabilise and protect the lumbar spine – has been taken to the hearts of many. Aficionados include Pilates instructors, athletes, sports trainers and physiotherapists.

Although initially based on Australian research showing its role in treating low back pain, use of the ‘core stability’ model has since been extended to other areas, such as upper and lower limb injuries and even as a prophylaxis against harm in healthy individuals, especially athletes.

The theory is that the transversus abdominis, a muscle of the abdomen, is key to lower spine health. Research has shown that in patients with back pain, there is TA dysfunction. This led to the belief that the muscle was not ‘recruited’ in time to protect the spine during movement. Retraining the TA would therefore solve the problem.

An attractive theory

It’s a very attractive theory, especially, as one of its detractors says, because it has cultural resonances and fits in with our ideas of what is beautiful. Abdominal hollowing – an important aspect of core stability – essentially means pulling our tummies in, and a flat stomach and erect posture are seen as desirable attributes.

Aesthetics aside, however, does it work? Or, as the authors of research published recently in the British Journal of Sports Medicine would put it, ‘Transversus abdominis and core stability: has the pendulum swung?’.1

If this is the case what does it say about the readiness of physiotherapists to embrace a theory that now, it seems, may be flawed? Are there lessons to be learned in how research is read and applied? (see panel: Reclaiming the middle ground). And, if core stability it is on its way out, is there a risk of throwing the baby out with the bathwater and losing any gains core exercise may bring?

Mr Gladwell, who works with the Bristol pain management service, believes physios seized on core stability because early studies showed promising results. He cautions: ‘The early research compared core stability intervention with GP care, rather than the best available approach. Almost any movement practice will compare well against GP care. More recent studies comparing with equivalent exercise do not show the same positive results.’

Lucy Goldby, spine specialist and director of the London-based private clinic Balance Physiotherapy, believes in the core stability approach. Her research showed core stability exercises were effective in improving pain and function in patients with low back pain.2

Anecdotal evidence

She would, however, be one of the first to admit there is a lack of real, hard evidence that it works better than other exercise regimes, but based on anecdotal evidence, she is quite convinced. ‘I’ve treated so many patients who have reported a tremendous difference – they’ve said to me they wouldn’t have believed two years ago that their condition would have improved so much.’

Her view is core stability exercises help achieve the two main goals of rehabilitation for back pain, which she says are shortening the time taken to get back to work and reducing recurrence. She does not believe it is a panacea, however. ‘I don’t think it’s the answer to everything under the sun,’ she says.

Eyal Lederman, an osteopath who runs the Centre for Professional Development in Osteopathy and Manual Therapy in London, really hopes the tide is beginning to turn. His paper ‘The myth of core stability’ was posted on the Physiotherapy Pain Association website and generated a heated debate on interactiveCSP, the Society’s member networking website.3

Prof Lederman debunks the main claims for the regime, saying there is little, if any, scientific basis for claims of its efficacy. ‘I’m very interested in motor control and movement,’ he says. ‘I think that there was a junction point in physiotherapy in 1997 or 1998, when the core stability model emerged from Australia. Unfortunately physiotherapy took the core stability path.’

He says the core stability model does not stand up when taken in the context of research into motor control over the previous 50 years. ‘It conflicts with so many areas of science,’ he says. ‘It’s possible that this can happen in science – when a big discovery moves things on – but when it does, it means rewriting all the text books. More likely, it means that the theory is wrong.’

He believes that the core stability model gained popularity because it offered a simple answer to complex problems. ‘Finding the universal exercise is the Holy Grail – and makes clinical life easier.’ His view is core stability exercises do not help functionality. Instead, he says, people should work on the areas where they want to improve. ‘Otherwise, it’s like wanting to play the piano, but thinking you can do it through practising the banjo.’

A lost decade

Prof Lederman, who has done collaborative research with physios at King’s College London, leading to his PhD, sounds frustrated when he talks of how core stability has taken hold. ‘It’s still a major part of practice. It’s been a lost decade for physiotherapy. There’s been a lot of money spent on it, which could have been used for research in other things.’

A review published last year examined the research as it stood on the use of what it called ‘lumbar stabilization exercises’ for the management of chronic low back pain.4

It concludes – and Dr Goldby’s research was one of just three studies that met the authors’ strict criteria – that while there was moderate evidence that lumbar stabilisation exercises were effective at improving pain and function in a heterogeneous group of patients with chronic low back pain, there was strong evidence that this treatment ‘is no more effective than a less specific, general exercise programme’.

It adds: ‘Although there seems to be a relatively sound theoretical and experimental basis for considering this type of exercise training, more information is needed on the types of patients for which it may be best suited, the optimal setting for delivering care and training, the most effective exercises, and the optimal dose, duration, frequency and progression.’

