Lower back pain core stability

Low back pain: Balancing mobility and stability

The title image of this post is an artists’ rendition of Philippe Petit’s 1974 high-wire walk between the previous Twin Towers of New York’s World Trade Center. Petit wrote a book: “To Reach the Clouds”, which was later release in paperback under the title “Man on Wire”.

The relevance of this image to this post cannot be understated. Petit’s unrivaled feat of balance and stability is an undisputed display that stability comes from control of movement, not the prevention of it. Philippe Petit would never have achieved his walk between the towers if he had been rigid. Faced with upwinds, crosswinds and a moving wire he had to use a dynamic approach to balance. He was so well poised that he was even able to lie down on the wire at the half way point. To watch his amazing achievement, and the beautiful dance on the wire you can watch it on the 2008 film Man on Wire.

Paul Hodges on balancing mobility and stability:

Paul Hodges is a Professor at the University of Queensland with over 520 research items listed on Researchgate.  He is well respected with over twenty-three thousand citations. His main area of focus is listed as “Neuromotor control of movement and stability, and changes in this system with pain”.

Current themes that Professor Hodges is working on:

  • Physiology and pathophysiology of movement control mechanisms.
  • Integration of neuroscience and biomechanics to investigate the nervous system control of joint stability and movement.
  • Effect of conflicting task demands control on spinal control.
  • Biomechanical effect of contraction of the intrinsic spinal muscles on stability of the spine.
  • The effect of pain on motor control and possible mechanisms.
  • Mechanism of efficacy of therapeutic exercise.

Paul Hodges was recently interviewed by Dr Karim Kahn of the British Journal of Sports Medicine for a BJSM Google hangout: Paul Hodges on BJSM

The summary of this interview:

According to Paul Hodges there are three major misconceptions with regards to “core stability”:
1) Misconception: It is all about stiffness
2) Misconception: It is all about one muscle (or a select handful of muscles)
3) Misconception: There is a one size fits all approach to fixing back pain

Reality 1: It is about dynamic control.

Different tasks place different demands on the body. Some movements require more stiffness/bracing while others require more fluidity. The dynamic control for weight lifting for example is different to the dynamic control of running. Weight lifting may require more stiffness, while the same level of stiffness applied to running would be detrimental to performance, and may lead to injury.

Dynamic control is therefore the control of movement relative to task, rather than the prevention of it.  Too many pseudo-core routines are designed around rigidity, stiffness and the prevention of movement. A plank is a prime example. Thousands, if not millions, of planks are performed annually with the belief that they are core-centric. However, a plank is not a core stability exercise, it is a pain tolerance exercise. Planks are terminated after a set time limit or due to pain in the shoulders/lower back.  They are not terminated due to core fatigue or loss of stability.

Reality 2: The body is a complex system of neuro-muscular-skeletal interactions.

There is more to the body than just one muscle or a select group of muscles. A number of paradigms promote the training / re-training of the Transversus Abdominus, which has been shown to be an important muscle for stability of the torso. It is hypothesised that the Transversus Abdominus achieves this by increasing its thickness and consequently the intra-abdominal pressure. However, it is one muscle. It is a local stabiliser, that is believed to fatigue quickly, and does not produce movement. It is therefore part of the puzzle, not the only piece. Countless patient hours are devoted to this muscle (along with Multifidus) using motor control exercises (precise movements aimed at “isolating” the muscles) at the expense of general exercise (cardio / weights / flexibility).

Reality 3: There is no one size fits all.

No two patients are the same. Some back cases may have similar signs and symptoms  but the human being experiencing the back pain is unique and needs to have a unique case management. Too often the approach is a one size fits all. In a best case scenario a patient should be given a bespoke exercise programme tailor made to their individual injury needs, goals and lifestyle.

The problem with the term “core”:

We have a problem in the rehabilitation/fitness industry: an obsession with the term “core”. The word core is reductionist in itself. It should be core + stability = core stability. In actual fact it is the stability component that should get the emphasis, not just the core.  Stability of the body is not derived from one particular system or isolated area of the anatomy. Nothing in the human body works in isolation. It is a “symphony” of Newtons 3rd law: action and reaction.




Medical professionals, trainers and the media have created a nervous condition involving a misinformed belief system that there is a catastrophic lack of spinal stability, and the only remedy is to “fix” the “core”. This paranoia can be conceptualised as a Corexia-nervousa or Core-dysmorphic-disorder .  Even though most patients have limited concept of what the core is anatomically, they know that they have to have one. It is like a magical unicorn, or pot of gold at the end of a rainbow.

We have created a generation of patients that believe that the centre of their back pain problem is due only to the lack of “core”. Their misconstrued philosophy is that the more core they do the better they will be. Unfortunately, there is never enough core in their minds. And if you do not give them core, the patient believes that their back will be left vulnerable. The tragedy of this scenario is that the seed of this misinformation is often planted by a medical professional. The spine is hugely resilient. It is not a dry twig waiting to snap at a moment’s notice.

