Is Back Pain Caused By A Weak Core (Weak Back)?

Is Back Pain Caused By A Weak Core?


Many people believe back pain is caused by a weak back. Let’s explore the evidence…


This article is sure to cause some controversy but here we go!


Back pain is the leading cause of disability and 80-90% of people will experience it at some point in their lives ( myself included!) Back pain costs the NHS £1.3 million every day (NHS, 2014) and results in many people needing to take time off work sick.


For me there is a huge, human cost where relationships break down, people experience low mood, high pain scores and are restricted and unable to lead the lives they want.


I believe that health care professionals may be part of the problem (unintentionally of course).


So let’s take a look at my interpretation of the evidence surrounding the ‘weak back’ hypothesis! I am only human so I urge you to read the original articles yourself and form your own opinion. I have included a list at the end.


I’m ready for you keyboard warriors! Please try and review this with an open mind and the perspective that everyone wants the same thing, to eliminate pain for patients and give them their lives back.

How Do We Experience Back Pain?


People can experience a variety of symptoms and the level of pain we experience doesn’t necessarily equate to tissue damage.


We know that many people have structural abnormalities on an MRI such as disc protrusion, disc degeneration or nerve impingement but can experience no pain or symptoms.


At aged 50, 80% of asymptomatic people with no symptoms or pain may have disk degeneration as demonstrated in this population group (please see supporting evidence table below). In the same way we get grey hairs on the outside we get changes on the inside too.


We can experience pain through noxious stimuli from around the body ( thermal, chemical, pressure) or we can experience pain from no tissue damage at all ( phantom limb pain).

Well How Is This Relevant To Back Pain? Is The Weak Back Hypothesis Doing More Harm Than Good?


We need to dive into a bit of pain science !


Stick with me as this valuable bit of education could change the way you experience pain forever.


How we think and understand our pain is very important.


Studies have shown if you tell someone they will experience more pain you can induce a ‘nocebo’ response. A nocebo response is the opposite of a placebo. It’s a negative effect caused by the administration of an inert/ sham/ dummy treatment.


For example Pfingsten et al (2001) looked at 50 participates with chronic lower back pain performed a single leg-flexion task. Members in the control group were informed that the movement would not result in any increase in pain, whereas the experimental group were told that a slight increase in pain could occur.


Inducing pain anticipation through these words led to…

  • Significantly lower levels of behavioural performance (which correlated with fear avoidance behaviour)
  • Increased pain intensity and fear during test



So Does It Matter What The Therapist Says To You?


Maybe more than we think.


Häuser et al (2014) discuss the unintentional negative suggestions in everyday practices. Patients receiving injections showed anxiety and pain were heightened by the use of negative words such as “sting” “burn” “hurt” “bad” and “pain” (Lang et al, 2000)


Even looking at red imagery can increase pain perception (Wiercioch-Kuzianik and Bąbel, 2019) which is why it’s important we don’t give patients explanations using models with red on them or show pictures with red on them.


This might seem over the top but we need to start looking holistically and controlling as many variables as possible to improve someone’s pain experience.


This Ted talk with Lorimer Moseley is a brilliant introduction to why we feel pain and should be watched, in full by anyone experiencing pain.

Watch it here…. why things hurt 

Understanding Pain


To understand back pain firstly we have to understand how we feel pain.


Pain is an output of the brain and we can experience pain with or without the presence of tissue damage ( such as phantom limb pain).


“Neurons that fire together wire together.”


This means that if we are exposed to a painful stimulus over a prolonged period we can become conditioned and more sensitive to that particular signal.


Imagine you get stung by a bee every day for 3 months.


How do you think your body would respond in the presence of a bee?


Think it would be highly tuned to the sound, visual characteristics and movements of a bee?


A bee being in close proximity may be enough to affect your sympathetic nervous system, increase your heart rate and make your muscles tense.


This is our flight / fight reaction. If we spend long periods in a state of fight or flight response this can affect our health.


In some cases, thoughts and feelings can elicit feelings of pain and tensing/ guarding. A perfect example of this is when people use their hands to get up from a chair or reach to put on their shoes in a rigid manner, even in the absence of pain. This is a learned conditioned response.


Can A Perception Of A ‘Weak Back’ Increased Guarding?


Olugbade et al (2019) studied the interrelationships between guarding, pain, anxiety and confidence in movement in people with chronic pain in everyday movements.


The absence of guarding was associated with lower levels of pain, anxiety, distress and higher movement efficacy.


It concluded that pain-related guarding is likely to be more effectively addressed by reducing anxiety rather than pain (analgesia).


