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Rethinking Chronic Pain

Chronic pain is a significant problem for many Mandurah residents, and can interrupt your ability to do the things you enjoy. In general terms, chronic pain can be defined as pain that has been present for longer than 3-months. Thankfully, over the past decade, research in the field of pain science has helped us to understand more about chronic pain, and how we can more effectively treat it. Chronic pain is a lot more complex than previously thought, and although we have been good in the past at treating the physical components to pain, the neurological and brain components to chronic pain have not been as well addressed.

What we have learnt about chronic pain is that after a long period of being in pain, our pain system can become over-protective and hypersensitive. This means that we can continue to feel pain signals (perhaps with certain movements), even after the physical component causing the pain has long since resolved. This may explain why some people suffering from chronic pain have normal x-ray/scan results!

So what can we do about it? Well, one of the simplest, and most effective ways to help chronic pain is to better understand what is happening. The short video below titled ‘Tame the Beast’ really helps to explain it well.

There is no single effective treatment for chronic pain, but what we do know, is that people get better with a combination of different types of treatment. This generally includes hands-on manual therapies, exercise and education on pain.

Regular Exercise Prevents Chronic Muscle Pain

We all know exercise is good for you, but it’s nice to have some good quality scientific evidence to prove it! The fact that people who exercise regularly are less likely to experience chronic pain is commonly observed in practice everyday, and by patients first-hand. It is not too far fetched to suggest that exercise keeps our musculoskeletal system strong, and therefore less likely to hurt ourselves, but a recent study has looked into the proposed mechanisms as to how exercise prevents pain, from a neurological perspective.

Without going into too much detail, it is commonly believed that exercise produces its chronic pain-prevention benefits by activating what is known as the central opioid receptors in the nervous system, and this is a key factor in reducing pain sensation.

In brief, the reseachers did a study on mice whereby they were given access to a running wheel prior to induction of chronic muscle hyperalgesia (pain), and compared them to a group of mice without the running wheels. They closely measured and compared the neurochemistry of both groups and found that the wheel running produced analgesia (pain-relief) via central pain inhibitory mechanisms.

If you are keen to get stuck into the full science of it, there full research article can be found here.

 

What does this mean for us in everyday life?

If you are suffering from chronic pain, it is likely that regular exercise will assist in conjunction with your existing treatment. Exercise doesn’t have to be super-high intensity either – brisk walking is good start! The key is finding exercise that is conducive with any existing injuries of musculoskeletal conditions you may have. It is recommended to consult with your usual health practitioner who can advise you on exercise that is appropriate to you.

 

References:

Brito, R.G., Rasmussen, L.A., Sluka, K.A., 2017. Regular physical activity prevents development of chronic muscle pain through modulation of supraspinal opioid and serotonergic mechanisms. PAIN Reports 2, e618. doi:10.1097/PR9.0000000000000618

https://journals.lww.com/painrpts/fulltext/2017/10000/Regular_physical_activity_prevents_development_of.7.aspx

Is My Child’s Schoolbag Too Heavy?

The start of the school year is often when we get an influx of rightfully concerned parents, worried about the weight of their child’s school backpack. Current recommendations suggest that a child’s backpack should not exceed 10% of their body weight.

Although back pain in children is a lot less common than in adults, there are a number things we can do as parents to ensure our children stay pain-free, with happy healthy spines!

 

Here are some simple hints and tips for correctly selecting and fitting your child’s back pack:

  • Ensure the backpack is the correct size. When the shoulder straps are adjusted, the bottom of the backpack should be above your child’s waist – not hanging over the buttock.
  • Get an adjustable backpack. Every kid is different, so make sure the backpack can be adjusted to suit your child’s frame, and change as they grow!
  • Look for features such as a moulded frame and/or hip strap, so that the weight of the contents can rest against your child’s pelvis instead of their shoulders and spine.
  • Ensure their backpack is fitted correctly. It should be snugly fitted over both shoulders and should comfortably fit the contour of their back. Don’t have the backpack hanging low off their shoulders.
  • Fill their backpack appropriately. Pack the heaviest items closest to their spine, which will help balance the load. Also using the backpacks compartments if you have them, will help stop the load moving around.

I hope you find this information helpful. If you are concerned or just want a spinal check-up for your child, feel free to contact us at the clinic to book a chiropractic appointment.

