Constructive criticism and debate is essential. Social media platforms can be useful to facilitate this. But they also allow misinformation that can influence patient care (Keter 2023). I decided to write a blog with some comments and criticisms of another blog. The blog in question is by Brendan Mouatt and is here:

https://www.physio-network.com/blog/why-we-need-to-stop-blaming-the-transversus-abdominis-for-back-pain/

The purpose here is not to provide an overview of the literature on specific stabilization exercise (SSE), but to provide some comments on the criticisms of this blog. I have concerns that students, young physiotherapists or even the public could be influenced by this blog since it appears the author is either not familiar with the issues in the literature or does not have a deep understanding of the topic.

Blog Title: Creating a title or question

Reductionism is a common strategy used to criticize the philosophy of SSE (Hodges et al 2012 p235). In the blog’s title, Mouatt’s strategy seems to suggest that transversus is responsible for all (implied) low back pain (LBP). Framing the statement like this is of course going to prove that transversus isn’t responsible for all LBP. Creating a question or blog title to make it easily dismissible is an extremely biased strategy.

Maybe a more healthy title to discuss the topic and relevant issues may be “is there a role for SSE in adults with low back pain”? or “Is changing the manner in which a patient controls the spine and pelvis likely to be beneficial in the rehabilitation of low back pain? (Hodges et al 2012).

Old News

Mouatt’s used an interview from 1997 to support this blog. That was a “quarter of a century” ago. There is no doubt that some mistakes were made in the initial days of SSE, but things have been different for a very long time (20 years maybe?) and continue to progress. Just for clarity, I am not aware of any statements or publications from the original group that suggested transverus function was related to the onset of LBP. The Queensland group was always adamant that the only known factor to cause the delayed timing in transversus was pain (as the research showed). There was, and still is the hypothesis that reduced translation control may be one of the mechanisms involved in recurrences in a subgroup of patients. Further, there has been a rather large body of literature Mouatt completely ignores (e.g., instability, damping, neuroplasticity, stiffness).

Systematic Reviews

Most of the critics of SSE bring up the results of clinical trials. Numerous systematic reviews have been conducted on non-specific chronic low back pain (NS-CLBP). The general consensus is that SSEs are beneficial compared to no treatment of passive treatment, but are not superior (but are equivalent) to other active therapies. It should be noted that a separate systematic review found favorable benefits for SSE when the principles of the exercise were applied (Ford et al 2020). (See “Fidelity” below).

Despite the wealth of clinical trials and systematic reviews, there are some important problems to consider as well as debatable points:

  • The use of NS-CLBP as an inclusion criteria: This has numerous issues such as: not ruling out visceral pain, thoracic pain, SIJ pain, hip pain, knee pain or vascular issues. You can go do some reading on the studies to see how many papers included in systematic reviews actually make an effort to ensure the included subjects truly had NS-CLBP. It is quite shocking how many don’t. Other issues include (but not limited to) not considering: pain mechanisms (e.g., nociplastic pain, neuropathic pain), social factors; low grade systemic inflammation; neurodevelopmental disorders; exposure to aggravating factors; and widespread variability in screening of behavioral issues. Since this applies to all interventions, not just SSE, we should appreciate that the current evidence base has some important limitations.

 

  • Treatment Fidelity. SSE require a high level of skill on the prescribing clinician. There isn’t enough information described in the majority of studies to know if the clinicians truly applied SSE in the manner they are supposed to be applied (Davidson et al 2021; Valagussa et al 2024). Personally, I have been in touch with one author of a clinical trial who was not sure if they used abdominal hollowing or abdominal bracing. Another author of a clinical trial was on a course with me and did not know how to tell the difference between a transversus based abdominal hollowing, an oblique based abdominal hollowing or abdominal bracing. They also thought doing a “pelvic floor contraction” was the same as doing a transversus exercise. These two clinical trials are regularly included in systematic reviews. On an advanced practitioner MSc course 5 years ago there were 16 students, all of whom stated they had vast experience in teaching transversus abdominus exercises.  Only one of them actually knew how to teach it properly. They had little knowledge in how to problem solve or to progress SSE. At an international conference, a highly influential presenter criticized SSE. At coffee I asked him his experience with it and he stated that someone told him over the phone to “do a pelvic floor contraction” and he felt it wasn’t beneficial so gave up. In teaching internationally, between 10-40% of people who actually think they know how to teach transversus abdominus hollowing actually know. Teaching SSE, problem solving, and progressing is an advanced skill just like many other skills that physiotherapists learn. SSE is highly specific. Not all physiotherapists can perform it themselves and many do not know the fundamentals of using it with patients. Unfortunately, this has not been brought to light in the literature.

