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Outdated Pain Theories, Part III – Muscle Imbalances & the “Core”

- do imbalanced muscles pull you out of place?

Part I discussed why persistent pain can’t always be explained by “pain signals” from damage and degeneration.

Part II picked apart the idea that pain is perpetuated by poor posture and abnormal body structure.

If degeneration, posture, and structure aren’t good explanations for persistent pain, then maybe the problem isn’t mechanical – maybe our muscles aren’t working properly?

This time, let’s take a look at muscle imbalances and core instability – two similar ideas that are currently insanely popular in the fitness industry and physical therapy (my own profession).

Supposedly, muscle imbalances push and pull us in awkward ways, and weak core muscles cause spinal instability. Both of which are thought to cause persistent pain (if you’ve read part I and II, you may already see some problems with this).

What does science have to say?

Muscle Imbalances

- do you need 'perfect' muscular proportions like David to avoid pain?

The idea of strengthening weak and “long” muscles, and stretching supposedly short and “tight” muscles, is the basis of many therapists approach to pain problems.

On assessment, people are taken through a bunch of awkward poses and movements to determine muscle “balance” and postural symmetry. Similar looking exercises are then prescribed to correct any imbalances.

However, the scientific evidence that this strength / stretch method actually works to correct postural asymmetry is poor. 1, 2 It appears that correcting muscle imbalances doesn’t even straighten you up!

And while pretty much any exercise helps with pain, there is no quality research demonstrating superior effects for correcting muscle imbalances. 6

In fact, there is very little quality research on this topic, period. Personally, I couldn’t find any research to suggest muscle imbalance predicts acute or chronic pain. If good research is so hard to find, why is this idea so popular?

Furthermore, muscle imbalance may not be as important for injury prevention as once thought. One study on a group of elite football players actually revealed that their amount of muscle imbalance (as seen through MRI) had no relationship with their number of injuries! 3 And another study involving military personnel explained that targeted muscle strengthening does not reduce injury rates. 11 Picking the “right” muscles to exercise isn’t so useful after all.

The “Core”

- the "core" usually refers to the deepest layers of muscle around the torso.

How about the popular “core”?

Thought to be important in stabilizing your spine, the core muscles include the abdominals and the lower back muscles (some people include the muscles around your hips too).

Perhaps you’ve even heard the specific names of the “most important” muscles: the transverse abdominus, and the multifidus. These two are often the target of “core stability training” – exercises that are meant to strengthen these muscles specifically. Theoretically, this will stabilize your spine, prevent injury and decrease lower back pain.

It all started in the 90’s, with the observation that these muscles are functionally altered in people with low back pain (so yes, there was a little science behind it). 4 Almost over-night, programs were designed to correct these alterations, and therapists and trainers flocked to spend their money on learning how to better train the “core”.

But does this stuff actually work?

As mentioned above, just about any exercise helps pain, so early studies supported core training as effective. 5 However, these early studies didn’t compare this type of training to any other form of exercise. Studies have since revealed that these highly specialized exercises are no better than “general exercise” (like going for a brisk walk),6 and improvements in pain are not associated with improvements in core muscle function! 7, 8, 9, 10

Learning to stabilize the muscles of your core may be important for athletic abilities and heavy lifting, but as a treatment for chronic pain… not so much.

Cause or Consequence?

cause or consequence?

When someone in pain walks into a clinic, they may appear to have altered posture and function that looks like muscle imbalance or core instability. But how do you know this isn’t something new – caused by the injury?

There is research showing that muscle imbalance exists in people with pain (in terms of activation – not necessarily size and strength). 12, 13, 14 And as mentioned, there are alterations in trunk muscle activity with low back pain. 4

However, these studies usually look at people who are presently affected by pain. Since pain is known to cause muscle inhibition, 15, 16, 17, 18, 19 it’s just as likely we’re seeing a consequence of pain, not the cause. This inhibition can even occur at distant locations from the source of pain (e.g. back pain inhibits quads). 16, 19

It’s even possible that this muscle inhibition isn’t even a defect, but a defense – a protective response to prevent further injury and pain. Who knows?


