Robin,

Thank you for your interesting comments.

You wrote:
"Thus,
muscle reeducation sequences should NOT be performed in isolated movements.
Instead they should be incorporated immediately into functional,
goal-oriented tasks".

***If you read my previous comment, the work on core stability does agree
with this. It states that while it is good to perform these isolated
movements, they are quite meaningless unless it becomes incorporated in
functional tasks. Have a read of the paper in Manual Therapy 1995 Vol
1:pp2-10 by Jull and Richardson entitled "Muscle control - pain control?
What exercises would you prescribe?" People such as O'Sullivan and Twomey
also suggest incorporating the TrA/Multifidus work with functional
activities.

I am just curious as to where you and Mel found comments relating to
activating these muscles in isolation ONLY - could you please publish your
references because been a University of Queensland graduate, this was
certainly not what I was taught (and certainly not what is stated in the
available literature that I have read so far... but I could have missed
something?).

You stated the following research.
"Helewa A, Goldsmith CH, Lee P, Smythe HA, Forwell L. "Does strengthening
the
abdominal muscles prevent low back pain - a randomised controlled trial" J
Rheumatol 1999;Aug26 (8) 1808-15"
Without quoting the whole study, the results showed no difference between
back ex's only and abdominal ex's and back ex's'. this was @ 3mnths, 6mnths,
12 mnths and 24 mnths."

***I would just like to quote the abstract from this study.
"OBJECTIVE: To investigate the effects of abdominal muscle strengthening
exercise on low back pain (LBP) risk reduction. METHODS: We compared the
effects of abdominal muscle strength (AMS) exercise and back education with
back education only on 402 asymptomatic subjects with weak AMS. The primary
outcome was the percentage of subjects with at least one episode of LBP at
24 months. A diary was used to monitor compliance. RESULTS: There were no
statistically significant differences between experimental (E) and control
(C) subjects at 24 months for LBP episodes (E: 34.7%, C: 30.4%; C-E = 4.2%,
P2 = 0.481; 95% CI -16.1%, 7.6%). The LBP episodes were also not
statistically significantly different at 6 months (E: 13.2%, C: 16.1%; C-E:
2.9%, P2 = 0.493; 95% CI -5.3%, 11.0%) or at 12 months (E: 24.8%, C: 23.6%;
C-E = -1.2%, P2 = 0.818; 95% CI -11.6%, 9.2%). Adjusting the data for strata
and baseline AMS did not alter the findings. Imputed results for LBP
episodes at 6 months (C-E: 4.8%, P2 = 0.191; 95% CI -2.4%, 12.0%), 12 months
(C-E: -1.0%, P2 = 0.821; 95% CI -9.5%, 7.6%), and 24 months (C-E: -3.3%, P2
= 0.483; 95% CI -12.6%, 5.9%) were also not statistically significantly
different. CONCLUSION: Back education and abdominal exercise instructions
are similar to back education alone. There were no group differences in LBP
episodes, possibly due to noncompliance with the exercise program. While the
estimated benefit of 2.9% at 6 months from the complete data and 4.8% from
the imputed data were not statistically significant, a larger study or
future metaanalyses may be needed to confirm whether there is a clinical
benefit or whether these results should be considered a chance finding."

If you read the comments made by Jull and Hodges in J Rheumatol. 2000
Sep;27(9):2286-8. UI: 20443664 and the authors replies, you would find that
this study alone does not show anything for or against core stability.
Furthermore, abdominal muscle strengtening does not equal isolated isometric
local muscle activation, and this was emphasized by Jull and Hodges. I think
we have to be very careful when interpreting the results - even the authors
do not make bold comments regarding core stability, and suggest that future
studies may be needed (even suggest that noncompliance with exercise may be
a problem in this study!!!). This reminds me of Cherkin's study that showed
no difference between Mckenzie techniques, chiropractic manipulations and a
educational book alone in the treatment of low back pain. So does this mean
that we stop Mckenzie techniques and spinal manipulations, and simply give
educational book on low back pain since financially, it seems more viable?


Your final comment:
"I might also add that the advocates of 'core stability' that are quoted in
references, almost always appear to be the same people - no one else appears
to be replicating this? So In conclusion the whole concept of 'isolation',
'core stability' et al' is only discussed as a good medium for academic
discourse, and contrasted with the physiological and biomechanical support
for such as PNF."

***Core stability was developed in Australia and is still in its prime
stages. The concept has definitely evolved over the last four years, and
continues to change. Actually, O'Sullivan and Twomey have replicated these
studies initially done by Jull, Hides et al. But does having studies done by
the same people negate the power of these studies - it is not a valid
argument. Are there any Physiotherapy concepts out there today that we can
just shut up and accept? Of course not, and if there was, then it is not
scientific :D

I think at the end of the day, with the available research at the moment, we
can continue to discuss this forever. I believe the questions asked by Mel
and others are quite important, and it is up academics and clinicians to
develop good studies to answer these questions... with the rate of journal
articles per day, hopefully, we won't have to wait for too long!

Henry***

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