3 Exercises to Improve Your Hip Strength and Mobility

Perhaps second only to shoulder rotator cuff issues, persistent pain and stiffness at the hip joints is one of the most common non-spinal complaints we treat in the clinic. Patients often describe stubbornly tight and painful hips that don’t respond to standard hip stretches. Due to the inherently stable nature of the ball-and-socket joint, months of intense ‘static stretching’ will often provide little benefit, and instead exercises that improve correct muscle contraction and movement patterns are the key to improving functional hip range of motion.

There are many underlying conditions that can account for poor mobility and flexibility, but for the majority of people, a program of home exercises in conjunction with your chiropractic treatment, can go a long way towards improving your hip range of motion, strength and overall function.

As always, it is advisable to first see your health practitioner before commencing any exercises described in these blogs. Some conditions can be aggravated with certain exercises, especially if performed incorrectly.

1. Reverse Active Straight Leg Raise

This exercise is fantastic for improving hip flexion in combination with hamstring flexibility, which is important for correct hip biomechanics. Start by  lying flat on your back with both legs elevated at 90 degrees. Be sure to activate your core muscles, ensuring your lower back stays flat against the floor. With a resistance band or rope around one leg, slowly lower the opposite leg down to ground level. Alternate between both legs, aiming to perform 2 x 10 reps.

2. Single Leg Hip Lift

This exercise is another that is excellent for those with tight hip flexors, and again combines flexibility with strengthening, to improve mobility. Start by lying on your back, with one hip pulled tight up against your chest. The knee is bent 90 degrees with the foot flat on the floor. Next, lift your hips up as high as possible, without arching the lower back. You should feel your glutes (buttock muscles) activating with this movement. Hold the position for 5 seconds, alternating between legs to do 2 x 10 reps.

3. The Psoas March

This is a great exercise to improve lumbopelvic control and hip flexibility. Lying on your back, raise both your legs with your hips and knees both bent at a 90/90 position. Be sure to keep your lower back flat against the ground by activating your core muscles. Slowly kick one leg out straight, whilst keeping your other leg stationary, and maintaining your lower back position. You can alternate from leg to leg, aiming to complete 2 x 10 reps. As you progress, you can add resistance band between both your feet to increase difficulty.

References:

https://thebarbellphysio.com/psoas-march-key-strong-flexible-hip-flexors/

https://drjohnrusin.com/end-static-stretching-hip-mobility/

5 Easy Shoulder Mobility Exercises You Can Do With a Broomstick!

Shoulder ‘stiffness’ is a common complaint from patients, and can be attributed to a number of underlying conditions. The good news is, that most shoulder complaints will benefit from some mobility exercises to improve pain-free range of motion. Here are 5 shoulder mobility exercises I find helpful for my patients, and the only equipment you need is a broomstick (or rake, mop, PVC pipe etc).

1. Shoulder Flexion

Hold the stick in both hands with your knuckles facing forwards. Gradually raise both arms up whilst keep the elbows straight. You can use your good arm to assist in elevating the injured/painful shoulder. Hold for 5 seconds and repeat 10 times.

2. Shoulder Extension

Hold the stick behind your back, again with your knuckles facing forwards. Slowly elevate the stick away from your back and hold this position for 5 seconds. Repeat 10 times.

3. Shoulder Abduction/Adduction

Hold the stick in both hands with your palms facing fowards. Keeping your elbows straight, use your good arm to elevate your injured shoulder up past 90 degrees if possible. Hold this position for 5 seconds and repeat 10 times.

4. Shoulder Internal Rotation

Hold the stick with both hands behind your back, with your uninjured shoulder behind your head, and your injured shoulder behind your back at waist-level. Move the stick up and down by bending at the elbows, with your uninjured arm (at the top) assisting the injured shoulder through gradual movements. Hold the elevated position for 5 seconds, repeating 10 times.

5. Shoulder External Rotation

This exercise is easiest performed lying on your back. Hold the stick in both hands with your palms facing upwards, and your elbows bent at 90 degrees. Ensure the back of your upper arms are resting against the floor. Use your good arm to swing your injured arm away from your body, whilst keeping the elbow of the injured arm by your side. Hold the stretch for 5 seconds and repeat 10 times.

These exercises are meant only as a guide, and should not replace proper consultation with your health practitioner. For some people, these exercises may not be appropriate, and could cause further irritation if performed incorrectly. If you are unsure as to the appropriate course of treatment for your shoulder pain, feel free to contact the clinic to book a chiropractic consultation with me.