Of course, including the core muscles and both sides of your body is still valuable in athletic training (which is a whole other topic). But we’re talking about pain here (especially persistent, chronic pain).

These ideas are often considered superior to those discussed in parts I and II because they are more proactive – involving exercise. Indeed, exercise is good for pain. But these theories unnecessarily complicate their prescription.

Exercise for people with pain, injury, or disease should be individualized to the person, taking into account their goals, and what their problems are (especially safety). It’s not a matter of finding the “right” muscles to exercise.

Where these ideas really fall short is in their underlying premise, which is not much different from the ideas discussed in the first two parts of this series. It assumes awkward forces cause “pain signals”, which is not exactly true (especially for chronic pain).

What’s next?

The next post will wrap-up these outdated theories with a discussion of why it’s important to let them go. The reason I’m writing these controversial articles is not just to be a contrarian, but because these unhelpful ideas can actually have negative effects.

Then, it’s finally time to start discussion how pain really works, with the first part of a new series: “How Pain Works”. Stay tuned!

Thanks for reading!

Speaking of controversy…. share and discuss! (rational arguments only please)


References will be posted as a comment below, in the following format:

ResearchBlogging.org6. van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, & van Tulder MW (2010). Exercise therapy for chronic nonspecific low-back pain. Best practice & research. Clinical rheumatology, 24 (2), 193-204 PMID: 20227641

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    36 Responses to Outdated Pain Theories, Part III – Muscle Imbalances & the “Core”

    1. Tony Ingram says:


      1. Hrysomallis C. Effectiveness of strengthening and stretching exercises for the postural correction of abducted scapulae: a review. J Strength Cond Res. 2010 Feb;24(2):567-74. Review. PubMed PMID: 20072041.

      2. Hrysomallis C, Goodman C. A review of resistance exercise and posture realignment. J Strength Cond Res. 2001 Aug;15(3):385-90. Review. PubMed PMID: 11710670.

      3. Hides J, Fan T, Stanton W, Stanton P, McMahon K, Wilson S. Psoas and quadratus lumborum muscle asymmetry among elite Australian Football League players. Br J Sports Med. 2010 Jun;44(8):563-7. Epub 2008 Sep 18. PubMed PMID: 18801772.

      4. Hodges PW, Richardson CA. Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limb. J Spinal Disord. 1998 Feb;11(1):46-56. PubMed PMID: 9493770.

      5. Hodges PW. Core stability exercise in chronic low back pain. Orthop Clin North Am. 2003 Apr;34(2):245-54. Review. PubMed PMID: 12914264.

      6. van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder MW. Exercise therapy for chronic nonspecific low-back pain. Best Pract Res Clin Rheumatol. 2010 Apr;24(2):193-204. Review. PubMed PMID: 20227641.

      7. Steiger F, Wirth B, de Bruin ED, Mannion AF. Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review. Eur Spine J. 2012 Apr;21(4):575-98. Epub 2011 Nov 10. PubMed PMID: 22072093; PubMed Central PMCID: PMC3326132.

      8. Mannion AF, Caporaso F, Pulkovski N, Sprott H. Spine stabilisation exercises in the treatment of chronic low back pain: a good clinical outcome is not associated with improved abdominal muscle function. Eur Spine J. 2012 Jul;21(7):1301-10. Epub 2012 Jan 24. PubMed PMID: 22270245; PubMed Central PMCID: PMC3389103.

      9. Mannion AF, Dvorak J, Taimela S, Müntener M. [Increase in strength after active therapy in chronic low back pain (CLBP) patients: muscular adaptations and clinical relevance]. Schmerz. 2001 Dec;15(6):468-73. German. PubMed PMID: 11793153.

      10. Gorbet N, Selkow NM, Hart JM, Saliba S. No Difference in Transverse Abdominis Activation Ratio between Healthy and Asymptomatic Low Back Pain Patients during Therapeutic Exercise. Rehabil Res Pract. 2010;2010:459738. Epub 2010 Aug 31. PubMed PMID: 22110965; PubMed Central PMCID: PMC3200274.

      11. Zambraski EJ, Yancosek KE. Prevention and rehabilitation of musculoskeletal injuries during military operations and training. J Strength Cond Res. 2012 Jul;26 Suppl 2:S101-6. PubMed PMID: 22728983.