Certainly, I have seen this in my clinical practice where we have taught patients to move more normally, educated them about conditioning and pain improves quickly as they begin to move normally.


Other studies have suggested the ‘so-called protective’ strategies often increase pain and restrict movement (Sullivan et al, 2006).


Ok, so we have learned about how we feel pain and how thoughts, feelings and perceptions can affect our pain experience. We have learned how words and red imagery can negatively affect our pain and how the language we use can increase pain scores, anxiety and guarding.


Next, we will look at whether exercise can help back pain. Are the exercises strengthening the ‘weak back’ or does exercise have another role?


Back pain weak core

Exercise And Back Pain


Gordan and Bloxham (2016) performed a systematic review of the effects of exercise and physical activity on non-specific lower back pain.


They summarise that a variety of different exercise types had been explored low to moderate aerobic, high intensity, core stability and flexibility however the most effective form of exercise in unknown.


This literature review is through a very narrow framework. It does not take into consideration confounding factors such as the role of patient expectation, perception or confidence in their therapist, something we have learned above is very important.


One study suggests people recover from acute low back pain within 4-6 weeks with or without treatment. However, another study found that out of 1000 primary care patients, about 39% had not recovered by 6 weeks (Hancock et al 2008).


The statistics for people who experience long-term back pain are interesting and show why early intervention and correct ‘framing’ and ‘education’ are important.


32% of workers may be absent at one month off work with 7% having long-term work absence (over 6 months).


What is inspiring is the results we see in clinic in people who have had back pain for a long time. I have examples of cases where people who have had pain for multiple years have been able to reduce their pain and return to normal function.


Neuroscience has an increasing body of evidence that supports and helps us understand neuroplasticity. This is the brain’s ability to change, remap and reprogram.


People who have lost the use of their arm during a stroke can use different parts of the brain to regain sensory and muscular ability in the area that they previously could not use.


back pain treatment

Key findings from Gordan and Bloxham (2016)

  • Aerobic exercise has been shown to increase blood flow, increase endorphin production, and reduce pain perception.
  • Cho et al (2014) analysed 30 patients (15 in the experimental group and 15 in the control group) and found the CORE exercise program could be used to manage pain and increase AROM in patients with chronic lower back pain.


Many misunderstand my messaging that ‘weak core stability doesn’t CAUSE back pain’ and interpret my words as ‘core stability is bad’


I’m a physio! I think strengthening muscles and becoming healthier is a good thing.


My point is that any exercise that calms the pain system can help and it’s less to do with the type of exercise and more to do with the way we understand back pain, reduce fear and get moving in whatever way we can!


Although the results in Cho’s study showed statistical significance in a sample size of 30 would mean it’s difficult to extrapolate to the wider population particularly as the group’s mean ages were 38.1 and 36.5 and we know predominantly back pain occurs in people over 40.


Other studies have shown Pilates (Gladwell et al, 2006), group exercises (Masharawi & Nadaf, 2013) and intensive training (Kuukkanen & Mailhia,2006) can also help chronic, non-specific lower back pain. The point is it doesn’t really matter what you do, you just need to move!


Another meta-analysis (Wang et al , 2012) found that core stability exercises were more effective in decreasing pain and improved physical function than general exercises in the short term, however, at 6 and 12 months, there was no significant differences.

I Believe It’s The Patient Understanding That Is The Key


The belief systems that I see negatively impact patients are when they are fixating on ‘strengthening their core because weakness causes back pain’.


The perceived threat to a person if they visualise their back as ‘weak’ ’unstable’ or ‘things slipping’ can make people fearful to move when the reality is when you dissect spines they are inherently strong, even once muscles have been dissected and removed. We also know that bones, tendon and ligaments respond and adapt to load so need stress to keep them strong. This is why the risk of osteoporosis (thinning of the ones) can be improved by walking and strength exercises.


I am not denying when people have back pain their muscle strength reduces. Many studies have shown poor activation in trans ab with people who are experiencing back pain.


I liken this to quad inhibition in a painful knee (Palmieri-Smith et al, 2013). Following relaxation and activation of static quads in knee pain, this can resolve pain and improve the ability to ‘fire’ the muscle ie produce a contraction. The reality is you have not strengthened the muscle after 5 contractions, you have simply woken up the connection between the brain and the muscle.


As with many injuries when we experience pain we can experience muscle inhibition and subsequent muscle atrophy and poor movement patterns.


This is where I believe some research has been misunderstood.

‘Correlation doesn’t imply causation.’


