Research


“In God We Trust, All Others Bring Data”
-W. Edwards Deming

 

In 1997, the Agency for Healthcare Policy and Research (AHCPR) reported:  “Spinal manipulation and the profession most closely associated with its use, chiropractic, have gained a legitimacy within the United States health care system that until very recently seemed unimaginable…In the past several decades, chiropractic has undergone a remarkable transformation…Labeled an ‘unscientific cult’ by organized medicine as little as 20 years ago, chiropractic is now recognized as the principle source of one of the few treatments recommended by national evidence-based guidelines for the treatment of low back pain, spinal manipulation.  In the areas of training, practice, and research, chiropractic has emerged from the periphery of the health care system and is playing an increasingly important role in discussions of health care policy.”  “Chiropractic has undergone a remarkable transformation…and so have I.”  Wayne B. Jonas, Director of the Office of Alternative Medicine (OAM) at the National Institutes of Health (NIH) from 1995-1998.

“The chiropractic profession is assuming its valuable and appropriate role in the health care system in this country and around the world. As this happens the professional battles of the past will fade and the patient at last will be the true winner.”  Wayne Jonas, MD, Director (1995-1998), National Center for Complementary and Alternative Medicine, US National Institutes of Health, Bethesda. Foreword to The Chiropractic Profession, Chapman-Smith D,NCMIC Group, West Des Moines, 2000.

Attorney David Chapman-Smith, editor of The Chiropractic Report, insists, “the bar has been raised for everyone in this era of evidence-based health care.  It is no longer acceptable to base claims of effectiveness on individual studies or controlled trials.  There must be a significant body of evidence which includes good quality trials, and all of this must be subjected to ‘systematic review’ by expert epidemiologists and clinicians appointed by government or affiliated with a respected research center.” (Chiropractic Report, March 2001).

Links to some of the original studies and guidelines:

American College of Physicians (ACP)–Clinical Practice Guidelines for Treating Low Back Pain (2017)

American College of Physicians and the American Pain Society (APS)–ACP-APS Clinical Practice Guideline (Chou) 2007Summary for patients (published in the Annals of Internal Medicine)Practice Guidelines for Low Back Pain–published by the American Chronic Pain Association and based on the ACP/APS guidelines.

AHCPR Guidelines (1994):  http://www.chirobase.org/07Strategy/AHCPR/ahcprclinician.html

AHRQ CAM for Back Pain Oct 2010:  Agency for Healthcare Research and Quality–Complementary/Alternative Medicine

Are we making progress?: the tenth international forum for primary care research on low back pain.

Back Surgery:  Too Many, Too Costly, Too Ineffective

CHIRO Study 2010

Consumer Reports Survey

Dagenais 2010 LBP CPGs

Degenerative Cascade–The Burton Report“There is no such thing as non-specific back pain, but there are non-specific doctors”

Degenerative changes following spinal fixation in a small animal model

Herniated Discs–Study shows “significant favorable outcomes” with chiropractic care

JOSPT–Back Pain Guidelines–Journal of Orthopedic and Sports Physical Therapy–2012

Kirkaldy-Willis, William H. and Burton, Charles V., Managing Low Back Pain, 4th Edition.  New York: Churchill Livingstone, Inc. 1999.

Medical Associates Clinical Practice Guideline for LBP–mentions SMT briefly

Murphy, Paskowski Article–Discusses the need for a Primary Spine Care Practitioner in the health care system and how a chiropractor could fill that role.

Neck Pain Evidence Summary 2010

NICE-CG88-Low Back Pain

NICE Quick Reference Guide

Non-specific low back pain–Kirkaldy-Willis study

Oregon Evidence Based Guideline

Oregon Guideline for Advanced Imaging

Senna Study on Maintenance

slosbergdocument

http://thechiropracticimpactreport.com/may-2012/  this is an update on the work being done by Niteesh Choudhry, MD, PhD, and Arnold Milstein, MD, MPH (Chief Physician at Mercer).

The UK Evidence Report (2010)

The Chiropractic Report–http://chiropracticreport.com/portal/

The Chiropractic Report–The Rise of Spine Care Pathways

University of Wisconsin-Integrative Medicine-Low Back Pain Module

 

The Natural Course of Low Back Pain (LBP) or Back Pain (BP) Studies:  These studies regarding the natural course of back pain are mentioned to address the myth that “if you do nothing, most episodes of back pain will resolve by themselves within 30 days.”