      12. Harris-Hayes M, Sahrmann SA, Van Dillen LR. Relationship between the hip and low back pain in athletes who participate in rotation-related sports. J Sport Rehabil. 2009 Feb;18(1):60-75. Review. PubMed PMID: 19321907; PubMed Central PMCID: PMC2699456.

      13. Renkawitz T, Boluki D, Grifka J. The association of low back pain, neuromuscular imbalance, and trunk extension strength in athletes. Spine J. 2006 Nov-Dec;6(6):673-83. PubMed PMID: 17088198.

      14. Nadler SF, Malanga GA, Feinberg JH, Prybicien M, Stitik TP, DePrince M. Relationship between hip muscle imbalance and occurrence of low back pain in collegiate athletes: a prospective study. Am J Phys Med Rehabil. 2001 Aug;80(8):572-7. PubMed PMID: 11475476.

      15. Schabrun SM, Hodges PW. Muscle pain differentially modulates short interval intracortical inhibition and intracortical facilitation in primary motor cortex.
      J Pain. 2012 Feb;13(2):187-94. Epub 2012 Jan 9. PubMed PMID: 22227117.

      16. Verbunt JA, Seelen HA, Vlaeyen JW, Bousema EJ, van der Heijden GJ, Heuts PH, Knottnerus JA. Pain-related factors contributing to muscle inhibition in patients with chronic low back pain: an experimental investigation based on superimposed electrical stimulation. Clin J Pain. 2005 May-Jun;21(3):232-40. PubMed PMID: 15818075.

      17. Graven-Nielsen T, Lund H, Arendt-Nielsen L, Danneskiold-Samsøe B, Bliddal H. Inhibition of maximal voluntary contraction force by experimental muscle pain: a centrally mediated mechanism. Muscle Nerve. 2002 Nov;26(5):708-12. PubMed PMID: 12402294.

      18. Le Pera D, Graven-Nielsen T, Valeriani M, Oliviero A, Di Lazzaro V, Tonali PA, Arendt-Nielsen L. Inhibition of motor system excitability at cortical and spinal level by tonic muscle pain. Clin Neurophysiol. 2001 Sep;112(9):1633-41. PubMed PMID: 11514246.

      19. Suter E, Lindsay D. Back muscle fatigability is associated with knee extensor inhibition in subjects with low back pain. Spine (Phila Pa 1976). 2001 Aug 15;26(16):E361-6. PubMed PMID: 11493865.

    2. Tony Ingram says:

      Preemptive defense:

      For those who think “well it helped me, so I know it works” – please read: Why Science? Part I – Because We’re Usually Wrong. Also check out Parts II and III. If you still don’t agree, I understand: because myth-busting ain’t easy. If you still think you’re intuition and experience is more reliable than all the scientific evidence I cited, get over yourself!


    3. Liza Kovacs says:

      Really interesting and food for thought. Hard to swallow (I teach movement wellness with great results) but it is always better to keep an open mind. Research tends to follow trends and is not as objective as we would like to think, statistics can be easily manipulated but I believe you have addressed that before. Nonetheless, thanks for doing the research for those who are out there busy teaching and learning through you!

      • Tony Ingram says:

        Thanks for the comment Liza.

        You’re right about the limitations of research. But the alternative – intuition and experience – is even less reliable. I find people are quick to point out limitations of research when the results are out of line with their beliefs. But if their beliefs are confirmed, science is great and has provided solid proof for what they “always knew”. All research should be equally considered as well as critically appraised no matter the results.

        The good results you get may not be due to the correction of muscle imbalances or mechanics, but due to other reasons which I’ve touched on before (likely neuro-physiological and biochemical reasons – which are far more interesting, in my opinion). I have little doubt that what you do is effective! But why – that’s the interesting question.


