Monday, January 27, 2020

Transverse Abdominis and Low Back Pain

I remember being a second year physiotherapy student in the early 90's when we had a special tutorial on how to assess and strengthen the Transverse Abdominis (TA). While in crook lying, you move your leg (bent knee fall out), leg straightening etc and had to maintain the TA contraction.

This was just before a young Paul Hodges and his supervisor Carolyn Richardson (both very famous physiotherapists) published his article on the TA. His research compared the timing of TA and Multifidus in people with low back pain (LBP) for 18 months or more against healthy subjects with no LBP.

Using fine wire and surface EMG, the participants had to move their leg or shoulder and their timing of TA and Multifidus muscles measured. Those with LBP had delayed activation of their TA/ Multifidus.
Hodges suggested that the TA was the likely to be the main cause of LBP as it is the most important and deepest muscle in the abdomen. It looks and works like a corset to stabilise the back.

This article made the allied healthcare/ fitness industry conclude that the TA was a trunk stabilising muscle that was very important to strengthen for those with LBP. Patients who had LBP had weaknesses in their TA which led to instability in the spine.

Because of Hodges' research, many other research on LBP went in that direction. However, out of the seven systematic reviews found, six of them now showed no increase in benefit in such TA based exercises over general exercises. Further research is probably not going to significantly alter this.

As I wrote last week, this early work by Hodges, Richardson and Gwen Jull was quickly adopted by the fitness industry (though Joseph Pilates never intended this). The Allied Health/ Physiotherapy community started assessing the TA via palpation, ultrasound etc and coming up with various rehabilitation exercises for it as well. There are various continuing education courses teaching this approach still.

Although research says this may help, it is no better than general graded exercise and we know that LBP is also associated with obesity and mental health (Maher et al, 2016).

There is even research advising those who have been trained to brace/ hollow their 'core' should be discouraged from doing this as this may create abnormal movement patterns creating more stress on the spine (Lederman et al, 2010).
Brace or hollow your core?
So rather than getting our patients to feel for a deep muscle (like the TA and Multifidus) in a low load movement, it would make more sense for us to get patients to do an exercise/ activity they enjoy that gives them similar benefits.


Hodges PA and Richardson CA (1998). Delayed Postural Contraction Of Transversus Abdominis In Low Back Pain Associated With Movement Of The Lower Limb. J Sp Disorders. 11(1): 46-56.

May S and Johnson R (2006). Stabilisation Exercises For Low Back Pain: A Systematic Review. Physiotherapy. 94(3): 179-189. DOI: 10.1016/

Maher CG, Underwood M et al (2016). Non-specific Low Back Pain. The Lancet. 389(10070): 736-747. DOI: 10.1016/S0140-6736(16)30970-9

Lederman E (2010). The Myth Of Core Stability. J of Bodywork, Mvt Ther. 14(1); 84-98. DOI: 10.1016/jbmt.2009.08.001

Saragitto B, Maher CG et al (2016). Motor Control Exercise For Nonspecific Low Back Pain. A Cochrane Review. Spine 41(16): 1288-1295. DOI: 10.1097/BRS.0000000000001645

Sunday, January 19, 2020

10 Helpful Facts About Low Back Pain

Favia Dubyk on her hangboard
Last week I discussed the myths about low back pain (LBP). This week I will write about 10 helpful facts about LBP once anything sinister and serious pathology are excluded. A positive mindset regarding LBP definitely helps with lower pain levels, disability and seeking healthcare.

Fact 1: LBP is not a serious life-threatening condition.

Fact 2: Most episodes of LBP improve and LBP does not get worse as we age.

Fact 3: A negative mindset, fear-avoidance behavior, negative recovery expectations, and poor pain coping behaviors are more strongly associated with persistent pain than is tissue damage.

Fact 4: Scans do not determine prognosis of LBP, the likelihood of future LBP disability, and do not improve LBP clinical outcomes.

Fact 5: Graduated exercise and movement in all directions is safe and healthy for the spine.

Fact 6: Spine posture during sitting, standing and lifting does not predict LBP or its persistence.

Fact 7: A weak core does not cause LBP, and some people with LBP tend to overtense their core muscles. while it is good to keep the trunk muscles strong, it is also helpful to relax them when they aren't needed.

Fact 8: Spine movement and loading is safe and builds structural resilience when it is graded.

Fact 9: Pain flare-ups are more related to changes in activity, stress and mood rather than structural damage.

Fact 10: Effective care for LBP is relatively cheap and safe. This includes: education that is patient-centered and fosters a positive mindset, and coaching people to optimize their physical and mental health (such as engaging in physical activity and exercise, social activities, healthy sleep habits and body weight, and remaining in employment.

There you have it. Quite different from what you have been told, read or heard. We seek to help patients confidently take up different postures, movement, graded loading physical activity, social and work engagement so you can live healthily. There are free educational resources to support these processes if you do have low back pain and have not seen us in our clinics.

You can watch this Youtube video or visit this site for more details. This will help reduce stress and build self sufficiency for you to better self mange your LBP and make better informed choices about your care.

In my next post, I will address how strengthening your 'core' (Transverse Abdominis and Multifidus) muscles was rapidly adopted by the Pilates, Physiotherapy and fitness community and if we should continue down that path.