I Have a Disc Herniation – What Does it Mean? How is it Treated?

he discs in the lower back play an important role in acting as shock absorbers between the vertebra, while at the same time allowing us to perform a wide range of motion with our spine. The discs are made up of a strong outer ring called the annulus fibrosis,  consisting of overlapping fibers, that helps to protect the inner gel liquid, called the nucleus pulposis.

Over time, the discs will naturally degenerate, and can cause lower back symptoms.

Lumbar disc herniations are very common, and in fact research has shown that even people without low back pain, are likely to have a few disc hernations. A research article from 2015 published in the American Journal of Neuroradiology (available here) found that over 50% of 30-39 year-olds with no low back pain, did in fact have signs of disc degeneration, as seen on MRI scans. The important take-home message, is that although degenerative changes do occur in all of our spines, this does not always have to equal pain.

How does a disc bulge?

If there is excessive load or stress placed on the spine, either from repetitive actions or a single trauma, the fibers of the outer annulus can tear, forming a point of weakness in the disc. The pressure from the inner nucleus can form a bulging or protrusion in the shape of the disc at this area, causing a bulge, that can put mechanical pressure on one of the nearby spinal nerve roots.

Material from within the disc, can also cause an inflammatory response at the area, and irritate the nerve. Both of these can result in sciatica, which is leg pain arising from irritation/compression of one of the these nerves that form the sciatic nerve, which runs down the back of the leg.

Progression of Disc Herniations:

There are a few different types of disc herniations as detailed in the following diagram.

If there has been tearing of the annular fibers but the ring is intact, this will cause just a bulge. As the fibers of the annulus tear further, the bulge can become more pronounced. If there is complete rupture of the annular fibers, disc material can leak though the tear, causing a chemical inflammatory irritation to the nerve. Free fragments of disc material can break off into the spinal canal, and can often be reabsorbed.

How long will the pain last?

Often patients will report initial pain with a disc injury, that settles as the associated inflammatory response reduces. Research has shown that about 90% of people with a disc hernation, will be pain-free at 6-weeks, even without any form of treatment. Current thinking is that the body sees the protruding disc material as a foreign body and breaks it down, resulting in less inflammatory material near the spinal nerves. Also, it is believed that the body reabsorbs some of the water from within the disc itself, causing it to shrink in size.

In some cases, where the herniation is severely compressing one of the spinal nerves, symptoms may persist longer. This is where further investigation and treatment may be warranted.

Do I need a scan?

In most cases, a diagnosis can be made without the need for scans. However, if symptoms are severe, if there are neurological symptoms such as foot-drop or other leg weakness, then imaging will be performed to assess the degree of hernation and nerve impingement. MRI is the ‘gold standard’ for imaging the discs and nerves of the lumbar spine, and will be needed in cases where surgery is being considered.

What are the treatment options for disc herniations?

For the vast majoirty of uncomplicated disc herniations, conservative non-surgical treatment should be the first option. Depending on the nature of the disc herniation, the treatment commonly provided by a chiropractor will include a combination of hands-on manual therapy to improve pain-free range of motion and alleviate pain, along with exercises to help reduce any nerve irritation, unload the disc, and also to strengthen the core stabiliser muscles. The aim of non-surgical treatment is to reduce the recovery time, and recondition the spine to avoid recurrence.

 

There will be cases where surgery is considered. This will often be if there is a very large disc herniation that is putting significant pressure on the spinal nerves and/or spinal cord. This is a whole topic of it’s own, that we might look at later in another blog!

References:

  1. Schroeder GD, Guyre C, Vaccaro A. The epidemiology and pathophysiology of lumbar disc herniations. Seminars in Spine Surgery. Volume 28, Issue 1, March 2016, Pages 2-7. Lumbar Disc Herniation. doi:10.1053/j.semss.2015.08.003.

  2. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR American journal of neuroradiology. 2015;36(4):811-816. doi:10.3174/ajnr.A4173.

  3. Abraham P, Rennert RC, Martin JR, et al. The role of surgery for treatment of low back pain: insights from the randomized controlled Spine Patient Outcomes Research Trials. Surgical Neurology International. 2016;7:38. doi:10.4103/2152-7806.180297.

