How I Discovered the Hidden Core
When I was just starting to practice neurosurgery, I experienced a month-long episode of severe back pain. A magnetic resonance imaging (MRI) test of my lumbar spine revealed a herniated L5
S1 disc, as well as a chronic condition called spondylolisthesis
the result of a stress fracture that had occurred while I was playing football years before (and that undoubtedly had been the cause of my adolescent back pain). I showed my MRI to my neurosurgical peers, who uniformly recommended
surgery. I was just starting my career, however, and couldn’t bear the idea of spending several
weeks in recovery. Although I had always preached the importance of exercise to my patients, I was too frightened to undertake any exertion myself. My pain had improved enough for me to function, but the fear that exercise would bring it back prevented me from following my own advice. Slowly, though, my hypocrisy ate away at me, until I finally got up and, despite the pain, started to exercise. I started slowly, with a few reps, then steadily increased the intensity of my workouts. I felt an immediate difference. My back began to feel a comforting sense of tone and strength. As my back pain slowly receded, I became convinced that I was on the right track.
I didn’t quite know it yet, but I had just backed my way into discovering the importance of
strengthening the back muscles and the correlation between these muscles and back pain, both as a
and as a
. I also realized that this kind of exercise could be initiated earlier than is
traditionally accepted in the course of a patient’s treatment. My search of the literature revealed
similar explorations into exercise strategies, but the strategies described had only sporadic success and thus had never become mainstream. That research convinced me that pain-plagued back muscles could be exercised safely, however, and so I began to treat my more ambitious patients with intense back-strengthening. The patients who committed to the program were rewarded with terrific results.
The muscles of the back
particularly the multifidus muscles
—are an integral part of our “core,” but they have too often been overlooked. I like to think of these muscles as the body’s “hidden core.”
Our culture has experienced a rich history of strengthening the core to alleviate back pain, a history that peaked in the 1990s when the transversalis muscle (the deep muscle located in the front of your abdomen) was singled out as the essence of the core. This faulty
and incomplete definition of “core”
suggested that an isolated group of muscles could be developed and used to stabilize the spine and, in turn, reduce back pain. The discipline of Pilates, for example, promotes the strengthening of the transversalis muscle as a means to stabilize the trunk of the body during movement, which limits stress on the spine.
While this movement has met with some success, it hasn’t turned out to be the panacea that was
hoped for in its initial stages. Isolating the front of the core is only half the story, and studies have shown that it can cause an asymmetry that may even weaken the back, an outcome that I will