Journal of Bodywork & Movement Therapies (2010) 14, 80e83
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
PREVENTION & REHABILITATION: EDITORIAL
Core stability is a subset of motor control
Warrick McNeill, MCSP, Associate Editor
PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL
United Kingdom
Love it or hate it the term ‘core stability’ is ubiquitous, and
is a firm part of the lexicon of modern life. While preparing
to write this editorial I asked many people, from therapists,
to clients, to the non-injured and healthy ‘man-in-the-gym’
what they thought of the term and what it meant. ‘‘I don’t
use the term when I am talking to my patients,’’ said Chris
Dorgu, an elite football Osteopath, working in the UK, ‘‘I
prefer to talk about the specifics of what I am working on
with them. The term core stability is imprecise and open to
interpretation.’’ Suzy Barton, a London based Pilates
Teacher said that, ‘‘The term core stability is used by
everyday people and, to most, it means a strong centre
while moving the arms and legs. People often have no idea
about the science behind the concept.’’ Phillip O’Calla-
ghan, currently working hard with a Personal Trainer in
a late stage rehab of an ACL reconstruction said, ‘‘It’s all
about the abdominals, isn’t it?’’
In this Prevention and Rehabilitation section, the JBMT is
publishing an article by Eyal Lederman, entitled ‘‘The myth
of core stability.’’ It is likely to be an interesting, perhaps
challenging, read for clinicians who use the concepts of
core stability in their everyday practice.
Lederman reflects a current increase in the popular
press, including the ‘New York Times’ (nytimes.com) and
the United Kingdom’s ‘The Times’ (timesonline.co.uk)
newspapers, questioning aspects of core stability theory.
Lederman’s approach to this article looks at identifying
assumptions within core stability theory and applying
research findings to see if the assumptions bear scrutiny.
In Lederman’s article the term core stability particularly
relates to the mid 1990s work of Hodges and Richardson
(1996), Richardson et al., 2004 from Australia’s Queensland
University, and the identification of a timing delay in the
firing of the transversus abdominis (TrA) during rapid
E-mail address: warrick@physioworks.co.uk
1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbmt.2009.10.001
shoulder movement in subjects with low back pain. In the
notes given out at a course I attended in 1996, presented by
Paul Hodges (Richardson et al., 1996), the term core
stability was not used. ‘Motor control’ was consistently
referred to, as was ‘local joint stabilization.’ The term core
stability appears to have developed, concurrently or later
and seems to have become the default term applied to all
motor control training around the trunk, through to
(possibly!) ‘a clean and jerk then squatting a water filled
Swiss ball’ (youtube.com).
There does seem to be consensus that there may be
some differences in the meaning of core stability as the
term core strengthening is also frequently found in the
literature and on the web. Comerford and Mottram (2001),
Comerford (2004) points out that some therapeutic exer-
cises are aimed at strengthening weak muscles around the
core, and others are designed to improve the recruitment
of muscles that may be underactive and not fulfilling their
role in the synergy of neuromuscular control about the
trunk and girdles. The difference Comerford suggests is
related to the threshold of the recruitment required for
each type of exercise, with ‘core strengthening’ needing to
bias the fast fatiguing, fast motor unit to effectively
strengthen, and ‘motor control core stability’ training of
smaller postural loads, aimed at improving the recruitment
and endurance of the slow motor unit. The clinical problem
is in providing the assessment of the clients’ faults so that
the correct threshold of exercise is given (Mottram and
Comerford, 2008).
Do we need a model of muscle function?
Regardless of how a model of muscle function is created,
the construction of a model is important for clinicians to
use to try and better understand the complexities of the
brains control of muscle, both voluntary and sub-conscious.
