I can’t tell you the number of times I’ve had a patient tell me they needed to strengthen their core, have asked for some specific spinal strengthening exercises for their chronic low back pain, or have had a physician write a physical therapy prescription for spinal stability training. Conservatively, I’d say it happens on a weekly basis. There are numerous programs out there that teach you how to selectively activate your deep spinal stabilizers and how to encourage this in your patients. The theory behind this approach postulates the deep spinal stabilizers have delayed activation in people with chronic low back pain when compared to pain-free individuals. This begs the questions, “Is that really what I should be doing?” I have my own thoughts/views on its use and place in physical therapy, but we’ll save that discussion for later.
An update of stabilisation exercises for low back pain: a systematic review with meta-analysis, an article published by Smith et al in 2014, discusses the discrepancy between what is assumed by many to be an excellent treatment protocol and questions its usefulness in relation to general exercise. I won’t go into the nitty gritty, but will say it was a well done systematic review with interesting conclusions. If you feel the urge to delve into it a bit more you can listen to an interview with Dr. Smith here, or you can read through an by The Sports Physio here. In a nutshell, the review concluded that spinal stability training was no more effective in treating non-specific low back pain than a general exercise program in reducing pain and improving functional outcomes, conversely leading to an increase in fear-avoidance scores. So what does this mean for us?
It means a lot, actually, and forces us to approach treating this patient population differently. I don’t completely agree with conclusions drawn by the research article and urge others to refrain from throwing the baby out with the bath water. In a group of patients with non-specific low back pain, a variety of factors could be contributing to their presentation. You cannot prescribe a cookie cutter spinal stabilization for all forms of nonspecific low back pain without evaluating the patients’ needs and expect a difference to occur. By lumping these patients into one treatment group (stabilization), you practically guarantee the scores aren’t going to show a significant change when compared to general exercise, given you’re achieving a similar response to general exercise if the stabilization exercises are performed at a high intensity.
I prefer and encourage using the treatment based classification system outlined by Fritz et al (2007) to determine when the use of “stability” training is warranted. Choosing the right patient is the first step in treating this complicated patient group and can improve your chance of prescribing an effective treatment early on. Blindly prescribing spinal stabilization exercises for any patient with non-specific low back pain will lead failure much of the time. I’m not advocating we ONLY use stabilization in this population. When stabilization activities are needed, use an approach that implements stabilization activities, graded exposure, and pain science education to ensure your patients are educated and properly progressed. Use spinal stabilization activities to encourage movement in an unloaded position, particularly if loaded positions trigger the patient’s symptoms to “flare up.” Use it improve the functional endurance of the hip/abdominal musculature. And finally, If you choose to use this program, use it because your evaluation and clinical reasoning led you in that direction, not because that’s what you’ve always done.
– Zach Huff, DPT, PT