Drawing cause-and-effect relationships can be inaccurate. For example ‘the muscle is weak therefore the weak muscle caused the back pain rather than the person experienced pain which resulted in weakness’


A widely studied example of this was a study that showed women taking combined hormone replacement therapy(HRT) also had a lower than average incidence of coronary heart disease (CHD), leading doctors to propose that HRT was protective against CHD. Later RCT trials showed HRT actually resulted in a slight increase in the risk of CHD.


The results were explained by confounding factors about the population group studied and that those recruited tended to be from higher socioeconomic background, and had better diets and exercise regimes.


So the correlation was incidental.


Why Does This Matter? Can Perception Of A Weak Back Really Increase Pain?


Well, it completely changes the framework in which we treat and the language that we use.


Do you not think it strange that back pain is more prevalent in countries with more developed economies? We have the best access to healthcare, knowledge, and drugs yet we are experiencing it more.


We need to ask ourselves why.


In conclusion, I think we need a fresh approach to back pain and not simply blame pain on a weak back.


We know what we think and feel about our pain can affect our pain intensity. It is therefore important that we educate patients on pain science, where appropriate show them dissections so they can feel confident in the stability of their backs.


We should avoid language that promotes fear, guarding or increases stiff movements.


Breathing and movement re-education is important to help them desensitise and reprogram the pain system.


Although we should continue to treat based on large research trials it is helpful to show examples of people who have had long-term back pain who have improved WITHOUT core stability exercises. Video testimonials or patient focus groups can help give people hope and see how these strategies have worked for others and help people who have fears around their back and break down unhelpful belief systems which may be holding them back from recovering.

People should not fear that a weak back will cause back pain.


If you have any questions please comment below email

nicole 🙂



 Kuukkanen T., Malkia E. Effects of a three-month therapeutic exercise programme on flexibility in subjects with low back pain. Physiother. Res. Int. 2000;5:46–61. doi: 10.1002/pri.183. [PubMed]

Karolina Wiercioch-Kuzianik, MSc, MA, Przemysław Bąbel, PhD, Color Hurts. The Effect of Color on Pain Perception, Pain Medicine, Volume 20, Issue 10, October 2019, Pages 1955–1962,

Pfingsten M, Leibing E, Harter W, et al. Fear-avoidance behavior and anticipation of pain in patients with chronic low back pain: a randomized controlled study. Pain Med. 2001;2(4):259‐266. doi:10.1046/j.1526-4637.2001.01044.x

Olugbade T, Bianchi-Berthouze N, Williams ACC. The relationship between guarding, pain, and emotion. Pain Rep. 2019;4(4):e770. Published 2019 Jul 22. doi:10.1097/PR9.0000000000000770

Hancock MJ, Maher CG, Latimer J. Spinal manipulative therapy for acute low back pain: a clinical perspective. J Man Manip Ther. 2008;16(4):198‐203. doi:10.1179/106698108790818279

Johansen O, Brox J, Flaten MA. Placebo and Nocebo responses, cortisol, and circulating beta-endorphin. Psychosom Med. 2003;65(5):786‐790. doi:10.1097/

Sullivan MJ, Thibault P, Savard A, Catchlove R, Kozey J, Stanish WD. The influence of communication goals and physical demands on different dimensions of pain behavior. Pain. 2006;125(3):270‐277. doi:10.1016/j.pain.2006.06.019

National Health Service (NHS) Backcare Awareness Week. [(accessed on 16 October 2014)]. Available online:

Häuser W, Hansen E, Enck P. Nocebo phenomena in medicine: their relevance in everyday clinical practice. Dtsch Arztebl Int. 2012;109(26):459‐465. doi:10.3238/arztebl.2012.0459

Lang EV, Benotsch EG, Fick LJ, et al. Adjunctive non-pharmacological analgesia for invasive medical procedures: a randomised trial. Lancet. 2000;355:1486–1490.

Wynne-Jones G, Cowen J, Jordan JL, et alAbsence from work and return to work in people with back pain: a systematic review and meta-analysisOccupational and Environmental Medicine 2014;71:448-456.

J Sport Rehabil. 2006,15, 338-350 © 2006 Human Kinetics, Inc. Does a Program of Pilates Improve Chronic Non-Specifi c Low Back Pain? Valerie Gladwell, Samantha Head, Martin Haggar, and Ralph Beneke

Palmieri-Smith RM, Villwock M, Downie B, Hecht G, Zernicke R. Pain and effusion and quadriceps activation and strength. J Athl Train. 2013;48(2):186‐191. doi:10.4085/1062-6050-48.2.10

The effect of non-weight bearing group-exercising on females with non-specific chronic low back pain: a randomized single blind controlled pilot study.

Masharawi Y, Nadaf NJ Back Musculoskelet Rehabil. 2013; 26(4):353-9.