 

  • Principles. The principles of motor skill learning are used in SSE. A recent systematic review found that most of the studies used in systematic reviews did not adhere to the principles of motor skill learning or neuroplasticity when applying SSE (Shankar Ganesh et al 2021). There are of course many more principles than this. Our group is currently working on a review of other principles for SSE used in clinical trials that are included in systematic reviews.

 

  • The definition of specific stabilization exercise used for inclusion criteria. Haliday et al (2013) reported that there is a lack of consistency in the language used to describe SSE. This creates issues since trials that use other exercise types can be included in reviews. Frequently, the definition is not described (e.g., they reference someone else) or includes something like “at least 50% of the therapy in the experimental group had to include specific stabilization exercise (or similar term)”. It is not known how many “co-therapies” influence the precision of SSE especially other types of exercise. It is likely not appropriate to include these in reviews papers. Certainly further research is needed to understand the influence of co-interventions and therapies on SSE.

 

  • The type of control group: There is no standard therapy for clinical trials in NS-CLBP to use. Hence anything and everything has been used. This is frustrating for any reviewer. Given what we know about low grade systemic inflammation and movement, it is quite possible that certain active or psychological interventions would favor the comparison group. Hence the importance of sub-classification.

 

  • Causation: a basic aspect of disease pathogenesis is to consider causation (of the mechanism). In NS-CLBP, if the mechanism was targeted (e.g., translation control), it would be necessary to address the causes of this mechanism. No clinical trial has ventured this deep with their clinical reasoning and intervention.

 

  • Sole Intervention: The use of SSE as an isolated intervention or for all LBP is not recommended and hasn’t been for over two decades. This was an early mistake by the group.

Lumbar Instability

Lumbar instability is real and is a mechanism by which tissues can be loaded. It should not be ignored or abdondoned.  The reported prevalence of spinal instability in CLBP is quite variable, but is not rare (e. g., 13–57 %) (Chatprem et al 2021). This forms part of the validity of subgrouping for lumbar instability in LBP rehabilitation. The language we use to communicate this to patients is very important as to not instill harm.  From very early on, the role of SSE was discussed for translation control and nociceptive related pain.

We shouldn’t debate the presence of lumbar instability or the importance of the language we use. What is a matter of debate is how to identify them and how best to manage them.

Beliefs of Vulnerability

Moutt states: “…that leads to benefits in these other domains rather than have them trying to feel for a deep muscle in a low-load movement, further feeding their beliefs of vulnerability?”

Is there any evidence that performing a low load exercise feeds into beliefs of vulnerability? I’m not aware of any. If there is, surely the language used could be adapted to minimize iatrogenic influences. There is considerable laboratory and clinical evidence to support the use of SSE. Education is a fundamental principle in applying SSE. Understanding the patients presentation facilitates individualized education. This is a very weak point to refute the use of SSE.

Co-morbidities and Mental Health

Moutt states: “…we know that LBP is associated with other comorbidities such as obesity and mental health”. This song is commonly used by critics to move away from many targeted therapies. However, it must be appreciated that all patients with NS-CLBP do not have obesity and or mental health diagnoses. If they do, it is not yet clear who it will prevent them from responding to various treatments. This is where sub-classification comes in (see below). There is no reason we can’t identify these patients and prioritize other types of therapy. It does not refute the absolute use of SSE.

