Back pain rehab: strengthening more than the core

While these targeted approaches focusing on core training are known to be helpful, some practitioners have wondered if this kind of training should be isolated or whether it might be better when combined with whole body strength training (WBST). Research has shown show that when targeted core training is combined with a general strength program, the risk of a future incidence of lower back pain is less than when only core training is performed⁽⁶⁾. Researchers have speculated that this is because WBST improves general fitness, posture, stability, as well as coordination and, hence might produce greater improvements in functional limitations than core training alone⁽⁷⁾.

New research

There’s actually very little data that has specifically compared a focused ‘core-only’ training program (the usual exercise prescription) to a ‘core plus whole body strength’ training program in people with chronic or recurrent lower back pain. For that reason, a team of researchers from the Department of Sports Medicine,  at the University of Wuppertal in Germany carried out a study, which has just been published in the Journal of Back and Musculoskeletal Rehabilitation⁽⁸⁾. The purpose of the study was to investigate how the addition of a broad-spectrum, whole-body resistance program to a traditional core training program influenced subjective pain intensity, localized pain sensitivity, and trunk strength in patients suffering from chronic low back pain.

What they did

Forty five patients were recruited from a local outpatient rehabilitation center. To be included, patients had to be 21 years of age or older and suffering from chronic low back pain. This was defined as ‘daily low back pain of at least 3 months’ duration, with a pain intensity of at least ‘3’ on a zero to 10 intensity scale. After some basic medical screening, the patients were randomly assigned to one of two groups for a 12-week study:

• Intervention group – the participants in this group trained using a 45-minute ‘core stability’ sports rehabilitation program once a week PLUS a whole body traditional strength program carried out in the gym once a week.
• Control group – the participants in this group performed the 45-minute core training program each week as above but did NO whole body strength training.

The core training sessions (performed by both groups) consisted of low- to moderate-intensity exercises focusing on mobility, coordination, balance, posture, and general physical activity designed for general orthopedic rehabilitation purposes. In the intervention group only, additional strength exercises for the whole body were performed using bodyweight exercises and resistance machines (EGym strength circuit machines). The following exercises were performed on the machines in the order shown: chest press, back extensor, leg press, torso rotation, knee extensor, knee flexor, abdominal trainer, and latissimus pull-down. The machines recorded strength circuit records and preselected machine-positioning settings, which were stored and automatically reproduced for each participant across training sessions. This ensured standardized positioning throughout the entire 12-week intervention.

What they measured

At the start of the study, the end of the study and again after a follow-up period of four weeks, the researchers took key measures of the participants’ back health. In particular, they tracked three metrics:

• Subjective pain intensity – where the participants were asked to give a subjective score of their pain on a 1-10 intensity scale.
• Pressure pain threshold – where the exact point at which an increasing mechanical pressure stimulus turns from uncomfortable to painful is measured. A higher threshold means a nervous system  that is desensitized, more resilient and less prone to pain.
• Core strength of the trunk – the maximum force in kilograms the participants could exert during a trunk flexion (abdominal crunch type movement) and trunk extension movement was measured.
• The two groups were then compared at the three time points to see whether the extra whole body strength sessions had delivered any extra benefits, and if so, how important these were.

What they found

When the data was analyzed, it was clear that the addition of the whole body strength training to the core program had produced significant benefits. Let’s summarize them:

• Subjective pain intensity – the intervention group who did additional strength training group experienced a marked drop in perceived back pain, falling from a baseline of 5.0 down to 3.8 at the end of the intervention - a benefit that remained during the 4-week follow-up period. Conversely, the core-only training group failed to achieve a statistically significant reduction in back pain over the same time.
• Pressure pain threshold – the whole body strength training plus core training group became less sensitive to pain, being able to tolerate an extra 10N/cm of mechanical pressure before reaching the pain threshold (see figure 2). The core-only group however showed no meaningful change.
• Strength of the trunk muscles – in the ‘core plus strength’ training group, trunk extension strength increased from 60.0kg to 74.4kg, while trunk flexion strength rose from 40.3 to 48.5kg. Once again, the ‘core-only’ training group did not see statistically significant improvements (see figure 3). What was also very interesting was that there was a strong positive correlation between trunk muscle strength and pain thresholds. In plain English, the more a participant increased his/her trunk strength, the higher their pain tolerance became.

Figure 2: Pressure pain threshold changes

Light bars = intervention (core plus strength training) group; dark bars = control (core-only) group. The intervention group raised their pain pressure threshold significantly (shown by **) between the start (T0) and the end (T1) of the 12-week study while there was no significant gain in the core-only group.

Figure 3: Trunk strength changes

Light bars = intervention (core plus strength training) group; dark bars = control (core-only) group. The intervention group increased trunk extension and trunk flexion strength significantly between the start (T0) and the end (T1) of the 12-week study. While the core-only group showed some tendency to improved trunk strength, the gains were too small to be considered statistically significant (ie they could have arisen by chance).

Implications for athletes

Let’s start with a caveat before we draw our conclusions. The eagle-eyed among you will have spotted that the control and the intervention groups were not matched for training volume. So while the core plus whole body strength group trained for 90 minutes a week (2 x 45mins), the core-only group trained for half that amount of time. Ideally, the core group should have trained twice per week too to eliminate the time spent training per week as a variable.

That said, the key finding here is that when whole body strength training was added to core training, it wasn’t just that trunk strength increased significantly, it was the dramatic increase in pressure pain threshold that was most surprising. In short, this study showed that engaging in whole body strength training appears to train the central nervous system to be less ‘hyper-reactive’ to mechanical stress, effectively raising your pain ceiling in other activities and day-to-day life. This no doubt accounted for why the subjective pain scores fell significantly in the core plus strength training group but not in the core-only group.

In terms of practical application, these findings suggest that while athletes with back pain might assume it’s best to ‘nanny’ the spine by only doing highly focused core exercises such as dead bugs or planks, this is not actually the case. While therapeutic core exercises have their place in the initial steps of a rehab program, athletes should not avoid heavy loading entirely. By gradually incorporating some whole-body strength training, you can build nervous system resilience, which can help when returning to sport.

Another take home message is that it’s not necessary to spend hours per week on core training; just one good core session per week plus one whole body strength session is not just less monotonous, it’s also likely to yield very good results. Using machines that provide a controlled training environment and which support the spine is recommended in the early stages however. As you become stronger, you can begin to add in free weights and movements that challenge the posterior chain – for example by performing trunk extensions, heavy carries and deadlifts. These types of exercises can help build the kind of trunk and glute strength needed to absorb sport-specific forces such as the impacts of foot strike when running or holding the forward-leaning positions in cycling.

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