  • Borkan, PhD, Van Tulder, PhD, et al. Advances in the field of low back pain in primary care. A report from the Fourth International Forum. Spine; 2002 27(5): E128-132. LBP is not easily classified as either an acute, self-limited condition or a chronic, unremitting ailment. It is more typically a recurrent or intermittent syndrome that erupts periodically over the course of a lifetime. The concept of LBP has undergone a dramatic shift in the dominant paradigm. Until 10 yrs ago, LBP was considered purely biomechanical & involved looking for anatomic damage & finding ways of fixing it. This approach hasn’t worked. The inadequacy of this model led to a radical shift – from thinking about LBP as a biomedical “injury” to viewing it as a multifactorial biopyschosocial pain syndrome.  The shift may be summarized as a change from viewing LBP as a “curable” acute bioanatomic problem to a manageable biopsychosocial recurrent complaint.  LBP is a functional disturbance rather than a signal of structural damage.  There are doubts that any form of medical treatment can alter the natural history of this condition over the long-term.
  • Hestbaek L. et al. Low back pain: What is the long-term course? A review of studies of general populations. Euro Spine Journal, 2003; 12: 149-65. Review 36 longitudinal studies (w at least 12 mo follow-up) in general patient populations. Study found no evidence to support the claim that 80%-90% of BP Pts become pain-free within a month. An average of 62% (between 42% & 75%) still experienced symptoms after 12 mo. Between 42% & 78% experienced relapses w/i  12 mo. Between 26% & 37% of workers with back-related absence, experienced a relapse of work absence. Those with a previous history of back pain were twice as likely to experience further back pain as those without a history.
  • McKenzie, R. The Myth of Short term Acute Low Back Pain. NZFP 2005; 32(2): 125-6. The chance of having a recurrence of BP after a first episode is >50%. Many recurrences are common & >1/3 of t BP population have a long-term problem. The message is that, in any one year, recurrences, exacerbations & persistence dominate the experience of LBP in the community. An individual’s experience of BP may well encompass their life history. The high rate of recurrences, episodes & persistence of symptoms seriously questions t myth of an acute/chronic dichotomy. BP should be seen from the perspective of the sufferer’s lifetime – & given such a perspective, the logic of self-management is over-whelming. Yet, the Accident Compensation Corporation has repeatedly advised the public & health care providers that acute BP is short term. All that is required is to remain active, remain at work & maintain a positive outlook for early recovery. This advice denies the opportunity for patients to learn, in the early stages of their problem, self-management protocols known to assist in early resolution.
  • Croft, PR, MD et al.  BMJ 1998;36:1356-1359.  Outcome of low back pain in general practice.  463 patients saw a GP for LBP in a 12 month period.  Pts hadn’t seen their GP for LBP in past 3 months & had a new episode of LBP.  59% of pts agreed to be followed by nurses & interviewed within 1 week of their first visit, at 3 & 12 months to determine the outcome of the LBP episode based on pain & disability scales.  59% of 463 pts saw their GP only once in the 6 months after 1st visit.  32% of pts did consult again, but only within the first 3 months & only 8% of pts had visits for >3 months.  By 3 months, only a minority of LBP pts recover and there was little increase in the percent who recovered by 12 months, emphasizing the recurrent and persistent nature of LBP.  Findings are in sharp contrast to the assumption that 90% of LBP in primary care resolves within 1 month.  Many patients seeing GPs for the first visit for an episode of LBP had symptoms for 1 month or more.  Although symptoms improve, most still have pain or disability 12 months later but are no longer seeing their MD.  Only 25% have fully recovered 12 months later.  We should stop characterizing LBP as multiple acute problems & a small number of chronic, long term problems.  LBP is a chronic problem with an untidy pattern of symptoms & periods of relative freedom from pain & disability interspersed with acute episodes, exacerbations & recurrencesA previous episode of LBP is the strongest risk factor for a new episode.  By age 30, almost half the population have had a substantive episode of LBP.  These figures simply do not fit with claims that 90% of episodes of LBP end in complete recovery.
  • Deyo, MD., Weinstein, DO. Low back pain. NEJM. 2001; 344(5): 363-369. Cross-sectional studies of nonspecific LBP, which best reflect primary care, suggest tt 1/3d of Pts are substantially improved at 1 wk & 2/3ds at 7 wks. Recurrences are common, affecting 40% of Pts w/i 6 mo. Most recurrences are not disabling, but the emerging picture is that of a chronic problem with intermittent exacerbations, analogous to asthma, rather than an acute disease that can be cured.
  • Suni J, PT, PhD, Rinne M, PT, MSci, Natri A, MD, DSci, et al. Control of the lumbar neutral zone decreases low back pain and improves self-evaluated work ability: a 12-month randomized controlled study. Spine 2006;31:E611-20. A single episode of ALBP has a favorable natural Hx but t course of LBP for most Pts is recurrent rather than acute or chronic.  Recurrence rates are high ranging from 60-86% in t first yr. Recurrent findings underscore t signif of early intervention aimed to prevent chronic problems. There’s growing evidence tt changes in motor control & function of trunk muscles may result in disorders as a result of abnormal tissue loading & pain. Stress, fear, anxiety, & depression are known to disrupt motor behavior. Controlling t neutral zone (NZ) in lumbar motion & avoiding full lumbar flexion appear to provide protection from ligament injury & posterior disc herniation. Co-contraction of torso muscles is necessary for maintaining stability around t NZ.
  • Hayden JA, DC, PhD, Dunn KM, PhD, van der Windt DA, PhD, Shaw WS, PhD. What is the prognosis of back pain? Best Practice & Research Clinical Rheumatology 2010;24:167–179. Most LBP episodes are mild & rarely disabling, w only a small proportion of Ss seeking care. Most new episodes recover within a few weeks. Among Pts presenting for care, ~62% will continue to have pain at 1 yr & ~16% who were initially off work will still be off at 6 mo. Among those w a new episode of ALBP, rapid improv’ts are common during t 1st mo after consultation. In studies looking at the most ‘acute’ Pts: 75–90% recover from pain & disability w/i wks of seeking care, & many off work will rapidly RTW. However, from a longer-term perspective, many Pts have recurrences after an initial LBP episode: 1/4 to 1/3 of ALBP Pts still report Sx 6–12 mo after a consultation. Chronic LBP Ss have a more persistent course w 2/3 not fully recovered 1–2 yrs after onset & ~80% still having pain a 1 yr F-U. Studies of mixed primary-care LBP Pts persistence rates are similar to chronic populations, reflecting t high proportion of primary care Ss w long-term problems. Between the initial visit & 1 yr F-U the course commonly consists of relapses: ~60% have relapses of pain & 33% repeated episodes of work absence. LBP hasfor 4 recovery courses: (1) recovering, (2) persistent mild symptoms, (3) constantly fluctuating problems & (4) severe chronic levels of pain.  Important prognostic factors explaining the variability of outcomes include: individual & psychological characteristics, work & social environment.