Core stability commentary
For me local muscles such as ‘Hodges’ TrA, (Hodges and
Richardson, 1996), or ‘Hides’ deep fibres of Multifidus (DM)
(Hides et al., 1996, 2001) have helped me build a concept
(however flawed?) of how the deeper muscles may work to
control joint translation which, if uncontrolled, may lead to
micro-trauma, wear and tear and possible injury (Panjabi,
1992). This led me, in my practice, to offer to those who I
felt would benefit from having the deeper muscle struc-
tures brought to their attention, an ‘educational’ session
identifying those muscles and a ‘muscle recruitment’ quiz
to see if they can ‘turn them on.’
Muscle inhibition due to pain is identified in the litera-
ture (Hides et al., 1996), as is increased activation (van
Dieen et al., 2003). If pain does cause DM inhibition and
leads to eventual DM atrophy over an affected motion
segment, I feel justified in teaching a client in the clinic
how to recruit this muscle. I have read MacDonald et al.’s
(2006) ‘The lumbar multifidus: does the evidence support
clinical beliefs?’ in which a review of data about the DM and
superficial multifidus (SM) is applied to the Queensland
approach, and though some beliefs are supported by the
data (for example: SM and DM are both segmental motion
controllers, DM can work as a translational movement
controller without having an antagonist), others are not (for
example: SM is not solely a rotator or extensor, DM is not
tonically active during static postures). The paper advises
that the findings have implications in clinical practice. It
appears, in my reading of the paper, that the DM remains an
important component of the integrated musculature of the
body, so I will continue to address its under-activation.
I certainly do not believe that any one muscle is any
more important than another in the so-called ‘core.’ ‘All
muscles are created equal’ but this does not mean we are
not allowed to shine a spotlight on a single cog in the
clockworks to discuss its role. All the cogs in a clockwork
mechanism need to work together to show the passing of
time.
In my practice not all of my clients get a ‘Queensland’
approach. History and presenting pain will inform my clin-
ical decisions. Some clients do not appear to have any
difficulty in proving a voluntary contact with their trunk
muscles, superficial or deep, statically, or dynamically.
They have a ‘flow’ while performing whole body move-
ments that appears to be a smooth sequencing of muscles
working in an efficient order, with no one muscle being
more dominant than another, or more correctly, no one
movement more dominant e as the ‘body knows move-
ments, not muscles’ (Siff, 2009a). If no indicators suggest I
use a ‘Queensland’ approach then I need to look for
another technique in my toolkit for an appropriate treat-
ment for the problems I do identify.
Explain muscles
If Butler and Moseley (2003) can ‘Explain Pain’ to a chronic
pain sufferer and a year later, with no other intervention,
improve their pain, perhaps an ‘Explain Muscles’ approach
could have a similar effect? In researching Complex regional
pain syndrome ‘motor imagery’ has proved (Moseley, 2004)
to be an effective tool. I feel that connecting a client to
under-recruited muscles using visual feedback, self
81
handling, imagery, or anatomical or pathological explana-
tions, gives the client raw material for their Central
Nervous System (CNS) to process and to come up with its
own solution(s) to the presenting motor control problems.
Hodges (2004) identifies that there are multiple strate-
gies available to the CNS for motor control and considerable
redundancy within this system. This means that there may
well be many correct solutions to ‘fix’ a motor control
problem, and each individual may need a different
approach to get to a solution that works for them. This
identifies to me a key difference between research and the
clinic. When a client comes in I have to provide a reasoned
approach to address the problems I find. Doing ‘something’
may only provide a placebo effect, though this can help
(Wittink and Michel, 2002), but it may also be doing
something positive that changes the situation and assists
the client back to a healthier footing than they were before
PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL
their presentation. What I think I am doing, may produce
the desired result, however, it may conceivably be by an
entirely different process! Furthermore, in the clinic we
don’t just do ‘one’ thing to the client, we provide multi-
modal treatment regimes which result in the clients even-
tual outcome. We may reflect and discard for an individual,
or all our clients, some approaches that may not have
appeared to work, but it is difficult to know with certainty,
that we are discarding the ineffective technique. Often,
through good luck, good management or the natural history
of a condition, the client improves to a greater or lesser
extent. The problem for the Researcher is to identify which
modality, or which combination of modalities had what
effect, which bears up to the rigour of evidence based
practice and which do not. This is clearly exceptionally
difficult. Being a clinician seems to be the easier choice.
