Documented research in Pilates and yoga is almost exclusively land-based. The challenge is applying the research and the implications for therapy and rehabilitation of low back issues to a water environment.

According to Andrew Cole, MD, a physiatrist at Northwest Spine and Sports Physicians in Bellevue, Wash., the elimination of gravitational forces directly related to the properties of water allows patients to train with decreased, yet variable, axial loads and shear forces.

The benefits of aquatic stabilization programs include the minimization of segmental trunk motion and shear forces; the reinforcement of lumbar control; and encouragement of hip, knee, and ankle propulsion. These programs have also been shown to develop of head and neck stability and establish arm control and strength.

Based on the premise that Pilates and yoga have been proven effective interventions for low back pain, moving selected exercises into the warm water pool provides additional advantages of land application. Water is an enabler for those unable to participate in Pilates or yoga instruction on land.

Pilates as Therapeutic Stability for Low Back Pain

From a clinical perspective, the multiple muscle synergies in Pilates include isometric, concentric, and eccentric muscle contractions and co-contractions. According to Smith & Smith, “Pilates emphasizes lumbo-pelvic stability, segmental mobilization of the spine, mobilization of the shoulder, hip, and other extremity joints, joint stability, precision, muscle stamina, coordination, and balance.” Water immersion requires continuous muscle activation with static positioning. Resultant benefits include reinforcement of lumbar control, postural awareness, increased core strength, and lower extremity strength.

The conceptual framework for spinal stabilization is delineated into specific interdependent subsystems of passive, active, and neural. We relate Pilates-based training to the coordination of the active and neural systems, minimizing stress on the passive subsystem. Dysfunction in one of the subsystems finds stabilization of the spine is affected secondary to adaptations in one or both of the other subsystems.

According to Panjabi, the spine’s neutral zone exists when an area of normal intervertebral motion occurs and there is minimal stress to the passive subsystem and the spine is in equilibrium. He hypothesized that clinical instability occurs when there is an increase in the neutral zone and an inability to maintain normal intervertebral motion with spinal dysfunction.

Comparing protocol of land and water requires adherence to the concept of bio-motor integration, indicating that all movement performed unsupported while on the feet requires an integrated combination of:

• Balance with proper alignment       
• Coordination with postural alignment
• Flexibility resultant of balance and coordination   
• Endurance to include full range of motion on a stable pelvis
• Power/Speed with full range of motion in all extremities while maintaining proximal pelvic stability       
• Strength for functional specific movements

Progression through the basic elements results in agility, leading to conditioning that permits functional movement of the body while maintaining pelvic alignment. Considering the importance of proper alignment, we know that the prime movers supporting the joint cannot function properly if brain senses joint instability and losing balance means loss of functional strength while regaining balance. Research demonstrates that neuromuscular control of the torso can impact balance, joint stability, and proprioception training via muscle co-contractions.

Spinal stabilization from a muscular perspective is defined as either local or global systems according to anatomical location and function. According to his definition, muscles of the local system include the transversus abdominus, lumbar multifidus, interspinal, intertransverse, internal oblique via thoracolumbar fascia attachments, and lumbar portions of the iliocostalis and longissimus muscles, which contribute to intervertebral stiffness and regulation of intervertebral motion for spinal stabilization.

The global muscles are spinal mobilizers and trunk stabilizers that consist of the lateral portion of the quadratus lumborum, thoracic portions of the iliocostalis and longissimus, rectus abdominus, and external and internal oblique muscles. They assist with force transference between the ribs and the pelvis. 

Richardson and Hodges developed a conceptual model for teaching lumbo-pelvic stabilization with focus on the musculofascial complex spanning from ribs to pelvis and categorized as an inner or outer unit. Muscles of the inner unit include the TrA, pelvic floor, diaphragm, and multifidus and provide lumbar segmental stabilization through their synergistic action as evidenced in the literature. Outer unit muscles contribute to general trunk stabilization and should be trained after the inner unit.

Another conceptual model for pelvic girdle stabilization introduced by Snijders and Vleeming identified a pelvic girdle stabilization model of the sacroiliac joint that included components of the osteo-ligamentous and muscle systems to provide stability through form and force closure mechanisms.

The goal of Pilates in the water is to begin with a supported core-strengthening program of corrective exercises similar to mat Pilates on land.  Muscle re-education uses abdominal bracing in a seated position against the wall of the pool. Cole refers to this as the “wall sit.”

The six points of the back against pool wall protects back, enables point of reference for maintaining neutral pelvis, and provides tactile input. The lumbopelvic region is in neutral with scapulae retracted and depressed. The rib cage is drawn downward and inward, and the sternum stays lifted, allowing the low back pain patient to maintain the position longer.  The efficient organization of the spine allows for corrective exercises with stabilization and articulation for controlled, precise, and geometric segmental movement.

