The recruitment of transverse abdominis (TVA) is delayed in people with lower back pain (Hodges, 2001).  This dysfunction is problematic as it reduces the local stability of the spine and could cause recurrent or sustained periods of back pain.

How should we retrain these patients back to function?

a.       Should we retrain these patients by performing isolated training of the local stabilisers such as TVA, multifidi, psoas, and pelvic floor muscles since these muscles show a clear pattern of dysfunction?

b.      Should we take a bracing or co-contraction approach using McGill type exercises such as bridging, 4-point exercises and curl ups?  This could be argued to be a more functional way of training, as trunk muscles act in co-contraction rather than isolation in movement.

Hall et al (2007) showed that exercises using a bracing approach did not improve the recruitment of TVA.  Performing bracing exercises did not improve the recruitment of TVA in a rapid arm movement test or in walking.  Specific local stabiliser training is required to improve TVA function (Tsao and Hodges, 2007).

Does that mean that there is no place for gross stability exercises in a rehab programme?  Are exercises such as lower abdominal exercises, bridges, functional exercises such as bent over row and dead lifts not useful?

The principle that needs to be followed here is isolate then integrate

Training only local stabilisers is a valid approach in the early stages of injury.  However, this will not provide the patient with enough strength and reserves if they are challenged with load in a functional situation.  Expecting TVA to protect you from injury when a 3 year old child unexpectedly launches at you from the couch causing you to side flex and rotate under load is a big ask!  Once local stabilisers are recruited the gross stabilisers are designed to cope with gross movement and large loads.

When working with acutely injured clients, I’d suggest that you work on local stabilisers then add functional exercises later – isolate then integrate.  Teaching local stability exercises is very challenging for therapists and clients.  I use a wide range of teaching techniques to cater for different learning styles – many of which will be taught on the Complete Core Conditioning workshop.  Some clients in pain are able to progress from isolated local stability exercises to fully integrated exercises within a single session.

Bracing and strengthening exercises are essential to build strength reserves to control gross movement of the spine.  I have used Shirley Sahrmann’s work which diagnoses DSMs (movement faults), and McGills bracing work with great success in these early stages.   I progress conditioning using Paul Chek’s concepts of core conditioning and primal patterns to ensure that my clients can cope with their life’s demands and 3 year old projectile missiles.

These concepts will be explained and taught in detail in the Complete Core Training: Rehabilitation to High Performance workshop