    4. Israel says:

      *Stands up and claps his hands*

    5. Adam Meakins says:

      Once again, excellent, this should be taught on all undergrad and MSc programmes so much crap being recycled in university’s that I fear a perpetual cycle of misinformed therapists thinking they are helping but actually making matters worse with there own beliefs being passed onto chronic pain patients, just as Domenech found http://www.ncbi.nlm.nih.gov/m/pubmed/21917377/?i=2&from=patient%20physiotherapist%20relationship%20low%20back%20pain

      Keep up the excellent work I will be passing on your site to all I meet



      • Tony Ingram says:

        Absolutely! That’s exactly what I’m writing about in the next post. Our choice of words and explanations to people have effects themselves, and we must pay attention!

        I agree about the education piece. My program was filled with this dogma, but luckily they also taught me to critically appraise evidence, so I could make my own decisions. Critical thinking is a timeless skill that I hope is being included in all education programs!

    6. Dave Nolan says:

      Another good post. Very relevant to a lady I saw this morning. She is doing everything everybody has told her for the last 4 years. She is trying to selectively recruit her trans abs and be mindful of her posture at all times, only rarely bending her back.

      This advice has totally disabled her and led to her current problems. She is frightened and has no understanding of her pain. She is over bracing and over protecting her spine. She is a product of the “core stability” generation; this has to stop….. please someone!

      • Tony Ingram says:

        Wow! What a perfect anecdote of the problem. My question to those who continue to treat patients this way is this:

        For such a patient, what’s your explanation? Where do you go from here? And don’t say “she must not have been taught correctly”.

        Thanks for the comment Dave!

        • Dave Nolan says:

          Tony, I often get the response that she “must have not been taught right”. But my problem is the paradigm. The lady I described above seems to be about 30% of my workload at present.

          Patients only listen to part of what we say. They create their own narrative of what is going on with their body and only take home key points and messages from our consultation. I would argue that with someone that is bracing themselves, for whatever reason, we should never mention the word “muscle” and “switch on” or “timing” in the same sentence, not even the same paragraph. The take home message has to be relax, movement and de-threaten. If we have some funky manual therapy interventions we can throw in then great but as long as the aim is to modulate the pain not “re-align” or “pop you back in” garbage that give the anxious patient the impression the are “out” or at risk of “going out” at any time…… its been a long day….. rant over!

    7. Fizziowizzio says:

      Very good piece and long overdue commentary.
      Unfortunately, those in a position to help like to have a niche in which they can be king.
      As a result, the message perpetually gets diluted. For “core stability” we could probably stick in Pilates as another form of strict dogma that is not a cure-all but sold as one.
      Any exercise is better than nothing, and the terminology needs to change to reflect that.
      On Adams point about UG education, he is partly correct but the students need to be exposed to a variety of contemporary approaches, and as u said, be given the tools to critically appraise what they r doing and wot works and wot is utter nonsense. If we send out students without any tools to try and use for back pain, it’s gonna be a short course…remember that they have no clinical experience and as such need more prescription than one would otherwise use.
      Well done for the post!!

      • Tony Ingram says:

        Thanks! And yes, we definitely need to teach tools, and I still use some “core” exercises in my work. But as you said, when they are sold as a cure-all – that’s a problem.

    8. Lindsay says:

      Thanks for this, it was eye-opening!

      I’m a weightlifter, and while I hadn’t heard a lot of the myths you discuss in your post, I had heard the one about muscle imbalances. Specifically, I’d heard about it with respect to ACL tears, where supposedly having built up your quadriceps while neglecting your hamstrings make you more likely to get them. Is that a myth too?

      I may have also heard core strengthening touted as an injury preventer, but I’m not sure because most of what I’ve heard about it is that it helps make you stronger all over, which you say is really true. (Helps with heavy lifting, which is a thing I do a lot of).

      But I was definitely taught to train different core muscles and avoid imbalances — I wasn’t told, like the lady mentioned above, to only target one random muscle like the trans abs, though; I was told to do lots of different core-strengthening exercises to make sure and get as many different muscles as possible (back and sides as well as abs). I don’t have any pain problems, I was doing this for athletic reasons.

      Was I taught wrong?

      • Tony Ingram says:

        Hey Lindsay,

        I don’t think what you’re doing is a bad idea at all. Trying to include more variety is a good thing. I’d say its simpler than people think, though – instead of doing tons of different exercises to target every muscle, doing compound exercises should be sufficient to cover them all.