Effectiveness Studies:

  • The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: A Randomized Controlled Trial on the Effectiveness of Clinical Practice Guidelines in the Medical and Chiropractic Management of Patients with Acute Mechanical Low Back Pain.  Spine J. 2010 (Dec); 10 (12): 1055-1064.  This is the first reported randomized controlled trial comparing evidence-based clinical practice guideline treatment (CPGs) (which includes reassurance and avoidance of passive treatments, acetaminophen, 4 weeks of lumbar chiropractic spinal manipulative therapy, and return to work within 8 weeks), to family physician-directed usual care (UC) in the treatment of patients with AM-LBP. Compared to family physician-directed UC, full CPG-based treatment including chiropractic spinal manipulative therapy is associated with significantly greater improvement in condition-specific functioning.
  • 2009—The Mercer Report:  Niteesh Choudhry, MD, PhD, and Arnold Milstein, MD, MPH (Chief Physician at Mercer) report:  “Effectiveness: chiropractic care is more effective than other modalities for treating low-back and neck pain.  Regarding cost-effectiveness:  “when considering effectiveness and cost together, chiropractic physician care for low-back and neck pain is highly cost-effective and represents a good value in comparison to medical physician care and to widely accepted cost-effectiveness thresholds.  Chiropractic care for the treatment of low-back and neck pain is likely to achieve equal or better health outcomes at a cost that compares very favorably to most therapies that are routinely covered in US health benefits plans. As a result, the addition of chiropractic coverage for the treatment of low-back and neck pain at prices typically payable in US employer-sponsored health benefits plans will likely increase value-for-dollar… ”  Choudhry N, Milstein A (2009)  Do Chiropractic Physician Services for Treatment of Low-Back and Neck Pain Improve the Value of Health Benefit Plans?  An Evidence-Based Assessment of Incremental Impact on Population Health and Total Health Care Spending.  Harvard Medical School, Boston, Mercer Health and Benefits, San Francisco.
  • The Manga Report:  “In our view, the constellation of the evidence of: 
    (a) The effectiveness and cost-effectiveness of chiropractic management of low back pain.