Lin I, Wiles L, Waller R et al (2019). What does Best Practice care for Musculoskeletal Pain Look Like? Eleven Consistent Recommendations From High-quality Clinical Practice Guidelines: Systematic Review. BJSM. DOI: 10.1136/bjsports-2018-099878

O' Sullivan PB, Caneiro JP et al (2019). Back To Basics: 10 Facts Every Person Should Know About Back Pain. BJSM. DOI: 10.1136/bjsports-2019-101611.

Monday, January 13, 2020

Dorian Yates And His Christmas Tree Back

Dorian Yates
As a teenager, I used to go to Times bookstore, Kinokuniya and Borders especially, browsing books and magazines. Other than the cycling, running and triathlon magazines, I used to be fascinated by the bodybuilding magazines. That's when I first learnt about Dorian Yates and his Christmas tree back. I was truly amazed with the definition and shape of his back. (Arnold Schwarzenegger had retired from competitions by then).
Arnold Schwarzenegger's back
Talking about backs, I never really had any low back pain (LBP) before I broke my back. Now it aches from time to time, especially if I see too many patients in a row or sit still for too long.

Many of the patients we see in our clinics have LBP too. LBP is the leading cause of disability worldwide and often associated with ineffective and costly care. Myths about LBP often causes disability, time off from work, taking too much medication and pain. These unhelpful beliefs are often reinforced by the media, health industry groups and well meaning clinicians.

Due to unhealthy beliefs, people with LBP may avoid slouching, bending, physical activities and other activities that load the spine. Meaningful activities and activities of daily living and work are affected.

This may lead to unhelpful protective behaviors such as muscle guarding, bracing 'core' muscles, slow and cautious movement.

Subsequently, this may lead to the patient opting for other medical and/or invasive interventions to ease symptoms (taking medication, injections) to 'fix' postural faults or allegedly damaged structures through surgery.

Here are 10 common unhelpful beliefs about LBP which are culturally endorsed and not supported by evidence (O' Sullivan et al, 2019).

Myth 1 : LBP is usually a serious condition.

Myth 2 : LBP will become persistent and deteriorate in later life.

Myth 3 : Persistent LBP is always related to tissue damage.

Myth 4 : Scans are always needed to detect the cause of LBP.

Myth 5 : Pain related to exercise and movement is always a warning that harm is being done to the spine and a signal to stop or modify activity.

Myth 6 : LBP is caused by poor posture when sitting, standing and lifting.

Myth 7 : LBP is caused by weak 'core' muscles and having a strong core protects against future LBP.

Myth 8 : Repeated spinal loading results in 'wear and tear' and tissue damage.

Myth 9 : Pain flare-ups are a sign of tissue damage and require rest.

Myth 10 : Treatments such as strong medications, injections and surgery are effective, and necessary, to treat LBP.

All the above factors can cause stress, anxiety and depression.

I will write about the 10 actual real facts about LBP in the next post. Stay tuned.


O' Sullivan PB, Caneiro JP et al (2019). Back To Basics: 10 Facts Every Person Should Know About Back Pain. BJSM. DOI: 10.1136/bjsports-2019-101611.

Another look at Arnie's back - not in competition

Sunday, January 5, 2020

Excuse Me, Are You A Physiotherapist?

At Pippa's b'day this morning
My boys were invited for a birthday party this morning and my wife and I accompanied them. I almost never introduce myself as a physiotherapist now in a social setting.

I used to, but not anymore. Every time I tell somebody I meet I'm a physiotherapist they end up asking me about a pain or condition they have. Even friends that I haven't met for a while will ask me about their pain before they've even said hello sometimes.

Don't get me wrong, I'm not complaining. And it's not because I don't want to help or prefer them to come to our clinic so I can charge them. It's natural to ask someone who knows what they're doing for an opinion. Hey, I do the same pretty much all the time.

I often ask my patients who work in financial markets whether the stock market is heading up or down. Or if the US dollar is appreciating. Or is it time to buy some gold or silver bullion?
Picture from USAGold
My patient who manages a hedge fund tells me that the truth is, most financial market professionals know that they are at best guessing with what information they have. What's worse is in the financial market is that it is also time dependent. An opinion can be wrong now but right in a year or two. Or vice versa.

He added that stock tip hunters never consider what time horizon lies behind the idea/ tip as they always assume the information leads to a "quick buck".

As a physiotherapist/ health care professional, I definitely do not mind helping someone who asks look for a pathway to solve their problem. For instance, which specialist to consider, which hospital that has the best facilities, MRI scan especially if the problem is beyond me.
Comic from
If I cannot assess someone properly, all I can do is ask questions. That will give me clues about the most probable reason for that person's problem. I know full well the dangers of offering opinions and how they can be interpreted differently depending on the person asking and circumstances. Hence without a proper assessment, giving a clinical diagnosis is not something I'll do.

For a clinical diagnosis is a well-informed weighing of probabilities. No diagnosis has a 100 percent certainty unless you can assess the patient physically.

If you do happen to ask for my thoughts on your pain/ condition (at a birthday party etc), I'll still give my opinion but will definitely suggest a physical assessment to follow up in our clinic or get another health professional to verify.

Happy New Year.

Another funny comic from Pinterest