        I wasn’t speaking on athletics in this post though, just pain treatment. Injury prevention and athletic performance will be covered more in the future.

        I think there is some evidence about the ACL injures and quads/hams imbalance, but the contribution is very small, and the imbalance has to be very big. It pales in comparison to the importance of proper landing and side cutting techniques (avoiding excessive knee abduction moments). I’ll talk more about that in the future too.

        Either way, I wouldn’t say you we’re taught wrong. Having a strong torso and good form for lifting is still good, an probably helpful for athletics. It’s just over blown as a form or “therapy”.

        Thanks for reading!


    9. Tony Ingram says:

      Folks, check out the comments section of the first article for more “special” exercise shenanigans…

    10. Tony,
      Just started checking out your blog and really like it! I will definitely be following and linking out from my page too. I teach similar concepts to my interns and we are on the same page. I, as well as others I’m sure, can get frustrated that all see things we learned do not have value! But in reality, it works. It is how we say it that gets to me too (such as poor posture, tight muscles, etc). The difficult part is being able to get it across to the patient that we can help me without having to use this terminology. I think as pain science improves, this will be the next step for higher education to teach.

      Keep it up! We all benefit from this information.

      • Tony Ingram says:

        Hey Harrison,

        “It is how we say it that gets to me too”

        Totally agree! I often think about what might be the best way to communicate these concepts. It’s going to be difficult, but I think one good step is creating awareness. There’s a zeitgeist of “my back is out”, and “cartilage is all gone” type thinking in the general public. Of course, it starts with changing how we professionals think and speak.

        Thanks for the kind words, and appreciate the links. I’m checking out your site too, looks great! One of the best things about starting this site is the connections I have made with other therapists and the resulting discussions. Love it.


    11. Miguel says:

      “However, the scientific evidence that this strength / stretch method actually works to correct postural asymmetry is poor. 1, 2 It appears that correcting muscle imbalances doesn’t even straighten you up!”

      “Exercise for people with pain, injury, or disease should be individualized to the person, taking into account their goals, and what their problems are (especially safety). It’s not a matter of finding the “right” muscles to exercise.”

      Shouldn’t safety be number one? And isn’t the idea to FIND the RIGHT muscles to exercise – otherwise what are we doing? I agree exercise should be individualized – but how?

      “Learning to stabilize the muscles of your core may be important for athletic abilities and heavy lifting, but as a treatment for chronic pain… not so much.”

      So what do we do when an athlete develops chronic pain? (golfer’s elbow? basketball players with anterior knee pain from constantly being “up”, baseball players and medial elbow pain from pitching?)

      Should you “stabilize the muscles of your core” to treat the chronic pain or for athletic abilities and heavy lifting? (Side note: What is the definition of heavy? Would multiple grocery bags qualify as heavy for a mother going shopping? Would she then qualify herself as an athlete? Would that qualification then allow her to start stabilizing the muscles of her core? What if she has chronic pain because of poor posture of picking up things on one side because of hand dominance and habits? Do we treat the stabilizing muscles… or just let her go because there isn’t conclusive evidence to do so?)

      I’m interested to see your response.

      • Tony Ingram says:

        Hi Miguel,

        I’ll keep this a little shorter than my response in the previous article. For those of you reading, Miguel also asked me a lot of great questions in the previous article, so check them out, and my response.

        Shouldn’t safety be number one?

        Definitely. I mentioned the importance of biomechanics on injury prevention in the last article, and I’ve written about how to improve it (sorta) here. When it comes to form and biomechanics, I think they are very important for injury prevention and sports performance – but tiny details causing chronic pain? That’s my issue.

        And isn’t the idea to FIND the RIGHT muscles to exercise – otherwise what are we doing? I agree exercise should be individualized – but how?

        Exercise isn’t a very good treatment for chronic pain – in fact, there’s evidence that exercise induced analgesia doesn’t even work in these people! However, encouraging people to move in non-painful, non-threatening ways is integral to their functional recovery… It’s not about “fixing” the right muscles. When I say exercise should be individualized, I mean in the context of their functional goals, their problems, the provoking and relieving factors of their pain. “Exercise” for these people may simply be taking their trash out, or going for a walk. We have to help them find a way to do that… not correct imbalances and tighten the “core” – you know what I mean?