Evidence against the “Corexia” / lack-of-core paradigm exists, but patients and practitioners choose to ignore it.  If you listen to Dr Fiona Wilson on the following soundcloud interview (Treating low back pain in sport: Dr Fiona Wilson. ) you will hear how some patient population groups have a direct correlation between amount of time spent on core, and back pain. What on earth does that mean?: it means that the more core training that this particular patient group performed the more likely they were to experience back pain. This can be attributed to both volume but also the type of exercise included in a core routine. Clearly we are getting it wrong! Lack of “core” is not the problem.

Advancing with the times:

If you are shoved into a generic Pilates class or force-fed the same tired dogma of “core” it is time for a change.  It is important to read wider than just the echo chamber of core and Pilates posts in your local magazine or Facebook feed. If you need bespoke exercise advice, seek out a Biokineticist / Physiotherapist with special interest in low back rehabilitation, but do not settle for mediocrity. Science has evolved and the Biokineticist / Physiotherapist that claims to be current and up to date with best practice needs to give you way more than just core. Like Phillipe Petit on his wire, you need a dynamic approach to your movement.

Paul Hodges BJSM interview with Karim Khan: https://www.youtube.com/watch?v=hplw6Lg95SY
Main image: http://www.perezosos.mx
Image: PsyPost

Treating the patient

If you are injured and want to use exercise as a modality it is important that you realise that the exercise does not treat pain directly.

Exercise may alleviate discomfort and improve functional ability.  But it does not “treat” the pain. Likewise, when you seek the advice of a Biokineticist or exercise specialist they should not have the goal of trying to “treat” your pain. They need to treat you. The patient. Not the pain. In the process of the exercise journey the pain may diminish. This is more often than not (depending on the condition) due to the exercises addressing the causative factors rather than just the symptoms/consequences of your particular injury.

Biokinetics Cape Town


Often practitioners and patients alike get stuck “looking down the microscope”. They are so focused on pain that they miss the factors that contribute to the pain.  Pain viewed from a “catastrophic model” perspective puts pain in the centre of attention. Something is wrong. There is a crisis, and the symptoms of that crisis need to be addressed immediately. And at a localised level. But you and your injury are more than just pain. Pain is complicated. It is multi-factorial. There are physical factors, biological factors, social factors, psychological factors, and even environmental/lifestyle factors.  For this reason the treatment approach should be multi-factorial. Causation rather than catastrophe.

Your treatment team needs to keep this in mind and work as a unit rather than as individuals. Each team member has a role to play in the management of your injury. Doctors / Physiotherapists / Biokineticists / Osteopaths / Chiropractors need to work in unison to meet your treatment goals.

Biokinetics Neil Hopkins

Voltaire was a philosopher in the 1700’s. He apparently wrote the following phrase: “Doctors/Physicians are like wizards/magicians, they enact trickery while the body effects the cure”. Given the right environment, and treatment approach, your body does the healing work. The therapists that you work with are privileged enough to be along for the ride. They may be highly educated/skilled, but your recovery is your responsibility and your achievement.

If you are injured and think that you could benefit from seeing a Biokineticist, speak to your Specialist / Doctor / Physiotherapist / Osteopath / Chiropractor, to see if you are a suitable candidate for Biokinetics exercise rehabilitation. Otherwise feel free to visit your local Biokineticist. If your injury is too acute, or in need of more physical therapy the Biokineticist will refer you to a Specialist / Doctor / Physiotherapist / Osteopath / Chiropractor for appropriate management and care.



Microscope image: Techtimes
Pain image: PBS Newshour
Voltaire image: Amazing people

Biokinetics: Return to running safely.

Biokinetics APP review: C25k

Biokinetics and return to running:

One of the most frequently asked questions from a running patient is: “when can I run again?”. This APP assists the return to running process in a somewhat objective way.  The running load (distance, as well as walk to run ratio) is controlled quite strictly to ensure that there is a lower risk of overuse injury. It is a very dull process for a runner, but it is worth the time you invest.

From sitting on the couch to running 5Km:

“C25K® is the easiest program to get beginners from couch potatoes to 5Km distance runners in 8 weeks. Over 5 million people did it! Tailored for first time runners.”

This is a great programme for patients that are wanting to begin running and / or for patients returning from injury. If you follow the prescribed running / walking intervals you will be progressed safely to 5km.

“The proven C25K (Couch to 5K) program was designed for inexperienced runners who are just beginning an exercise routine.The plan’s structure prevents new runners from giving up and at the same time challenges them to continue moving forward. C25K works because it starts with a mix of running and walking, gradually building up strength and stamina to fully running 5Km.”


