When you think core muscles, what do you think? When I ask patients how they work on their core at the gym, the typical answers are abdominal crunches, obliques, and lots of planks.
That is not quite accurate. Certain gym exercises may be contributing to chronic low back pain by overusing compensating muscles and underusing the inner core muscles.
When we talk about core muscles, we are talking about the deep muscles in the body whose main function is to stabilize the lumbar spine and the pelvis. They must work together and automatically to create this stabilization. In order to be most effective, the body must be in relatively good alignment to elicit this automatic response of activation of these muscles.
The deep inner core muscles are comprised of:
- Diaphragm
- Pelvic Floor
- Transversus Abdominis
- Deep back multifidus muscles
I love the analogy of a tin can. The top of the can is the diaphragm; the bottom is the 3 sets of muscles making up the pelvic floor; the wall of the can is the transversus abdominus which are the deepest layer of the abdominal muscles; and the seam of the can is the deep back multifudus muscles
Are the muscles even working?
For these muscles to protect the back, it is not enough to just strengthen the muscles. In fact, that may actually worsen the pain and dysfunction of the back. Initially, it is much more important to ensure the muscles are even firing at all. An injured muscle may be inhibited to prevent further injuries. If the muscle continues to not be used, the brain will not register it anymore. Without awakening these muscles again, the body will find other ways to stabilize the back. The compensatory muscles used may be one of the reasons why people continue to have chronic low back tightness and pain.
Think of someone who has a cast on their arm. The muscles would have been not used for 6 weeks or so. When the arm first comes out of a cast, the brain has lost its connection to the muscles of the arm. The arm muscles do not automatically start working without the person first having to think really hard and get it going. It is only once the brain can activate the muscles that strengthening is effective.
The first step in retraining the core muscles is getting the brain to recognize that the muscle exists in the first place! When we are working on re-training, we first work on isolating the muscle. The better the muscle can be isolated, the faster it can be integrated into functional activities.
Timing vs. Strengthening
Once there is a connection between the brain and each of the muscles, training then works on getting them to fire in a certain pattern.
Recent research shows chronic low back pain may be caused by the lack of synergy of contraction of the inner core muscles. What happens then is there is a disruption in the communication between the brain and the core muscles. The body then compensates for this and contracts muscles in a non-optimal pattern. This pattern then further causes continual reinforcement of a pattern that is not effective for the body. This poor pattern of movement may cause the breakdown of tissues leading to pain and further dysfunction.
Re-training the core muscles is thus not just about strengthening. It is more about first getting the muscles to fire synergistically. Initial treatment focuses on getting all 4 core muscles to fire at once to provide a girdle-like stability for the low back and pelvis.
Strengthening
Once the muscles are able to fire all at once to provide the stability for the low back, training then works on getting these muscles to activate in anticipation of movement. I know the first time I realized my core was firing on its own was when I had to slam on the brakes at an intersection. Never mind I avoided an accident! I was more excited that I felt my core kick in without me having to work at it! I digress….
The role of the core muscles is to provide stability. But we don’t want to have to always think about how to activate each muscle and then all 4 of them together every time we need to lift something or move or challenge our bodies in any way. So when we talk about strengthening, we are actually talking about challenging these inner core muscles to maintain stability while we use the bigger muscles to do things like bending over, twisting, lifting, running, or any other functional or athletic activities.
How to Isolate the Muscles?
The hardest part of starting work on the inner core muscles is to actually learn how to feel for them. This is also the most important part. Without awareness of these muscles, your brain will continually use other muscles to stabilize the spine. These muscles are not designed to stabilize for the long term. Consequently, they will start to break down after a while.
To re-establish the connection between the brain and the muscles, the use of visualization and imagery is very effective. This is what makes Pilates programming so efficient in recruitment of muscles.
Diaphragm
Lie on your back with your legs supported on a couple of pillows. Place a hand on your belly. Close your eyes. Imagine your belly like a balloon. Without putting effort in, visualize your belly expanding in ALL directions. The belly should feel like it’s expanding at the front, back, and the sides on inhalation. On an exhalation, just relax and allow the muscle to release. Again, the important part of this is to NOT PUT EFFORT IN. It will block the proper movement of the diaphragm.
Transversus Abdominus (TA)
I have found the most effective way to feel these muscles is to lie on your back in NEUTRAL SPINE. Which means when you’re lying down, the pubic bones and the bony protuberances of the pelvis (some people call them hip bones) are on the same level. I like putting my palm on the hip bones and reach my fingers towards the pubic bones to see if they are approximately at the same level. If done correctly, there should be a small curve in the low back.
In this neutral spine position, practice breathing as described above. Be mindful that with breathing, the curve of the back and the level of the bones are maintained.
Once you have established that, then visualize the muscles between where your hands are on the hip bones. As you inhale, follow your diaphragm. As you exhale, allow the diaphragm to relax but at the very end of exhalation, gently bring your belly button in and up. If done correctly, you will feel the hip bones under your hands spreading apart.
To reiterate, throughout the breathing and activation, the curve in the low back and the level of the bones remain the same.
Pelvic Floor
Working with my patients, I have found that once breathing and activation of the TA is established, the pelvic floor naturally kicks in easier.
One note… often people think activation of the Pelvic Floor muscles is doing Kegels. But doing Kegels is not quite accurate. Often if the pelvic alignment is off, Kegel’s will only create more of a misalignment of the pelvis. Only the front pelvic floor muscles are then activated.
Instead, think of the pelvic floor like a bowl. Again, being in neutral spine position and maintaining this position will ensure that you are activating the entire pelvic floor and not just parts of it. Follow the directions as above for diaphragm and TA engagement. For the Pelvic Floor specifically, visualize a guy wire or line from the anus up to the back of your pubic bone and connect along this line.
When done properly, there should be no contractions of the buttock or leg muscles. And you will feel a tension in the deep part of your lower abdominal muscles.
Multifidus Muscles
These muscles are amazing and very complicated. They are the deepest muscles of the back and go between one vertebra to the next or between multi-levels. They act to stabilize the segments but also work in movement. I have to admit, they are hard to feel and isolate and often patients and therapists alike find it difficult to feel them.
In my practice, I often work on the other 3 muscle groups first and then once the patient has awareness of them, I will use movements of the lower extremity to bring more awareness to the multifidus.
As such, I will leave the explanation of isolating multifidus muscles off this article. In my opinion, any attempts at trying to isolate these muscles without supervision may be at risk of reinforcing poor muscle firing patterns.
Continue to work on the other muscles, maintain a neutral spine and most likely with proper breathing, the multifidus muscles are engaging.
As you can see, working the core muscles is way more complicated than just doing a lot of planks. Ultimately, the core is to provide stability during functional activities. So once you have learned to activate these muscles and engage them properly, then it’s essential you use these principles to all your functional activities.