        So what do we do when an athlete develops chronic pain?

        My knee-jerk reaction is: refer them to an appropriate health-care professional – perhaps a competent physical therapist who’s privy to modern pain science and chronic pain treatment techniques. I’ll talk about good options in the future, as I plan on writing about treatment more once I write my articles explaining how pain works.

        Should you “stabilize the muscles of your core” to treat the chronic pain or for athletic abilities and heavy lifting?

        If someone has chronic low back pain, having them lift heavy is questionable… But if healthy you have a healthy athlete, I’d say proper lifting mechanics are most important for injury prevention. About core stabilization – read this article. It illustrates more myths of how to use the core during exercise.

        What is the definition of heavy?

        That’s rather contextual and based on different exercises and tasks – but I’d say anything in the “strength training” range. Again, now we’re talking about athletic training – which you probably know more about than me. How would you define heavy?

        But as I’ve said before, caution must be taken with people with chronic pain, even if they were strong athletes before the onset of pain.

        1. Would multiple grocery bags qualify as heavy for a mother going shopping? 2. Would she then qualify herself as an athlete? 3. Would that qualification then allow her to start stabilizing the muscles of her core? 4. What if she has chronic pain because of poor posture of picking up things on one side because of hand dominance and habits? 5. Do we treat the stabilizing muscles… or just let her go because there isn’t conclusive evidence to do so?

        I’m not sure where you are going with this… But I’ll try to answer each question (I put numbers in your quote above to keep things clear):

        1. Maybe, depending how strong she is.
        2. I’m not sure… would she think so?
        3. Why do you ask? I’m guessing you’re implying that I think only athletes should work on their core… but I am not saying that. What I am saying is that core training is not necessarily a good treatment for chronic low back pain.
        4. Could you prove that? And if so, perhaps all she needs to do is stop using that hand? Also, why doesn’t everyone else with such habits have chronic low back pain?
        5. You do not “let her go” – you would send her to an appropriate health-care professional who is qualified to treat someone in pain, and to get a proper diagnosis. There are many far more promising treatments for chronic back pain than core stabilization exercises.

        Again, Miguel, I’m very happy to meet you, but I did find your first comments a little condescending… I hope I’m just reading things wrong, and that we can have some awesome discussions and educate dancers all over the world.



    12. Wyatt says:

      I was recently exposed to this site, so I’m obviously late to the party, but again I’m impressed with your perspective. Very evidence-based and on point. It’s good to know there are other PT’s out there fighting the good fight on chronic pain from an evidence-based perspective. I can’t agree more on the importance of any form of exercise in LBP. One criticism I often hear is that this is unskilled care. I completely disagree with that notion, as we provide (or should be providing) quality education addressing pain science, fear-avoidance, catastrophization, etc., evidence-based manual therapy (which often opens up a completely different can of worms), and also we are trained and skilled at general exercise prescription. I also hope for the future that we can better educate patients with first-time back pain to reduce the likelihood that it turns chronic. I feel current evidence is gently nudging PT’s the right direction to go, and we’re currently experiencing the slow process of people getting on board. Anyways, thanks for the great reads Tony!

      • Tony Ingram says:

        Hey Wyatt, again, I’m feeling you!

        “and also we are trained and skilled at general exercise prescription.” Absolutely, and furthermore PT’s are also broadly educated in pathology. It seems people keep forgetting this. How are you supposed to help people move when you aren’t educated in what’s keeping them from moving?

        The idea that you need highly specialized or technical exercises and hands-on techniques to be considered “skilled” is absolutely ridiculous. What’s “unskilled” is when people who aren’t educated in the problem (in this case pain) decide they are qualified to treat that problem. This bothers me to no end – fitness professionals who take numerous weekend certifications and read a few articles suddenly think they are now healthcare professionals. I don’t care how good you are at activating the glutes – don’t “treat” a person with pathology! Refer to someone more appropriate… like a PT!

        PT’s not only need to establish as stronger evidence-base, but also to advocate for our profession more strongly.

        Sorry for the rant! The “unskilled” thing just really gets to me! :D Cheers!