The basic wall sit develops isometric strength primarily in quads and hamstring group and trains abdominal muscles to hold an appropriate neutral spine posture. Upon mastering the wall sit, initial Pilates exercises along with upper- and lower-extremity movements can begin. The lead-in to the “Hundred” with symmetrical arm pumps is oppositional arm pumps.

Additional moves for the arms include “Ai Chi” floating, uplifting, and enclosing; clapping in front; windshield wipers; and alternate straight arm pumps. Beginning moves for legs include alternate toe taps, heel slides, and knee extension. Once these exercises are correctly mastered in the wall sit position, progressive resistance is added before moving away from the support of the wall.

Single-leg circles and single-leg stretches train abdominal muscles to hold appropriate neutral spine, and challenge contra lateral gluteals, ipsilateral hip flexor, and Para spinal muscles. To co-activate the deeper Para spinal, obliques, and TrA muscles, use abdominal bracing or hollowing. The ribcage is slightly elevated without restriction on natural, relaxed breathing. Depression of rib cage or protrusion of abdominal wall usually indicates incorrect activation technique and the rectus abdominus rather than the deeper abdominal muscles are predominating in the co-contraction pattern.

Yoga as Therapeutic for Low Back Pain

When practiced correctly, yoga appears to be effective in treating a wide variety of health conditions. Iyengar yoga is most commonly found in therapy as it strives for precise anatomical alignment and uses various props to assist positioning. The attention to precise anatomical positioning makes it well-suited to back pain, where dysfunctional alignment may be either contributing to or causing the problem. A growing yoga division is yoga therapy.

Yoga therapy can be used as a complement to traditional therapy and medicine. It is a holistic approach working the body, mind, and spirit and is distinct from traditional yoga classes commonly available. The addition of these elements and increased body awareness distinguish yoga from general stretching and callisthenic activity. 

Yoga links back pain to posture, muscle tightness, muscle weakness, and a lack of body awareness. The yogic approach is to determine which muscles need strengthening and which ones need stretching. Independent of the effect on individual muscles, asanas (poses) help back pain by improving the circulation that brings nutrients to the intervertebral disks while removing toxins.

The disks that cushion vertebrae and act as gelatinous shock absorbers do not have their own independent blood supply and depend on movement of the surrounding structures to aid in the delivery of nutrients. Movement causes the disks to be compressed, which squeezes out stale disk fluid, and then to expand, bringing a fresh supply.

A review of literature on research addressing yoga and low back pain is land-based, but applicable to the water in many ways. A 1983 to 1984 study at the London-based Yoga Biomedical Trust, run by Robin Monro, PhD, surveyed 2700 people between 31 and 60 who used yoga therapeutically. They were required to have practiced yoga for at least two hours a week for a year or longer. Of the 1142 participants reporting, 98 percent of back-pain sufferers found yoga helpful.

The Yoga Journal (May/June 2003) introduced a program called “Back Builders” by Vijay Vad, MD, a specialist in sports medicine at the Hospital for Special Surgery in New York combining yoga, breath work, and Pilates. He theorized that lower back pain is really a mind-body problem, closely related to stress. All participants took the medications Celebrex and Vicodin. After six months, Vad found that 80 percent of those in program experienced markedly decreased pain, compared with 44 percent on medication only. Only 12 percent of the yoga practitioners experienced another acute episode of their injury, compared with 56 percent of those on medications alone.

Another significant result showed pain medication use of those doing yoga declined by 40 percent. The basic idea behind Back Builders is to build core strength and flexibility and lengthen the spine to create space between the vertebrae, thus minimizing pressure on the disks and allowing them to heal.

The program eliminates potentially harmful poses such as sitting postures and forward bends, which can compress the vertebrae of the lower spine and emphasizes asanas that build support for the spine by strengthening the abdominal and back muscles. Hip-opening poses encourage spinal length as do postures that stretch the hamstrings and claves. This has direct application to practice in the water because the properties of water assist the specifics he addressed.

In the Annals of Internal Medicine (Dec. 2005) Loren Fishman, MD, specialist in back pain with a rehabilitation clinic in New York City and author of Relief Is in the Stretch: End Back Pain Through Yoga, published a randomized, controlled clinical trial with low back pain that showed not only did yoga work, but it worked so well that it surpassed even traditional physical therapy exercises.

Researcher Karen Sherman at the Group Health Cooperative in Seattle studied 101 adults suffering from chronic low back pain and randomly assigned them into three groups. One group attended weekly yoga classes for 12 weeks, following a therapeutic yoga routine developed specifically for lower back pain. Participants were expected to also practice at home every day.

