Introduction - What do we hope to achieve as Instructors
It is surprising how many people claim to know all the correct procedures for reaching and/or lifting objects, and yet they don't actually internalize and use those safety procedures. 'Picking up a mug of coffee from the opposite side of a table, for example, can produce more force against the intervertebral discs than lifting a 20-pound weight next to one's body.' (Norris) It is incredible how many everyday movements put stress on the back, and how few people know how to prevent the risk of back injury by using simple movement adjustments, back stabilization, good posture, and exercise.
Healthy Back is exactly what it says.......what can we do in terms of exercise to keep the back healthy. What can a water exercise instructor offer in the water for clients to practice safe, effective healthy back protocols. There are clearly defined exercises that will help the currently healthy individual and the person with simple back pain.
A Key Message for Instructors: By calling this class Healthy Back you will be able to present safe guidelines to a clearly defined population, without liability. Back problems are extensive and can be complex. The water exercise instructor is not qualified to diagnose the problem, nor are they qualified to prescribe treatment. Be careful, because you can have many clients in your classes with back problems. It is not your intention to find the problem, solve the problem, rehab the injury, or even tell them what to do. You will offer a series of exercises based on sound physiological principles. These exercises will be generally applicable because they deal with back stability.....something that everyone needs, even the asymptomatic.
Back Stability
Back pain is universal. The number of sufferers is increasing dramatically. The traditional treatment of bed rest has not helped this situation. New studies have found that bed rest is actually harmful, and the new model for the treatment of back pain is exercise. This approach supports water classes like Healthy Back where fitness professionals can be an adjunct to the 'active' methodology.
Exercise programs are being used to enhance lumbar stabilization, and that is the main goal of the Healthy Back class. The most important concept underlying the program is the promotion of lumbar back stability versus lumbar back instability. Instability of the lumbar spine means greater than normal range of motion. Whereas we might welcome this increased range of motion elsewhere in the body, in the lumbar region, excessive range of motion without protective muscular control will lead to damage. An unstable spine can damage neural tissue, cause inflammation, and stretch or compress pain-sensitive structures.
The essence of a back stability program is the control of two positions of the lumbar spine: neutral zone and neutral position. Neutral zone refers to the movements of each individual vertebra. Each vertebra has the ability to move, but we don't want this movement to be excessive. We need a "stiff" back when it comes to movement in the neutral zone. If a back is not stiff enough, it will buckle and move under very little force. We want the neutral zone to be small so that the spine can withstand any resistance or forces placed upon it without buckling.
Neutral position refers to the overall movement of the lumbar spine. Neutral position is midway between full posterior tilt and full anterior tilt of the pelvis. Instructors can definitely work on neutral position in the water. Back stabilization skills need accuracy, so take plenty of time to help clients find this neutral position. Within this, you will be helping control neutral zone. However, we will not be able to directly effect change in the neutral zone. It requires palpation from a Physical Therapist to truly locate and work with this area. The resistance of the water will help stiffen the back, but there will be a fine line between a back in correct alignment, and one that is misaligned, and then stressed with water resistance.
Structures of the Lumbar Spine
Some level of understanding of the anatomical structures of the lumbar spine will help us comprehend the back stabilization. When you take a closer look at the way the spine is supported it makes sense that we would be better off to be four-legged creatures! Our bipedal, erect stance does put a lot more stress on the back. Instructors should know the following:
any two neighboring vertebra make up a spinal segment
a spinal segment has 3 joints: the disc, and the two facet joints
The ligaments that run through the neural arch act as a single unit and factor strongly in back stabilization. The fact that one of these ligaments merges into the thoracolumbar fascia, means that there is an immediate connection to the deep abdominal muscles. It is important to realize how much the deep abdominal muscles influence spinal stabilization by transmitting forces into the ligaments around the spinal column.
There are 24 intervertebral discs. They provide both rigidity and elasticity in the spinal column. The discs get bigger as they descend the column. The nucleus of each disc is water-attracting, and depends on its water content for life and mechanical viability. Regular movement is vital to the life of the discs. We need to feed the discs with movement.