    13. Wyatt says:

      I completely agree!

    14. david says:

      Hullo again Tony.
      I left the site open and came for another bite. your note ‘re training’ is both valid and to some extent not so. i saw a patient who was literally green .. Ca liver? he declined traditional treatments and went via alternatives. dentally he took all filled and root filled teeth out and I selected the least harmful acrylic to make 2 plates for him.
      a German GP came with him one day and asked if i could ease a little of the bite over his upper right molar as his healing had plateaued. reluctantly i did and 20 seconds later, right on Q the gut rumbled. and they declared the illeocaecal valve had opened… so starting a new phase in his journey of healing. So we do know a great deal, but we also know so very little.

      • Tony Ingram says:

        Hullo David,

        I’m not sure what that anecdote proves. But I do agree with you that we know a great deal, but also know very little. In fact, I would say we barely understand anything about pain right now.

        We are only less wrong now – but not right.


    15. Rey says:

      Tony, is there an official definition to “core” yet?
      I would love to hear your take this or attempt to define this meaning.

      • Tony Ingram says:

        haha, I’m not sure, but that comment reads like a challenge. I sort of defined it vaguely (since that’s the only way you can) in the article.

        I’m not sure what you would take as “official” – I can’t think of any governing body or group of researchers that I would take as authoritative enough to make an “official” definition. Then again, I feel the same way about a definition of “pain”, “fatigue”, and “strength”.

        In the context of exercise science, the “core” usually refers to the muscles of the trunk, especially those that flex, extend, rotate, and side-bend the lumbar spine. Many people also include anything that crosses over it, such as the muscles crossing the hips, and latissimus dorsi. The lack of consensus is, in my opinion, an indication of how shaky the concept is.

        No muscle (or group of them) truly acts in isolation from the rest of the body. The “core” may be a useful label for a region (like “upper extremity”) but that’s pretty much it, in my opinion.


    16. jess says:

      Every instance is different. Exercise won’t get rid of pain but it can sometimes help with elevating the problem, such as that someone has better support/strength/endurance in their bodies. It depends what the diagnosis is! And the fact that fitness has no certain affect on chronic pain is not surprising. Obviously chronic pain is a deeper problem caused by degeneration or injury and exercise will mostly irritate the problem further. However, a fitter body will probably always have a less chance of developing issues or higher chance of a slower development of issues, unless the problem is caused by exercise. Finally, working out does help elevate mild pain/from mild conditions. It is dependant on the situation and the individual. For example; fibromyalgia can be elevated because it is caused by stress as can joint problems caused by weak muscles but split discs may become worse and twisted spines may cause pain if pushed too hard, especially in the wrong places. Degenerative knees would benefit from strong muscles, but working the areas can make it worse.

    17. ed champagnee says:

      My condition is and causes acute pain, yet relaxing the muscles using painkillers in the U.S. is unacceptable, thus my recovery is achievable.
      Like starting a car, you must put energy in and allow the engine to move long enough to recover. Treat the pain so I can move, move so I can recover, without doing both recovery is unlikely. Pain treatment is only allowed if I’m terminal.

    18. Chris says:


      I believe that the “almighty” 6 week PT prescription, when effective, is probably due more to rest/abstinence from the aggravating activity than the 6 week course of strengthening (although I believe engaging and strengthening is beneficial regardless of your situation). I just wish this wasn’t the first script the doc pulled out.

    19. Pancho says:

      Hey Tony,
      Great article, big on research myself (as it is my main current activity; albeit different field); love how you put stuff out there in regards o chronic pain in such a way that it goes against a popular idea (paradigm shift). Having understand that there’s little evidence supporting posture as a cause of chronic pain I have a couple other questions:
      What part does muscle imbalance play in posture and obtaining a correct or straight posture (or bad one for that matter)? Is there such thing as a correct posture? It seems also that the whole idea of a muscle being imbalanced doesn’t sit you well, or is it just something that appears (as in becomes significant or evident) when performing an activity that engages a muscle group.
      I apologize if the questions seem kind of off subject (chronic pain) but cant help relating both.
      Best regards