    (b) The untested, questionable or harmful nature of many current medical therapies.

    (c) The economic efficiency of chiropractic care for low-back pain compared with medical care.

    (d) The safety of chiropractic levels.

    (e) The higher satisfaction levels expressed by patients of chiropractors

    together offers an overwhelming case in favor of much greater use of chiropractic services in the management of low-back pain.”  Manga P, Angus D et al. (1993)  The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain, Pran Manga & Associates, University of Ottawa, Ottaw, Ontario.

  • UK BEAM Study results:
    (a)When manipulation alone, or in combination with a class-based exercise program was added to best medical care, patients had better recovery in the short term (3 months) and longer term (12 months).

    (b) “Spinal manipulation is a cost effective addition to ‘best care’ for back pain in general practice” and “manipulation alone probably gives better value for money than manipulation followed by exercise.”

    (c) There were “no serious adverse events” following spinal manipulation.                                                                                                                                                                                                                                                                                       The 17-member multidisciplinary BEAM Trial team concluded that the trial “shows convincingly” that manipulation is cost-effective and that it should be made generally available to back pain patients through the British National Health Service (NHS).  (2004) United Kingdom Back Pain Exercise and Manipulation (UK BEAM) Randomized Trial: Cost Effectiveness of Physical Treatments for Back Pain in Primary Care, BMJ;329:1381.

  • Duke University Evidence-based Practice Center (EPC)—Duke University is 1 of 14 research centers given the EPC trademark status by the US Department of Health and Human Services—the 18-member interdisciplinary panel did a comprehensive systematic literature review on headaches and concluded, “manipulation is effective in patients with cervicogenic headache.” (McCrory, 2001).  In the Executive Summary, the researchers added that “these non-pharmacological treatments may be the first choice for most patients.”
  • 2010—AHRQ—Agency for Healthcare Research and Quality—Complementary/Alternative Medicine (CAM) for Back and Neck PainA massive research review and analysis conducted by the University of Ottawa Evidence-Based Practice Center, as commissioned by the U.S. Agency for Healthcare Research and Quality (AHRQ), and “summarized” in nearly 700 pages, provides insight into the clinical efficacy and cost-effectiveness of chiropractic, acupuncture, and massage therapy (what I would consider “the big three” of CAM therapy).  The report relies on data from 265 randomized, controlled trials (RCTs) and 5 non-RCTs involving CAM use by adults with back, neck, and/or thoracic pain.For both low back and neck pain, manipulation was significantly better than placebo or no treatment in reducing pain immediately or short-term after the end of treatment. Manipulation was also better than acupuncture in improving pain and function in chronic nonspecific low back pain. Results from studies comparing manipulation to massage, medication, or physiotherapy were inconsistent, either in favor of manipulation or indicating no significant difference between the two treatments. Findings of studies regarding costs of manipulation relative to other therapies were inconsistent.Mobilization was superior to no treatment but not different from placebo in reducing low back pain or spinal flexibility after the treatment. Mobilization was better than physiotherapy in reducing low back pain (VAS: -0.50, 95 percent CI: -0.70, -0.30) and disability (Oswestry: -4.93, 95 percent CI: -5.91, -3.96). In subjects with acute or subacute neck pain, mobilization compared to placebo significantly reduced neck pain. Mobilization and placebo did not differ in subjects with chronic neck pain.Complementary and Alternative Therapies for Back Pain II, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, AHRQ Publication No. 10(11)-E007 October 2010.

Cost-Effectiveness Studies:

  • A Hospital-Based Standardized Spine Care Pathway:  Report of a Multidisciplinary, Evidence-Based ProcessJ Manipulative Physiol Ther 2011 (Feb); 34 (2): 98–106.  A health care facility (Jordan Hospital) implemented a multidimensional spine care pathway (SCP) using the National Center for Quality Assurance (NCQA) Back Pain Recognition Program (BPRP) as its foundation. The findings for 518 consecutive patients were included. One hundred sixteen patients were seen once and triaged to specialty care; 7% of patients received magnetic resonance imagings. Four hundred thirty-two patients (83%) were classified and treated by doctors of chiropractic and/or physical therapists. Results for the patients treated by doctors of chiropractic were mean of 5.2 visits, mean cost per case of $302, mean intake pain rating score of 6.2 of 10, and mean discharge score of 1.9 of 10; 95% of patients rated their care as “excellent.”
  • Cost of Care for Common Back Pain Conditions Initiated With Chiropractic Doctor vs Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health InsurerJ Manipulative Physiol Ther 2010 (Nov); 33 (9): 640–643.  Paid costs for episodes of care initiated with a DC were almost 40% less than episodes initiated with an MD. Even after risk adjusting each patient’s costs, we found that episodes of care initiated with a DC were 20% less expensive than episodes initiated with an MD. This clearly demonstrates the savings that are possible when a patient is permitted to choose a chiropractor, rather than an MD for their care.