  4. Kreiner, D. S., Hwang, S. W., Easa, J. E., Resnick, D. K., Baisden, J. L., Bess, S., … Toton, J. F. (2014). An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. The Spine Journal : Official Journal of the North American Spine Society, 14(1), 180–191. https://doi.org/10.1016/j.spinee.2013.08.003

2 Simple Exercises to Keep Your Shoulders Strong and Pain-Free

Following on from our blog last week on subacromial bursitis and shoulder impingement, I thought it would be useful to provide some information on two exercises I have found to be very helpful for my patients with various forms of shoulder pain.

Stretches are beneficial to keep soft tissue structures flexible, but strengthening is really the key to enabling the shoulder to move correctly and be stabilised. Strengthening increases the capacity of the muscles to perform the tasks we demand of them, in a pain-free manner.

 

1. Resisted External Rotation

This is an excellent and very popular exercise to strengthen the rotator cuff muscles, and will generally form part of the initial rehabilitation phase in most clinics.

With your elbows by your side at 90 degrees, hold a length or resistance band between both hands. Keep one arm still as an anchor point, and slowly rotate the opposite arm away from your body. Alternatively, you can tie the band onto a pole or hook. It is important to keep your elbow up tight against your body with the movement, to ensure the rotator cuff muscles are doing the work and not the torso trying to help out. Also ensure that the wrist stays straight, as it too can try to compensate for a weakness in the rotator cuff. The body will look for ways to cheat and avoid using the shoulder if it is painful, so keep an eye on your form!

2. Seated Rows

This exercise helps to strengthen the muscles of the upper back that help support the scapula(shoulder blade). The scapula forms the base of support from which the upper limb operates, so it important that we have a strong, stable foundation here. Issues with scapular control and stability, can often have a significant flow-on effect down the chain.

It is best to start with this exercises in a seated position, with your arms slightly elevated out to your sides. With the resistance band in each hand, have it looped around a pole or a hook in front of you. Focus on squeezing the shoulder blades together in the middle of your back, without shrugging your shoulders. Try to focus most of the strength and movement at the shoulder blades, and not the arms/elbows. Also, be careful not to jut the neck/chin forward!

 

These exercises are meant as a guide only. It is recommended that you consult with your usual healthcare practitioner prior to commencing exercises, to rule out any contraindications or underlying pathology that may need to be addressed.

Shoulder Bursitis – what is it and how is it treated?

Shoulder bursitis most commonly refers to inflammation of the subacromial bursa, which is a fluid filled sac, that sits at the outer-front aspect of the shoulder. Subacromial bursitis, is one of the most common complaint

s we see in the clinic, and it typically presents as tenderness at the outer aspect of the shoulder, more so when raising the arm, which confines the subcromial space, where the bursa is located. (1)

What is the bursa? Why is it sore?

The bursa is a thin, lubricated cushion, and acts as a barrier at points of friction, between bones and surrounding soft tissue structures. There are about 160 of them around the body, and they vary in size depending on location and the nature of the forces being applied across it. The bursa sac is made up of synovial membrane, which both produces and maintains the synovial fluid within the bursa. (2,3)

The subacromial bursa sits below a bony structure of the shoulder, called the acromion, and provides a cushion barrier between the bone and the rotator cuff muscles that run directly below it. (3)

Bursitis (or inflammation of the bursa), occurs when the synovial membrane  becomes inflamed, causing it to thicken and produce an excess of synovial fluid, causing the bursa to swell and become painful. The most common causes for this are excessive friction on the bursa, a direct injury, or an underlying inflammatory condition, such as rheumatoid arthritis. You can also get bone spurs (osteophytes) that grow down from the bottom of the acromion, narrowing the subacromial space that the bursa and rotator cuff tendons sit within. (3)

When the subacromial bursa becomes irritated, it can thicken and cause what it sometimes referred to as Shoulder Impingement Syndrome, which is a painful pinching of the soft tissue structures that sit in the small space between the acromion and the shoulder ball-and-socket joint. This space is call the subacromial space. The tendons of the rotator cuff muscles can also become inflamed, resulting in tendonitis, which contributes to the pain. (4)

 

How is shoulder bursitis treated?

Most patients generally respond well to a combination of stretches and rehabilitation

exercises provided by their health practitioner, to strengthen the muscles that support and control movement at the shoulder. This helps treat the current bursitis and tendonitis, and minimise the risk of future irritation. Manual therapy techniques including joint mobilisation/manipulation and soft tissue techniques are also often incorporated into most treatment plans.