For me, the choice to use ‘core stability’ techniques
remains valid under the current body of evidence.
Core robustness exercises
Is ‘core stability’ new? Is it a re-badging of other concepts?
Wallden (2009), My Co-Editor of this section, in his recent
‘Neutral spine principle’ Wallden (2009) discusses ‘neutral’
which is an integral component of ‘core stability’ yet there
is not a mention of core stability in his piece. Why is this?
Perhaps its because neutral concepts aren’t exclusive to
core stability?
Siff (2009b) suggests that at one time we had kin-
aesthetic, proprioceptive, or motor skill training, but now it
is core stability training, he suggests that this is not a suit-
able modern substitute. He opines that the core, in most
instances, operates in a world where peripheral contact
with a surface is important and peripheral stabilization is
more important than the stabilization of the core. In rela-
tion to knee injury risk, however, Zazulak et al. (2007a,b,
2008) show that deficits in neuromuscular control of the
trunk predicts knee injury, in female, but not male
athletes. Forces affecting the body from foot contact up
the kinetic chain are clearly important, but, so too, it
appears, are centre down forces.
‘Stability’ itself is poorly understood (Reeves et al.,
2007), differentiating between static and dynamic systems
is important. Reeves states that ‘static stability
 82
explanations’ account for the findings ‘that there is
a potential for injury under low level loading’ (Cholewicki
and McGill, 1996) and ‘that a lack of stiffness was associ-
ated with injury’ and that this led to the development of
concepts of core stability. Reeves suggests that this was
taken from a static understanding of spinal stability where
increasing stiffness does increase stability. In a dynamic
model of stability, however, there are times when less
stiffness is desirable to help in the precision of motor
controlled activities such as standing, balancing or gait by
providing a more supple spine. The ‘central controller’
needs to exhibit a variable control and efficient feedback,
and this continues in a loop. Reeves goes on to say that
a system is either stable or unstable, but it is the robustness
(how well the system copes with uncertainties and distur-
bances) of the system that is important. Reeves comments
that stability is often confused with robustness, ‘‘Core
PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL
stabilizing exercises do not make the spine more stable,
they make it more robust, thus reducing risk of injury.’’
Perhaps the next new hot exercise fad to take over from
core stability training will be ‘core robustness exercise!’
Canada Vs. Australia
Within the world of core stability research there appears to
be two schools of thought perhaps best personalised by
Stuart McGill from Canada and Paul Hodges from Australia.
Their work frequently references each other as it appears
they both produce good science with interesting results
that can be applied to the theoretical models that they
propose. Both are passionate (Chaitow, 2005), and if you
have to identify the key area of research for each you may
possibly choose spinal biomechanics for McGill and spinal
motor control for Hodges, though the distinctions between
them would be blurred. Both advocate exercise regimes for
the prevention or treatment of spinal pain. Some of Hodges
exercises are regarded as isolationist (Siff, 2009a), this
could be interpreted, and has been, according to Leder-
man, in that the TrA and Mf are to be exercised and
strengthened in isolation. This is reminiscent of the fitness
(gym) worlds isolated exercise of the ‘biceps curl’ (not truly
just a biceps brachii exercise, it is the synergy of elbow
flexion/extension that is actually exercised). Admittedly
the TrA and Mf muscles are identified and recruited in
isolation, (not strengthened!) but this immediately
precedes integrating those muscles into function, so it may
be fair to say ‘isolationist’ but only until functional move-
ment is added to the regime.