The Myth of Core Stability

Mouatt references and describes Lederman’s infamous paper “The Myth of Core Stability” as “A lovely review in detail of other research around the core”. I’ll let the below comments by McGill reflect my thoughts…

A “sister paper” of Lederman’s entitled “The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain” https://pubmed.ncbi.nlm.nih.gov/21419349/ contains some relevant information to the above paper. It was heavily criticized by Stuart McGill (who is no fan of SSE).

“I have generalized philosophical concerns together with concerns over substantive issues regarding this paper. The topics are worthy of discussion, however, the sensational title sets the expectation for solid evidence and rigor in developing an issue and the counterpoint. The author repeatedly used a strategy in the framing of a question to make it easily dismissible, and then declared that “there is no evidence to support XXXX”. The arguments put forth in many instances were unidimensional, incomplete, based on undeveloped expressions of concepts, and neglectful of developed bodies of knowledge together with their interactions. Critique of cited works was, for the most part, absent.” p 152

This is how I would describe the original paper, highlighting again, my concerns over the overall knowledge of the topic by the author of this blog.

Sub-classification

Who may respond well to SSE? Although it may be beyond the scope of this blog, I thought it may be relevant to describe who is more likely to respond to SSE.

Nociceptive Related Pain

SSE are designed for a “mechanical response”, hence it is important to rule out nociplastic and neuropathic pain. I’m not aware of a clinical trial that has considered this.

Lumbar Instability

As noted, from very early on the Queensland group recommended SSE for control of shear (i.e., translation control). So lumbar instability is a target. A secondary analysis suggests those with spinal instability may do better with SSE than graded exercise (Macedo et al 2014). This is being followed up with a clinical trial (Macedo et al 2021).

This can be screened with the Lumbar Spine Instability Questionnaire.

Motor Skill Learning Ability

As noted above, SSE use principles of motor skill learning. Therefore, the ability to learn the exercises is critical to their application and hence, the response someone has. At least 20% of adults with NS-CLBP will not be able to learn these exercises.There are numerous possible reasons for poor motor skill learning (e.g., neurodevelopmental disorders, learning difficulties, post concussion syndrome, low grade systemic inflammation/neuroinflammation and related endocrine dysregulation). Unfortunately, this hasn’t been addressed well in the literature and in clinical trials.

This can be screened with the Motor Control Abilities Questionnaire© (Gibbons 2009).

Behavioral Factors

Having behavioral factors like high kinesiophobia, stress, and catastrophication are likely a greater priority to address clinically than SSE. The screening and analysis of this has not been addressed well in clinical trials.

These can be screened with ultra brief questionnaires or the full length questionnaires.

Low Grade Systemic Inflammation

Low grade systemic inflammation (LGSI) is relatively new as a subgroup. It is considered to be involved in the development of most, if not all chronic diseases. We are gradually gaining an understanding of the influence of LGSI on the musculoskeletal system and other subgroups (e.g., behavioral factors, motor skill learning ability). Work is in progress to screen this with the NISE-Questionnaire (Gibbons 2016)

Note: all of these factors have not been tested in a clinical trial. Our group is working on the background, however a qualitative study found that experience clinicians use this type of sub-grouping in their clinical reasoning for the use of SSE (Gibbons et al 2024)

Summary

Social media has many potential benefits for information exchange, however it could lead to followers easily accepting the information presented without seeing the full scope of the topic. The question being asked regarding SSE should not be framed to automatically form an answer that is impossible to be positive. The blog by Mouatt seems to lack a proper understanding of SSE and neglects a wider body of evidence on the topic. The reader should aim to understand all of the issues and the limitations of the literature on SSE. The current body of evidence in clinical trials does not reflect how experienced clinicians apply SSE. In a nociceptive related pain presentation, the therapist’s clinical reasoning should match the patient’s patho-anatomical diagnosis to the symptoms and the mechanism(s). If a mechanism is translation control, SSE may be indicated. It may take some time before the clinical efficacy using the suggested sub-classification gets answered. This is an important question, which has not been fully answered despite the blogs commentary. There is a large body of evidence not discussed, but hopefully, the issues mentioned make the reader appreciate the limitations of the Mouatt blog.