    20. Shelby says:

      Mr. Ingram, thank you for writing these articles! I am 29 years old and have been suffering with chronic pain for about 8 years now. It started with low back pain and I went to several different doctors trying to find what the cause of my pain was. I was referred to an orthopedic surgeon in late 2007 and though I had an MRI done before (which that doctor said they could not find anything wrong), the orthopedic surgeon ordered a new MRI and was told I had two herniated discs at L4/L5 and L5/S1. He recommended spinal fusion because I was not a good candidate for disc replacement. Long story short, the fusion (that only happened at L5/S1) did not help at all. The pain has only gotten worse and worse over the last several years and I wholeheartedly believed it was due to muscle imbalances because my body definitely feels “off.” I am really at my wit’s end when it comes to finding any solutions to help relieve the pain because I am exhausted and depressed living this way and I just don’t know what to do anymore. I don’t think more surgery is the answer, but even just walking causes increased pain just a few hours after I’ve tried. I also feel nauseous a lot more (everyday) than I ever used to when this first started. I am on some very strong narcotic pain medications to help me live a somewhat more normal life (still ain’t much of a life if you ask me). What would you suggest I try next? I am just so tired of being a slave to pain meds that have stopped working as well as they once did and pain meds don’t solve the problem, they are just a Band-Aid until my pain (and brain) says “You need more pain relief meds again. I hope you can advise me on doing something different because right now, my life has no quality or value to it. I can’t hold a job, don’t sleep well (unless I have enough meds to mask the pain), and generally just have no life outside my home. I refuse to take antidepressants because the depression really only stems from the severe chronic pain. Is there anything I can try that doesn’t require much energy, as I am extremely fatigued from so many restless and anxious nights. I have zero energy and will need to start SMALL! I hope you can shed some light as to how I can handle all this. Just a side note: I’ve done chiropractics and physical therapy to no avail. Please help me before I actually act on my suicidal thoughts…..it is really frustrating and scares me so much. I hope you read this and can understand. Look forward to hearing from you!

    21. Nicole says:

      Shelby I hope you feel better. It was heartbreaking to read your post. If you live near NYC I could refer you to an orthopedic massage therapist that is one of the smartest people I have ever meet. I have been to a chiropractor, acupuncture, Reiki, PT, sports massage, heat therapy, etc. But he listened, really listened to my pain history and was super interested in finding out what might be going on in my body. I left the office with no back pain and my knee felt like it had a brace on it and more stable than it had in 4 years. Crazy. You have to find someone that is smart, listens and you can trust. Good luck!

    22. D says:

      This has to be the dumbest article and website I’ve come across yet. The amount of support from people who actually deal with a painful back, day-in and day-out, shows that focusing on weakened muscles, improper balance of muscles in function, and muscle-inhibition, clearly shows how effective focusing on these problem areas are in dealing with back-pain. You literally stated that there was no scientific evidence to support the core-theory claim of back-pain yet you admitted that there is some science behind it that started the core bandwagon going. Then you theorize how muscle-inhibition may be a DEFENSE and not a CAUSE of back-pain.. XP OF COURSE IT IS STUPID!!! The body works both ways, it inhibits muscles that may be injured so they don’t cause pain and also inhibits muscles when it experiences pain so using certain muscle-groups don’t increase the pain. The problem is in our EVERYDAY Habits! Specifically, how sedentary we have become and how poor-posture has become a culturally acceptable thing. Standing up straight in a crowd of Californians can cause you to stand-out like a sore-thumb :P Being both a chronic-pain patient and a Californian, I can say all this with confidence and by my own personal observation on how my body works! There is such a PLETHORA of Information coming from everywhere now that shows clearly how wrong this WHOLE article series really is! For those that want the fastest approach to back-pain elimination, I recommend, “8 Steps to a Pain-Free Back” by Esther Gokhale. It came out in 2008 and has MORE THAN ENOUGH Scientific Evidence to back-up it’s position on back pain and what’s more, TONS OF PEOPLE WHO SUFFERED FROM PAIN AND THEN CURED THEMSELVES USING HER METHODS!!! XP I don’t know how stupid you can be with so much information available to people with such ease of access, but it seems the Author of this Article-Series is testing those limits for us.. XP

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