McGill’s exercises reflect his opinion that ‘‘the relative
contribution from every muscle source is dynamically
changing’’ (McGill, 2007). His exercises, such as bird dog
(see a description of this exercise in Leibenson’s ‘The
missing link in protecting against back pain’ later in this
editions Prevention and Rehabilitation section), and side
bridge could be called co-contraction exercises as they
recruit all muscles in the trunk, though will bias different
muscle groups, and are aimed at promoting control of
spinal posture in positions that are bio-mechanically sound.
Liebenson (2007) reports on Koumantakis et al. (2005) study
that demonstrated the ‘‘general’’ approach (McGill’s)
was superior to the Australian ‘‘deep’’ local stabilization.
W. McNeill
Liebenson therefore advocates an abdominal co-contrac-
tion (bracing) exercise regime in this paper.
Tsao and Hodges (2008) in their study on subjects with
low back pain, reported validating a motor control training
strategy that improved TrA timing (feedforward) and
maintained it for the follow up at six months. It was the first
study to show such a finding. The authors took care to
emphasise that the study, ‘‘does not advocate that
repeated isolated voluntary contractions is sufficient to
treat low back pain (LBP). Rather, the study indicates that
one impairment often identified in LBP (i.e., delayed
activity of TrA) can be changed with training.’’
A similar study by Hall et al. (2009) (including in the
authorship Tsao and Hodges), looked at the co-contraction
exercises favoured by McGill and showed that a single
session of this type of training did not change the feed-
forward timing of the TrA in low back pain subjects.
Admittedly both these studies had a low number of
subjects but the findings are very interesting and may show
there still is life in the theory of core stability.
It is very possible that in the future we will look back and
say that McGill and Hodges’ theories both had merit
and were looking at the same problem; that their views and
exercises were not mutually exclusive, as the CNS has many
strategies to deal with movement control. In the clinic,
where distinctions are blurred, I am happy to use both
commentators’ ideas at different times. I contend that
McGill and Hodges, in the field of low back biomechanics
and motor control, may have more common ground they
agree on than ground over which they do not.
Future research
Chronic low back pain (CLBP) is a complex subject to
investigate, not least because of the many various influ-
ences that may cause the pain. Hebert et al. (2008)
attempted to subgroup patients with non-specific low back
pain (LBP) to place them into various treatment categories
including specific exercise, stabilization exercise, manipu-
lation and traction. It appears that subgrouping LBP may
help in future experimental design and provide cleaner
results for interpretation.
Where is core stability research going? In fact is that the
real question we should be asking? If Lederman is effective
in his argument the term core stability will be phased out
and research funding placed elsewhere. McGill, Hodges and
others are perhaps less likely to think they are specifically
undertaking core stability research but would refer to their
work as research in motor control.
Core stability has really only ever been a subset of the
broader church of ‘motor control’.
So where is motor control research going? It seems that
the assessment of movement control is starting to show
interesting results Luomajoki et al. (2008) looked at 6
motor control tests of the lumbar spine with a study size
involving 210 subjects, half with LBP and the control half
without. The study showed a significant difference in the
ability between the groups to actively control the move-
ments of the low back. The LBP groups control was poorer.
Roussel et al. (2009) has shown in dancers that two
lumbo-pelvic movement control tests (standing bow and
Core stability commentary
a crook lying single knee lift) are predictive of injury risk to
the low back or lower limb. Roussel’s findings suggest that
motor control or strengthening interventions may reduce
the chance of an injury happening at all.
Conclusion
Is the term ‘core stability’ limiting? I believe it is. Leder-
man’s article shows how some ideas around core stability
have become part of the problem and not part of the
solution, and it is definitely time to move on from there.
If this topic and this edition provokes a response from
you, please email me as I would like to report back to the
readership in my next editorial what your views are.
The last word comes from the Pilates Teacher Suzy
Barton we met earlier. ‘‘If the public are asking for core
stability exercises, don’t send them away saying we don’t
do that any more, take their request and give them exer-
cises to fit their individual issues!’’
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