Patient Satisfaction Studies:

  • Patients in Medicare Demonstration Project Give Their Chiropractors High Marks.  ACA Online report of HHS’s Final Demonstration Project Report—Data collected from 2005-2007.  When asked to rate their satisfaction on a 10-point scale: 87 percent of patients in the study gave their doctor of chiropractic a level of 8 or higher, and 56 percent of those patients rated their chiropractor with a perfect 10.
  • Consumer Reports Lists Chiropractic Patients As Most SatisfiedConsumer Reports ~ May 2009.  A study in the May issue of Consumer Reports shows that hands-on therapies were tops among treatments for relief of back pain. The study, which surveyed more than 14,000 consumers, was conducted by the Consumer Reports Health Ratings Center. The report states that, “eighty-eight percent of those who tried chiropractic manipulation said it helped a lot, and 59 percent were ‘completely’ or ‘very’ satisfied with their chiropractor.”
  • Factors Associated With Patient Satisfaction With Chiropractic Care:  Survey and Review of the LiteratureJ Manipulative Physiol Ther 2006 (Jul); 29 (6): 455–462.  The results here generally confirm the findings elsewhere in the literature. Of the 23% of the adult population who have ever visited a chiropractor, overall rates of satisfaction are once again found to be quite high (83% satisfied or better) and the number dissatisfied is quite low (less than 10% dissatisfied or very dissatisfied). This is remarkable given the fact that much of the financial burden of the care is borne by patients, and the preponderance of care is for difficult chronic problems of back and neck.
  • Perceived Benefit of Complementary and Alternative Medicine (CAM) for Back Pain: A National SurveyJournal of the American Board of Family Medicine 2010 (May); 23 (3): 354–62.  This new reports on interviews with 31,044 individuals who used CAM for low back pain. The results are quite fascinating:  The top 6 CAM therapies for LBP, from the most-used are chiropractic, massage, herbal therapy, acupuncture, yoga/tai chi/qi gong, and relaxation techniques.  Chiropractic use (76% of respondents) was greater than all the other 5 therapies combined.  Chiropractic users scored their satisfaction (and benefits) the highest of all 6 approaches used. This reconfirms earlier findings from the Archives of Physical Medicine & Rehabilitation 2005, which reported that SMT provided the greatest pain relief [7.33], scoring higher than nerve blocks (6.75), Opioid analgesics (6.37), muscle relaxants (5.78), Acupuncture (5.29), or NSAIDs (5.22).

Safety

Neck Pain and Headache. In the 1990s multidisciplinary expert panels in Canada and the US reviewed the current evidence on risks and benefits of various treatments and specifically recommended cervical manipulation and mobilization for patients with common categories of head and neck pain, including motor vehicle accident victims with Grades I-III whiplash-associated disorders.

Those reviews were updated by the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders, an international expert panel led by neurologist Scott Haldeman, MD DC PhD from the University of California at Irvine. Its report, published in the two leading spine journals (Spine and The European Spine Journal) is described by medical leaders as a “major milestone for musculoskeletal science” that will have “a significant impact on the way in which neck pain is perceived, treated and studied around the world.”

Spinal manipulation and mobilization are recommended as safe, effective and appropriate treatment approaches for most patients with disabling neck pain (Grade 2 under the Task Force’s new classification), whether traumatic or non-traumatic in origin. Chapman-Smith D, 2010 The Chiropractic Report, July 2010 Vol. 24 No. 4

The risk of vertebrobasilar (VBA) stroke following a visit to a chiropractor’s office appears to be no different from the risk of stroke following a visit to an MD’s office.  It is likely that patients in the early stages of VBA stroke are presenting to both chiropractors and family doctors because of neck pain and headache due to pre-existing vertebral artery dissection, which is a risk factor for VBA stroke.  VBA dissection and stroke is extremely rare and there is no practical way to screen neck pain and headache patients for this problem.  Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders [Supplement to February 15, 2008]. Spine. 2008; 33(4 Suppl).  Neck Pain Evidence Summary—The Bone and Joint Decade Task Force on Neck Pain.  Institute for Work & Health, 481 University  Ave, Suite 800 Toronto, ON M5G 2E9  www.iwh.on.ca

