Strengthening Methods for Deep Spinal Musculature: Evidence and Outcomes

Strengthening the deep layer musculature of the spine—primarily the multifidus and deep erector spinae—relies on targeted exercise interventions. Motor control exercises, isolated lumbar extension, and general strengthening are the most studied methods, with evidence supporting their role in improving muscle morphology, function, and pain, though structural changes are often modest.

Main Strengthening Methods and Evidence

Method	Evidence & Results	Citations
Motor Control Exercise (MCE)	Focuses on activating and coordinating deep trunk muscles. Reduces pain in chronic low back pain, but not more effective than other exercise for disability or acute pain.	(Saragiotto et al., 2016; Falla & Hodges, 2017)
Combined Motor Control + Isolated Extension (MC+ILEX)	Greater improvements in multifidus and erector spinae size and thickness than general exercise. Both approaches improve pain and function.	(Fortin et al., 2023)
General Strengthening/Resistance Training	Improves pain, function, and quality of life; less specific effect on deep muscle morphology compared to targeted approaches.	(Fortin et al., 2023; Falla & Hodges, 2017; Katzman et al., 2017; Warneke et al., 2024; Arokoski et al., 2001; Colado et al., 2011)
Posture Training/Spine-Specific Exercise	Reduces kyphosis and improves self-image in older adults, but may not significantly increase muscle strength or density if baseline strength is high.	(Katzman et al., 2017)
Electrical Muscle Stimulation (EMS/NMES)	May improve trunk muscle strength/endurance when combined with exercise, but not superior to exercise alone; effects on muscle morphology are limited and may reverse after detraining.	(Wolfe et al., 2023; Chen et al., 2024)
Stretching	Not effective for improving muscle imbalance or posture; strengthening is superior.	(Warneke et al., 2024)

Figure 1: Table summarizing strengthening methods, evidence, and outcomes.

Additional Insights

• Muscle Quality: Moderate evidence suggests exercise does not reliably reverse fatty infiltration in paraspinal muscles in low back pain, though some single-arm studies show localized improvement (Wesselink et al., 2022).

• Exercise Specificity: High-load resistance training is needed to address atrophy and fatty infiltration, while low-load motor control training improves activation and coordination but not necessarily muscle size (Falla & Hodges, 2017).

• Exercise Progression: Increasing load, instability, and complexity in exercises (e.g., deadlifts, dynamic movements) enhances paraspinal muscle activation (Arokoski et al., 2001; Colado et al., 2011).

Conclusion

Targeted motor control and isolated extension exercises are most effective for improving deep spinal muscle morphology, while general strengthening and posture training improve pain and function. Structural muscle changes are modest, and exercise alone may not reverse fatty infiltration. Combining methods and individualizing programs yields the best functional outcomes.

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References

Saragiotto, B., Maher, C., Yamato, T., Costa, L., Costa, L., Ostelo, R., & Macedo, L. (2016). Motor Control Exercise for Nonspecific Low Back Pain: A Cochrane Review. SPINE, 41, 1284–1295. https://doi.org/10.1097/brs.0000000000001645

Fortin, M., Rye, M., Roussac, A., Montpetit, C., Burdick, J., Naghdi, N., Rosenstein, B., Bertrand, C., Macedo, L., Elliott, J., Dover, G., DeMont, R., Weber, M., & Pepin, V. (2023). The Effects of Combined Motor Control and Isolated Extensor Strengthening Versus General Exercise on Paraspinal Muscle Morphology, Composition, and Function in Patients with Chronic Low Back Pain: A Randomized Controlled Trial. Journal of Clinical Medicine, 12. https://doi.org/10.3390/jcm12185920

Falla, D., & Hodges, P. (2017). Individualized Exercise Interventions for Spinal Pain. Exercise and Sport Sciences Reviews, 45, 105–115. https://doi.org/10.1249/jes.0000000000000103

Katzman, W., Vittinghoff, E., Lin, F., Schafer, A., Long, R., Wong, S., Gladin, A., Fan, B., Allaire, B., Kado, D., & Lane, N. (2017). Targeted spine strengthening exercise and posture training program to reduce hyperkyphosis in older adults: results from the study of hyperkyphosis, exercise, and function (SHEAF) randomized controlled trial. Osteoporosis International, 28, 2831-2841. https://doi.org/10.1007/s00198-017-4109-x

Wesselink, E., Pool, J., Mollema, J., Weber, K., Elliott, J., Coppieters, M., & Pool-Goudzwaard, A. (2022). Is fatty infiltration in paraspinal muscles reversible with exercise in people with low back pain? A systematic review. European Spine Journal, 32, 787-796. https://doi.org/10.1007/s00586-022-07471-w

Warneke, K., Lohmann, L., & Wilke, J. (2024). Effects of Stretching or Strengthening Exercise on Spinal and Lumbopelvic Posture: A Systematic Review with Meta-Analysis. Sports Medicine - Open, 10. https://doi.org/10.1186/s40798-024-00733-5

Wolfe, D., Rosenstein, B., & Fortin, M. (2023). The Effect of Transcutaneous Electrotherapy on Lumbar Range of Motion and Paraspinal Muscle Characteristics in Chronic Low Back Pain Patients: A Systematic Review and Meta-Analysis. Journal of Clinical Medicine, 12. https://doi.org/10.3390/jcm12144680

Arokoski, J., Valta, T., Airaksinen, O., & Kankaanpää, M. (2001). Back and abdominal muscle function during stabilization exercises.. Archives of physical medicine and rehabilitation, 82 8, 1089-98. https://doi.org/10.1053/apmr.2001.23819

Colado, J., Pablos, C., Chulvi-Medrano, I., García-Massó, X., Flandez, J., & Behm, D. (2011). The progression of paraspinal muscle recruitment intensity in localized and global strength training exercises is not based on instability alone.. Archives of physical medicine and rehabilitation, 92 11, 1875-83. https://doi.org/10.1016/j.apmr.2011.05.015

Chen, L., Islam, M., Harvey, L., Whitehead, N., Hossain, M., Rahman, E., Taoheed, F., Urme, N., & Glinsky, J. (2024). Strength training with electrical stimulation has no or little effect on the very weak muscles of patients with spinal cord injury: a randomised trial.. Journal of physiotherapy. https://doi.org/10.1016/j.jphys.2024.11.012