A second group attended a once-a-week program of stretching and strengthening exercises developed by a physical therapist with expected daily home practice. The third group received a self-care book that included some stretches and relaxation exercises. The yoga participants had less pain and were better able to go about their daily activities than people in either of the comparison groups. Follow-up at three months showed the yoga practitioners continued to have less pain and better function and needed fewer pain medications.

Reported in the International Journal of Yoga Therapy (2003), Kimberly Williams at the West Virginia University School of Medicine compared effects of an adapted regimen of Iyengar yoga on patients with chronic low back pain to a group that received a weekly informational newsletter. Forty-two of 66 subjects completed the study. The yoga group attended 16 weekly classes.

Compared to control subjects, the yoga group experienced a 64-percent reduction in pain, a 77-percent reduction in “functional disability,” and a 25-percent improvement in perceived control over pain. They also gained significantly in hip flexibility. Participants taking pain medication at the beginning of the study found 88 percent of the yoga group either reduced their dose or eliminated medication entirely as compared to 35 percent in the control group.

Elise Browning Miller has done extensive work with yoga and scoliosis. Scoliosis is classified as either structural or functional. Structural is more serious than functional and develops as a result of unequal growth of the two sides of the vertebral bodies and usually appears during adolescence.

Functional scoliosis is more common and affects the muscular back. It does not alter the body structurally and can result from poor posture or repeated unbalanced activity such as carrying heavy objects always on one side. In Yoga for Scoliosis, the goal is to stretch muscles that have tightened and strengthen muscles that have become weak from asymmetrical imbalance.

Examining yoga poses that are most often included in therapeutic land yoga that transfer to the pool, we find some direct correlations. They can facilitate harmony between the muscular and nervous systems of the body possibly resulting in more fluid movement and relief from muscle tension.

General benefits of aquatic yoga include increased flexibility and balance, increased range of motion in the joints, and improved muscle tone by isometrically working most of the body’s muscle groups. The range of motion in these poses is adjusted to the ability of the patient on each particular day. Holding the pose not only challenges balance, but requires moderate strength through correct body alignment and awareness, and cognitive attention to the posture’s position to enhance key areas relating to Activities of Daily Living.

The buoyancy of the water enables many to continue an exercise program in a supportive, positive environment resulting in improved coordination and balance, increased flexibility and strength, and an overall feeling of well-being.

Poses moved to the water can begin at the wall for support and moved to chest depth water when lumbar stability is proven. Some can be incorporated into Pilates exercises such as straight leg stretch (“Supta Padangusthasana”), cross over stretch (“Jathara Parivartanasana”) and “Eye of Needle” (caution - hip replacements). Examples of progressive postures include chair and tree – two-legged balance to one-legged balance and multiple movement planes including tree, chair, and spinal rotation emphasizing axial elongation.

References:

• Akuthota, V., Nadler, S.F. 2004. “Core Strengthening”. Arch Phys Med Rehabilitation.
• Biondi, Marty, PT and Joseph T. Alleva, MD. Researched presentations
• Book of Body Maintenance and Repair. Ronald Stone Press. 1999.
• Cole, Andrew J., MD & Bruce E. Becker, MD. Comprehensive Aquatic Therapy. 2004.
• Kavcic, N., Grenier, S. McGill, S.M. 2004. “Determining the Stabilizing role of Individual Torso Muscles During Rehabilitation Exercises”. Spine.
• Lumbar Stabilization for Spinal Fusions References – research documents from Walter Reed ARMC.
• McCall, Timothy, M.D. Yoga As Medicine.
• McGill, S. Ultimate Back Fitness and Performance.
• Miller, Elise Browning. Yoga For Scoliosis.
• Moffat, Marilyn and Steve Vickery. The American Physical Therapy Association
• Panjabi, M.M. “The Stabilizing System of the Spine.” Journal of Spinal Disorders.
• Richardson, D., Jull, G., Hodges, P., Hides, J. 1999. Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain: Scientific Basis and Clinical Approach.
• Smith, Elizabeth, PT and Kristin Smith. Pilates Rehab.
• Snijders, C.J., Vleeming, A. Stoeckart, R. 1993. “Transfer of Lumbosacral Load to Iliac Bones and Legs.” Clinical Biomechanics
• Stiles, Mukunda. Structural Yoga Therapy. Adapting to the Individual. 2000.
• Walter Reed Army Regional Medical Center. Orthopedic and Physical Therapy Progressions.
• Wykle, Mary, PhD. Aqua Pi-Yo-Chi (DVD). 2007.
• Wykle, Mary, PhD. Transitioning Yoga and Pilates Between Land and Water. 2nd ed. 2006.

— Mary Wykle, PhD, ATRIC, is an adjunct professor of physical education at  Northern Virginia Community College in Annandale and founder of MW Aquatics, which offers consulting workshops in health and aquatics. Questions and comments can be directed to editorial@therapytimes.com.