Download the programme:

C25k (APPLE)

Image: Fatboyruns (LINK)

Below is a visual representation of the walking to running ratio:

Image: Reddit (LINK)
 “The journey of a thousand miles begins with a single step” Lao Tzu

Biokinetics App review: Muscle Trigger Point Anatomy

APP review: Muscle trigger point anatomy

“Discover the source of your pain” – Muscle trigger point anatomy by Real Bodywork (LINK)

Muscle trigger point anatomy:

The Muscle trigger point anatomy App is an anatomy reference for the most common trigger points and referral patterns for over 70 muscles. Muscle trigger point anatomy is a great App for Biokineticists, Physiotherapists, Osteopaths, Chiropractors, Therapeutic massage therapists, Physical therapists, students, or patients wanting to discover trigger points, locate the source of muscular pain, and learn about muscle function.

The App features 100+ trigger points with their corresponding referral patterns. Each muscle includes the visual referral pattern and point location, plus a written muscle action, referral and comments for each muscle. You can choose to view each muscle individually, or use the zones view to see all the muscles that refer into a specific area, a great help in discovering the source of pain.

As a stand alone tool this App is limited. But if it is used as a guide in conjunction with the advice from your Biokineticist / Physiotherapist / Osteopath, it can be very useful. Please ask your therapist for their recommendations.  Your Biokineticist / Physiotherapist / Osteopath can illustrate which trigger points are most relevant to your condition and prescribe the correct self directed soft tissue release (SDSTR).

This is a paid for App that can be downloaded from either Google Play Store or Apple iTunes.

Download the APP:
Muscle trigger point anatomy (APPLE)
Muscle trigger point anatomy (ANDROID)


Biokinetics Product Review: Rogz Asteroidz

Rogz Asteroidz for Self Directed Soft Tissue Release (SDSTR)

The Rogz Asteroidz is a pet toy that can be purchased at most pet stores. It is popular with pets… but also with Biokineticists, Physiotherapists, Osteopaths, Chiropractors, and Physical therapists. Either as a tool to be used in the patient-practitioner session, or for homework use. Using the Rogz Asteroidz for self directed soft tissue release (SDSTR) is a way to empower patients in the treatment process. Patients can use the ball to treat themselves when they are unable to see their practitioner due to time, travel, or financial constraints. The Asteroidz balls are superior to most other SDSTR balls available on the market because they are light weight, have a medium density, and are able to “adhere” to vertical and horizontal surfaces due to the asteroid pock marks.

Rogz Asteroidz Ball (LINK)

“Soft enough not to hurt your dog’s teeth, but firm enough to bounce. The lightest, bounciest ball in the cosmic universe.”

Rogz Asteroidz sizes:

Ball size matters, just as much as placement.  Be prepared to buy more than one ball to target different areas.

AS01 Small 49mm
Small ball application:

  • Very tight muscles.
  • Very intricate angle of application.
  • Scapula / shoulder.
  • Mid thoracic erector spinae
  • Forearm.
  • Lateral lower limb.

AS02 Medium 64mm
Medium ball application:

  • Very tight muscles.
  • Less intricate angle of application.
  • Scapula / shoulder.
  • Tricep.
  • Bicep.
  • Forearm.
  • Lateral lower limb.
  • Calf.
  • Quads.
  • TFL.
  • Glutes.
  • Piriformis.

AS04 Large 78mm
Large ball application:

  • Deeper muscles.
  • Muscles that have “graduated’ from the two smaller Asteroidz balls. “Softer” muscles.
  • Easy angle of application.
  • Tricep.
  • Bicep.
  • Lateral lower limb.
  • Medial lower limb
  • Calf.
  • Quads.
  • Glutes.
  • Piriformis.
  • Hamstrings.

Choice of ball:
The question that us often asked: “surely a harder ball is better?” – The answer is no.

Durometer is one of several measures of the hardness of a material. Hardness may be defined as a material’s resistance to permanent indentation.

The higher the Durometer the more resistant to change. The more resistant to change, the more likely it will result in bruising and negative net-effect.

The Rogz Asteroidz is NOT to be mistaken with Rogz Gumz (LINK)

Rogz version of Durometer: 
Rogz uses a Durometer called a Bitometer. It is the strength and durability of the ball. Rogz use different Durometer rubbers/plastics for different pet applications. For bighting, bouncing, floating, or a combination.

Rogz Asteroidz “Bitometer”:  Medium
Rogz Gumz “Bitometer”:  Hard

Ask your Biokineticist / Physiotherapist / Osteopath to advise you on:

  1. If you are a suitable candidate for self directed soft tissue release (SDSTR).
  2. Which areas would benefit from SDSTR. See post on Muscle Trigger Point Anatomy (LINK)
  3. What techniques you should apply with SDSTR.
  4. Which tools you can use to assist with SDSTR.
  5. How frequently you should use SDSTR.
  6. What contraindications you should watch out for.