Certified Personal Trainer core exercises core stability drawing-in Research Study smr trigger point back pain balance myofascial myofascial release

Research in Review: Impact of core stability exercises plus myofascial trigger point application on dynamic balance.

Kyle Stull
Kyle Stull

See how research on core stability exercise plus myofascial trigger point therapy improved dynamic balance for patients with low back pain.

Journal Article Review:

Trampas, A., Mpeneka, A., Malliou, V., Godolias, G., & Vlachakis, P. (2015). Immediate effects of core-stability exercises and clinical massage on dynamic-balance performance of patients with chronic specific low back pain. Journal of Sport Rehabilitation, 24(4), 373-383.

Purpose of the Study:

The primary purpose of this study was to investigate the immediate effects of myofascial trigger point therapy plus core stability exercises on dynamic balance of patient’s clinical spinal instability and chronic myofascial pain syndrome.

The secondary objective was to determine whether myofascial trigger point therapy and core stability exercises had any accompanying effects on the pressure-pain threshold.

Study Participants:

A convenience sample of 10 active participants, with clinical instability, volunteered for the study. Inclusion requirements were the presence of low back pain with or without distribution of symptoms or at least 1 recurrence after the initial intake. The participants also had to test “positive” on three of the following tests, which have been proposed to help clinicians accurately identify patients for a stabilization focused exercise program:

  • Age of 40 years
  • Straight-leg raise >91°
  • Positive prone instability test
  • Abnormal motions during flexion of lumbar spine:
    • instability catch, painful motion, “thigh climbing,” reversal of lumbopelvic rhythm

To identify the myofascial trigger points, participants were examined on symptomatic and functionally related muscle groups. Traditional Chinese-medicine charts were used to record the names of myofascial trigger points to standardize the procedure. Trigger points were characterized as being active if they referred pain that reproduced complaints when 4 kg of pressure was applied for 10 seconds.

Procedure or Methods:

All participants were tested 1 week before beginning the study and immediately at the conclusion of the study. The examiner was blinded to the groups. The study consisted of 1 treatment session.

Two physical therapists, who were blinded to the purpose of the study, performed the interventions. Both had a minimum of 10 years of experience and had completed courses on core stability and myofascial trigger point therapy education.

The participants were divided in to two groups. Group 1 performed the following 7 core stabilization exercises after being taught the abdominal drawing-in maneuver in supine, sitting, and standing with a pressure biofeedback unit:

  1. Control of translation (supine)—pressure biofeedback unit, lower-abdominal hollowing, initial pressure 40 mmHg, holding pressure 50-60 mmHg. No breath holding, no ribcage depression, no upper-abdominal hollowing or bulge.
  2. Control of translation (sitting)—same as above, but sitting.
  3. Control of translation (standing)—same as above, but standing.
  4. Single-leg heel touch—crook-lying position, 1 lower limb off the floor (hip flexed to 90° and knee relaxed), pressure biofeedback unit, initial pressure 40 mmHg, holding pressure 50-60 mmHg during hip flexion and extension of non-weight-bearing limb. No breath holding, no ribcage depression, no upper-abdominal hollowing or bulge.
  5. Single-leg supported slide, pressure biofeedback unit, initial pressure 40 mmHg, holding pressure 50-60 mmHg while participant slides foot on the supporting surface. No breath holding, no ribcage depression, no upper-abdominal hollowing or bulge.
  6. Contralateral-arm lift—palpation of lumbar multifidus, opposite-arm lift from 0 to 90° shoulder flexion, hold the contraction through range during arm movement. No breath holding, no diminished muscle activity when arm changes direction of movement.
  7. Forward weight transfer—standing as in normal gait with full weight on the rear lower limb, palpation of lumbar multifidus on the rear-limb side; forward and backward movement of body onto the front and rear limb, respectively; hold contraction just after heel lift until back on the ground. No breath holding, no pelvic sway, no over rotation of pelvis.

Each session lasted 45 to 60 minutes.

Group 2 performed the same exercises as group 1. However, the exercises were performed after the elimination of active (painful) myofascial trigger points. Non-painful cross-fiber friction massage was applied over the trigger point for 3.5 minutes (during this time multiple releases would have been felt, each time going to a new resistance barrier). 3 trigger points were treated for every patient, thus this part of the study lasted approximately 10 minutes.


Both groups saw improvement, however, the core stability exercise plus myofascial trigger point therapy group experienced better improvements in dynamic balance on the painful side. The differences were considered statistically significant.


The results demonstrated statistically and clinically significant and immediate improvements in the core stability exercises and myofascial trigger point release therapy group in decreasing pain. These findings support previous research that cross-fiber friction massage immediately increases pain pressure threshold and reduces pain in participants with low back pain.

Take away for NASM-CPT’s:

These results indicate that one can see immediate improvements in balance asymmetries and decreases of chronic low back pain through a program of myofascial trigger point release and core stability exercises. The NASM-CPT should take note of the attention to detail in this study. Pressure was held on “tender” spots for 3.5 minutes each. These results cannot be generalized to foam rolling because this was performed by a licensed clinician. However, it does indicate that a significant amount of time should be held before one can expect a “release.” In addition, the researchers indicated that “non-painful pressure” was used. Some discomfort is to be expected while foam rolling, but the goal is not to cause as much pain as possible from the start. Encourage the client to slowly increase pressure over the period of several minutes. Last, the core exercises were performed with precision. For transversus abdominis activation a pressure biofeedback was used to ensure each participant appropriately controlled the lumbar spine. For lumbar multifidus activation, the therapist palpated the muscle during the necessary exercises. While palpation may be out of the CPT’s scope of practice, it should again highlight the need to pay attention to the details when executing a core stabilization program.

Clients with low back pain can get great results and relief by using self-myofascial release and core stabilization exercises. The CPT should share the results of this research with their clients to not only highlight the benefits of the OPT Model, but to also set realistic expectations. If the goal is low back pain relief, then each session will consist of very specific exercises that are performed slowly with excellent form. Any deviation from this will likely lead to less than desirable results.


Tags: Certified Personal Trainer Tags: core exercises Tags: core stability Tags: drawing-in Tags: Research Study Tags: smr Tags: trigger point Tags: back pain Tags: balance Tags: myofascial Tags: myofascial release

The Author

Kyle Stull

Kyle Stull

Kyle Stull, DHSc, MS, LMT, NASM-CPT, CES, PES, NASM Master Instructor, is a faculty instructor for NASM. Kyle is also an Adjunct Professor for Concordia University Chicago.