In the initial phase, rest from activities that are causing aggravation, such as lifting, reaching and overhead work is helpful. Your practitioner can also advise you on activity modification, or changing the way you perform repetitive tasks, in order to reduce irritation on the bursa and tendons. Your doctor may also prescribed you an anti-inflammatory medication to reduce the inflammation and swelling of the bursa. In some cases, a corticosteroid injection (anti-inflammatory) into the bursa, in conjunction with an aspiration (or draining) of the bursa can be beneficial. (5)

Surgery (acromioplasty) may be considered in cases where there is significant bone spurs impinging on the bursa and tendons, that is not improving with conservative treamtment. Surgery will generally include removing part of the acromion and sometimes the bursa itself, such that there is more space for the soft tissue structures. (6)

 

Will it happen again?

Subacromial bursitis is very common, and can often recur, if the causative factors haven’t been addressed. Most bursae will settle with anti-inflammatories, but it is important to correct postural and movement patterns that are causing it to become aggravated in the first place. If there is significant spurs, and conservative measures are not resolving it, then symptoms will likely recur until this is surgically addressed.

If you are suffering from bursitis, feel free to book an appointment at the clinic for a full assessment and appropriate course of treatment.

 

References:

  1. Luime JJ, Koes BW, Hendriksen IJ, Burdorf A, Verhagen AP, Miedema HS, Verhaar JA. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol. 2004;33(2):73-81. Review. PubMed PMID: 15163107.
  2. van Holsbeeck & Strouse. Sonography of the shoulder: evaluation of the subacromial-subdeltoid bursa. AJR Am J Roentgenol. 1993 Mar;160(3):561-4. PubMed PMID: 8430553.
  3. Anastasios Papadonikolakis, Mark McKenna, Winston Warme, Brook I. Martin, Frederick A. Matsen, III; Published Evidence Relevant to the Diagnosis of Impingement Syndrome of the Shoulder. The Journal of Bone & Joint Surgery. 2011 Oct;93(19):1827-1832.
  4. National Institute of Arthritis, Musculoskeletal and Skin Diseases, “Shoulder Problems.” May 2010. Accessed March 8, 2012. http://www.niams.nih.gov
  5. Codsi MJ. The painful shoulder: when to inject and when to refer. Cleve Clin J Med. 2007 Jul;74(7):473-4, 477-8, 480-2 passim. Review. PubMed PMID: 17682625.
  6. Donigan JA, Wolf BR. Arthroscopic subacromial decompression: acromioplasty versus bursectomy alone–does it really matter? A systematic review. Iowa Orthop J. 2011;31:121-6. PubMed PMID: 22096430; PubMed Central PMCID: PMC3215124.

5 Easy Stretches for the Busy Office-Worker

I see a lot of desk-bound office workers at the clinic, who often present with similar symptoms of neck and shoulder pain, and stiffness in the mid to upper back. The human frame is designed to move, and long hours in one fixed position are not going to help things!

Here are 5 easy stretches that you can do while at work, to keep mobility in the neck and upper back:

1. The Chin Tuck

No, this is not a cosmetic plastic surgery procedure. The chin tuck is a postural position of the neck that takes load off some of common pain generating structures in the neck, as well strengthening the stabilising muscles of the neck, that encourage good posture.

Simply tuck your chin back a few centimetres, to represent a ‘double-chin’. Try not move your head downwards, but more a backwards sliding position. You can add to this, by having your head against a headrest and pushing into it with light pressure. This will help to strengthen the neck muscle.

2. Scapular Setting:

This is another important postural position, that reduces load on the neck, and encourages activation of the upper back muscles, that support the shoulder blades. In a seated position with your elbows by your side, gently draw your shoulder blades back and down together. You should feel the muscles at the base of the shoulder blade working. Be sure avoid shrugging your shoulder blades upwards.

3. Shoulder Rolls:

Move your shoulders in a backwards circular pattern as shown. This helps to improve mobility in the shoulder girdle, and also resets the muscles at the top of your shoulders (upper trapezius), if you find yourself hunching.

Slow, wide circles generally work best.