Clinical Practice Guidelines:

“Since the 1990s, evidence-based national clinical guidelines for the management of acute and chronic low-back pain, prepared by expert interdisciplinary panels in the US, UK, and various other countries, have recommended spinal manipulation, NSAIDs, patient education and motivation, and early return to activity as an appropriate first line of management for patients with non-specific or common mechanical back pain. Spinal manipulation has now been recommended also in European Back Pain Guidelines and in practice guidelines from the American College of Physicians and the American Pain Society.”  Chapman-Smith D, 2010 The Chiropractic Report—July 2010 Vol. 24 No. 4

  • Dagenais S, DC, PhD, Tricco AC, PhD, Haldeman S, DC, MD, PhD. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. The Spine Journal 2010; 10: 514–529. The volume of literature related to LBP & NP precludes clinicians reading all studies in their fields. Clinical practice guidelines (CPGs) & systematic reviews locate, evaluate, & summarize the scientific evidence & are important tools in the implementation of evidence-based medicine. Ideally, providers involved in managing LBP & NP should be guided by the best available scientific evidence to minimize the use of ineffective, excessively costly, or even harmful procedures. Adherence to recommendations from CPGs on the management of LBP is associated with improved clinical outcomes & decreased costs.
  • Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society.  Annals of Internal Medicine 2007 (Oct 2); 147 (7): 478–491.  Low back pain is the fifth most common reason for all physician visits in the United States. Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months, and 7.6% reported at least 1 episode of severe acute low back pain within a 1-year period. Low back pain is also very costly: Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $26.3 billion in 1998. In addition, indirect costs related to days lost from work are substantial, with approximately 2% of the U.S. work force compensated for back injuries each year. Spinal manipulation is recommended for acute and chronic back and neck pain.
  • European Guidelines for the Management of Acute and Chronic Nonspecific Low Back Pain in Primary Care.  European Commission on Low Back Pain  recently published evidence-based guidelines for the management of acute and chronic low back pain. Both the Acute Back Pain Guideline and the Chronic Back Pain Guideline recommend spinal manipulation as being an effective conservative treatment. Interestingly, a lot of what’s considered “standard medical treatment” is listed as invasive treatment.
  • Acute Low Back Problems in Adults (Clinical Guide).  Bigos, Stanley J et al. December 1994 (AHCPR Publication No. 95–0642).  U.S. Agency for Health Care Policy and Research

Exercise Studies:

  • Reynolds G. Is Your Ab Workout Hurting Your Back? New York Times 2009, June 17.  In subjects with healthy backs, the transverse abdominis (TrA) contracts milliseconds before the deltoid when raising the arm into flexion. The nervous system activates the TrA to brace the spine in advance of movement. In LBP patients, TrA firing was delayed. LBP patients were trained to isolate & strengthen the TrA by sucking in their abdomen & a booming industry of fitness classes was born. The idea leaked into gyms & Pilates classes that core health was “all about the TrA.”  But there is growing dissent among sports scientists about whether all this attention to the TrA gives you a more stronger core/ back & whether it’s even safe.  “There’s so much mythology about the core,” says Stuart McGill, PhD, a highly regarded professor of spine biomechanics.  “The idea has reached trainers & thru them, the public, that the core means only the abs.  There’s no science behind that idea.”  The muscles forming the core must be balanced to allow the spine to bear large loads. If you concentrate on strengthening only one set of muscles within the core, you can destabilize the spine.  “In our lab, the amount of load the spine can bear without injury was greatly reduced when subjects pulled in their belly buttons” during crunches & other exercises.  Instead, he suggests, a core exercise program should emphasize all of the major muscles that girdle the spine – Abdominal Bracing – including the abs.  Side bridge & “bird dog” exercise the important muscles embedded along the back & sides of the core.  As for the abdominals, no sit-ups, McGill said; they place devastating loads on the disks. “Do not hollow your stomach or press your back against the floor,” McGill says.  Gently lift your head & shoulders, hold briefly & relax back down. These 3 exercises – “the Big Three” – Bird Dog, Side Bridge, & Curl-Up can provide well-rounded, thorough core stability & avoid the pitfalls of the all-abs core routine. “I see too many people,” McGill said “who have six-pack abs and a ruined back.”