The authors certainly don’t throw out any idea that core stability is a waste of time; indeed, they say it ‘may be considered a useful tool in the management of patients with CLBP’.

Terminology issues

But core stability means different things to different people. Mark Bender, a physiotherapist with the private practice Six Physio, says terminology is a real problem. ‘Core stability is such a rubbish term. I hear it from everyone, from my milkman and local butcher to the trainers at the gym, and nobody – including physiotherapists – really knows what they mean by it.

‘I’ve been involved in what might loosely be called core stability for about 20 years now. It started out as muscle-specific exercises and they really didn’t do much at all. Then came the work from Queensland University [about TA] and that didn’t really do much either. I think the pendulum is swinging towards functional movement – that’s improving motor control and optimising performance both in top athletes and in people in everyday life.’

Prof Lederman also considers functional movement is the future – and he wishes physiotherapy hadn’t been diverted on to the ‘extra-functional’ route of core stability. Is he confident that as a result of recent research the idea of core stability has had its day? While change will come, Prof Lederman is not optimistic it will happen overnight. He says: ‘An elderly GP once told me that it takes 75 years for a medical myth to disappear. We’ve had this one for 10 years, so there are 65 to go.’ FL

References

1 Allison et al. ‘Transversus abdominis and core stability: has the pendulum swung?’, British Journal of Sports Medicine (2008), 42:930

2 Goldby et al. ‘A randomized controlled trial investigating the efficiency of musculoskeletal physiotherapy on chronic low back disorder’, Spine (2006), 31:1083

3 Lederman. ‘The myth of core stability’, www.cpdo.net/myth_of_core_stability.doc

4 Standaert et al. ‘Evidence-informed management of chronic low back pain

with lumbar stabilization exercises’, The Spine Journal (2008), 8(1):114

5 Cook. ‘Jumping on bandwagons: taking the right clinical message from research’, British Journal of Sports Medicine (2008), 42(11):563

Reclaiming the middle ground

Just like hemlines, certain exercises and equipment go up and down in popularity.

According to Grant Syme, a consultant physiotherapist with NHS Fife, it’s all part of an evolution that is helping the profession develop.

‘I think there is a danger that physiotherapists get convinced of the benefits of a particular therapy without going back and looking at the evidence.

They listen to a lot of people saying something’s great then jump on the bandwagon,’ he says. ‘But I don’t think we should be too hard on ourselves. Physiotherapy is a young profession and it’s evolving all the time. Look at medicine – do you think everything that doctors do is backed by evidence?’

He compares the current controversy over transversus abdominis to exercises tackling another muscle, the vastus medialis obliquus. Part of the inside muscle of the thigh, this was believed to be important in treating patellofemoral (knee) pain. This may be the case for some patients, but there is little evidence that treatments targeting VMO work.

Writing in the British Journal of Sports Medicine, Jill Cook, of the Musculoskeletal Research Centre at Deakin University, Melbourne, also cautions against taking research and applying it beyond what could reasonably be claimed.5 ‘There are instances where clinical practice has steamed ahead of research knowledge,’ she writes. ‘Experienced practitioners will recall the thousands of dollars spent on isokinetic machines in the 1980s and note that only slightly less is now being spent on Pilates-based exercises.’ Both are excellent modes of rehabilitation, she believes, but adds: ‘Claims for the effectiveness of these modalities has been touted well beyond what the research has shown.’

Other treatments have also come and gone, while those that make up practice at the moment may prove to be fads. According to Mr Syme, current ‘fashions’ include kinesio taping – using specific taping or strapping techniques for a number of symptoms, including swelling and ligament injuries.

Then there’s whole body vibration therapy, put forward as a treatment for neurological conditions as well as a sports training aid and featured in Frontline last year (21 May). The evidence base is mixed.

Similarly, and also featured recently in Frontline (3 December, 2008), many physiotherapists are having great fun introducing the Nintendo Wii and Wii Fit to their patients and clients. Again, although the initial results are positive, it’s unclear if this will stand the test of time.

One danger, Mr Syme believes, is that the benefits of particular therapies may be lost if they are used for every ill in every patient, rather than only where they will do the most good. That can be a result of rushing over-enthusiastically at a treatment, only to see it fall by the wayside in a few years.

Even so, he’s optimistic that the best will survive and come back, possibly in an improved form. ‘We always go too far first, then come back to the middle ground.’

Frontline would like to hear from you

Which side of the core stability controversy are you on and why? Are physiotherapists too keen to jump on the latest therapy bandwagons? What are the lessons to be learnt from how research is read and applied? Email your responses, stating if you are happy for them to be published, to features editor Catherine Hill at hillc@csp.org.uk

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