Sean GT Gibbons

 

Select References

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Davidson SRE, Kamper SJ, Haskins R, et al. Exercise interventions for low back pain are poorly reported: a systematic review. J Clin Epidemiol. 2021;139:279-286. doi:10.1016/j.jclinepi.2021.05.020

Ford J, Bower SE, Ford I, de Mello MM, Carneiro SR, Balasundaram AP, Hahne AJ. Effects of specific muscle activation for low back pain on activity limitation, pain, work participation, or recurrence: A systematic review. Musculoskelet Sci Pract . 2020. doi: 10.1016/j.msksp.2020.102276.

Gibbons SGT 2009 The development, initial reliability and construct validity of the motor control abilities questionnaire. Manual Therapy. 14 (S1): S22

Gibbons SGT 2016 Preliminary development of items to identify a neuro-immune-autonomic-endocrine involvement in complex pain presentations. Manual Therapy 25: e109-e110

Gibbons SGT, Valagussa G, Cantarelli F. 2024 Development of principles for the clinical use of specific stabilization exercises. Submitted.

Haladay DE, Miller SJ, Challis J, Denegar CR. Quality of systematic reviews on specific spinal stabilization exercise for chronic low back pain. J Orthop Sports Phys Ther. 2013 Apr;43(4):242-50. doi: 10.2519/jospt.2013.4346.

Hodges PW, McGill S, Hides JA (Eds). Motor control of the spine and changes in pain:  debate about the extrapolation from research observations of motor control strategies to effective treatments for back pain In: Hodges PW, Cholewicki J and van Dieen JH 2012 Spinal Control: The Rehabilitation of Back Pain. Elsevier

Keter DL 2023 Credible or Questionable? Assessing Quality of Evidence Presented on Social Media https://www.jospt.org/do/10.2519/jospt.blog.20231213/full/

Macedo LG, Hodges PW, Bostick G, Hancock M, Laberge M, Hanna S, Spadoni G, Gross A, Schneider J. Which Exercise for Low Back Pain? (WELBack) trial predicting response to exercise treatments for patients with low back pain: a validation randomised controlled trial protocol. BMJ Open . 2021 Jan 20;11(1):e042792.  doi: 10.1136/bmjopen-2020-042792.

Macedo LG, Maher CG, Hancock MJ, Kamper SJ, McAuley JH, Stanton TR, Stafford R, Hodges PW. Predicting response to motor control exercises and graded activity for patients with low back pain: preplanned secondary analysis of a randomized controlled trial. Phys Ther. 2014 Nov;94(11):1543-54. doi: 10.2522/ptj.20140014.

McGill S Invited response to: Lederman E The fall of the postural-structural-biomechanical model in manual and physical therapies: Exemplified by lower back pain. J Bodyw Mov Ther. 2011 Apr;15(2):131-8.  doi: 10.1016/j.jbmt.2011.01.011.

Parfrey K, Gibbons SGT, Drinkwater EJ, Behm DG 2014 Head and limb position influence superficial EMG of abdominals during an abdominal hollowing exercise. BMC Musculoskeletal Disorders. 15:52. DOI: 10.1186/1471-2474-15-52

Shankar Ganesh G, Kaur P, Meena S. Systematic reviews evaluating the effectiveness of motor control exercises in patients with non-specific low back pain do not consider its principles – A review. J Bodyw Mov Ther. . 2021. doi: 10.1016/j.jbmt.2020.08.010.

Valagussa G, Andreotti D, Cantarelli F, Lador Vogel V, Gibbons SGT. Specific stabilisation exercise interventions for non-specific low back pain are poorly reported in randomized controlled trials: findings from a literature review. 2024. Accepted. IFOMPT 2024