4. Upper Trapezius Stretch:

Sit on one hand with your palm facing up, ensuring you are sitting up straight and not slouched. Turn your head 45 degrees to the opposite side. With your other hand, grasp the back of your head and lightly pull down, such that you are looking towards your armpit. You should feel a stretch across the top of your shoulder. By altering how much you turn your head, you can target slightly different muscles.

5. Upper Back Rotation:

In the seated position, rotated your upper body as far you can, keeping your pelvis straight. You can hold onto the side of your chair to get some extra stretch. Repeat this slowly from side to side a few times, to keep movement in the thoracic spine. Turning your head to the same side also helps with overall mobility in the upper spine.

4 Simple Exercises to Improve Your Core Stability

There are countless rehab exercise programs floating around, promising to improve core stability and cure low back pain, much of which all revolve around the same basic principles. That is, strengthening the transverse abdominus, gluteals, and lumbar extensor muscles, that aid in supporting and controlling movement in the lumbopelvic region. It has been shown that this can reduce low back pain, and it should make an integral part of your treatment regime. (1) (2)

Core stability exercises don’t need to be hard and complicated. In fact, I have found clinically,  that people get better improvements with exercises that are simple and easy to perform, and therefore more likely to be done on a regular basis! There is actually still some uncertainty in the research as to the effectiveness of specific core stability exercises over general exercise for reducing low back pain. (3) (4)

Here are 4 core stability exercises that I get all of my patients with lower back pain performing, especially if I suspect there is a deficiency in activation of the core muscles.

1. Anterior Pelvic Tilt (Transverse Abdominus Activation)

The transverse abdominus can be a difficult muscle to contract, and performing a pelvic tilt can be a helpful way to get it firing. Lie on your back with bent knees and your feet flat on the floor. Try to pull your bellybutton down towards your spine, while at the same time clenching your buttock muscles. You should feel your tail bone rolling up off the floor. Hold this for a 10 seconds, relax and then repeat. You should be able to perform this while still breathing. It is helpful to also perform this during day-to-day activities such as sitting at the desk and walking.

Image taken from Physitrack® www.physitrack.com.au

2. The Dead Bug

While lying on your back, bring your legs up in the air with your hips and knees both bent to 90 degrees. Bring your arms up, pointing straight up vertically over your head. Ensuring you keep your back flat, slowly lower your opposite arm and leg away from each other towards the floor. Make sure nothing else moves as this motion occurs. Return back to the starting position and perform on the opposite side.

Image taken from Physitrack® www.physitrack.com.au

3. The Bird Dog

Get into an all-fours position on your hands and knees, with your hands directly under your shoulders, and knees under your hips. Tighten your abdominal core muscles. Extend your opposite arm and leg out straight from your body, ensuring to keep good control in your torso. Avoid twisting in the hips and pelvis. Bring them back in, and repeat on the opposite side. This can be a difficult exercise in the beginning, and in a lot of cases I start with people just elevating one arm or leg at a time, until core strength and motor control improves.

Image taken from Physitrack® www.physitrack.com.au

 

4. The Side Bridge on Knees

Start lying on your side and push yourself up onto your elbows. Bend your knees and lift at the hips until your body is in a straight line running from head to knees. Hold this position for as long as possible, then slowly lower and repeat.

Please keep in mind, these exercises may not be suitable for everyone. It is advisable to consult your chiropractor or other health professional before starting any new exercises. How many repetitions to perform is different for everyone, but generally try starting with 2 sets of 8-10 reps.

For more information on low back pain and how core stability training may help, feel free to contact me at the clinic for more information.

References:

1. Akuthota, Venu, Andrea Ferreiro, Tamara Moore, and Michael Fredericson. 2008. Core stability exercise principles. Current sports medicine reports 7, no. 1: 39-44.
2. Hodges, P W. 2003. Core stability exercise in chronic low back pain. Orthop Clin North Am 34, no. 2: 245-254. http://www.ncbi.nlm.nih.gov/pubmed/12914264.
3. Education, Field Coaching, and Exercise Science. 2012. On rethinking core stability exercise programs. Australasian Musculoskeletal Medicine: 9-14.
4. Wang, Xue Qiang, Jie Jiao Zheng, Zhuo Wei Yu, Xia Bi, Shu Jie Lou, Jing Liu, Bin Cai, et al. 2012. A Meta-Analysis of Core Stability Exercise versus General Exercise for Chronic
Low Back Pain. PLoS ONE 7, no. 12.
Images taken from Physitrack® www.physitrack.com.au