Vertical loading of the lumbar spine (axial compression) occurs during upright (standing or sitting) postures, exacerbating certain forms of back pain. It is important to be aware of the constant compression forces that are occurring within the vertebra itself, in the intervertebral discs, and in the facet joints. The structures of the spine are designed to tolerate compression forces up to a point. However, it is often the case that we overdo this compression, and some part of the spine gets damaged. For us, the message is simple....get in the water, and remove the force of gravity from the spine. This will allow the discs and joints to return to a healthy placement.
Stabilization Mechanisms in the Lumbar Spine
Posterior Ligamentous System - the interspinous and supraspinous ligaments, facet joint capsules, and thoracolumbar fascia together provide passive support for the spine. The ligaments have some unique properties, in that their fibers line up and become stiffer as they are stretched. They stiffen when loaded, and thus provide a constant compressive force along the axis of the spine. When the spine is flexed, this system creates tension by stretching, and in conjunction with the action of the erector spinae, provide a substantial stabilizing mechanism. It's like a giant elastic band.
Thoracolumbar Fascia - the thoracolumbar fascia (TLF) has three layers that cover the muscles of the back. The TLF is woven amongst all the major muscles: quadratus lumborum, transverse abdominis, erector spinae, Plus it attaches to the transverse process of the vertebra and the intertransverse ligaments. The TLF provides passive resistance to flexion.
Trunk Muscles - co-contraction of the muscles surrounding the lumbar spine can enhance spinal stability. These muscles include the erector spinae, transverse abdominis, mutifidus, and oblique abdominals. Instructors need to know primary features of these mucles: erector spinae, multifidus, interspinales, intertransversarii, iliopsoas, rectus abdominis, external oblique, transverse abdominis, internal oblique.
Intra-Abdominal Pressure - intra-abdominal pressure is created by synchronous contraction of the abdominal muscles, the diaphragm, and the muscles of the pelvic floor. This "inflated balloon" effect is considered to add additional extensor torque to the spine, especially in heavy lifting.
Helping with Basic Skills for Establishing Stability
Based on this information, the water exercise instructor should provide exercises to keep practicing this muscle education.
Control of pelvic tilt - the ability to dissociate movement of the lumbar spine from movement of the pelvis is essential for the healthy functioning of the back. Teach pelvic tilts, both in frontal and sagittal planes. Teach clients to hold their pelvis in good alignment.
Neutral Position - needs constant reminders, and re-establishment for every exercise.
Abdominal Hollowing - hollowing is a technique used to isolate the deep abdominals from the superficial abdominals. The action of hollowing uses the internal obliques and the transverse abdominis. In theory it is simple: pull the belly in at the navel without moving the rib cage, or the spine.
Contracting the Multifidus - the multifidus is the key stabilizer muscle in the spine extensor group. However, you will not be able to help clients contract it, because this requires isolation, palpation, and touch from a PT.
Muscle Imbalance
Muscle imbalance occurs when a particular agonist is significantly stronger than its antagonist. We also see imbalance when muscles are over-stretched or abnormally shortened. Compensatory movements in the body to accommodate these imbalances usually lead to further problems and eventually serious disability.
The water becomes an ideal place to work on muscle balance, because the three-dimensional property of water enables us to work agonist and antagonist muscle pairs at the same time. We can also use water resistance to strengthen areas that are over-stretched (like the middle back) and stretch muscles that can be notoriously tight (like the hamstrings).
From the recognized list of stretching techniques, static and active stretching will be the ones that we can facilitate in water. Static stretching is known to produce the best results on land, but unless your water is warm, static stretches in the pool will not work. The majority of our stretching will have to be active. For example, in the cross-country ski, as the leg swings back, with the gluteals and hamstrings acting as agonists, the hip flexors can be actively stretched.
Abdominal Muscle Training
Abdominal strengthening is considered a primary component of a back stability program. In the water we can strengthen the abdominals, and also provide many exercises for dynamic core stabilization. In the water, with the use of floatation equipment, we can create a supine working position with the hip flexors more relaxed than on land. The disadvantage of the water is getting cold when you are working isolated muscle groups, so include lots of full body activities, and standing abdominal exercises where the larger muscle groups remain more active.
Posture
We can be of most help to our clients by simply knowing the placement for standard postural alignment. Positioning is judged in relation to the line of gravity. If you position the body sideways next to plumb line, the line will fall just in front of the lateral malleolus at the ankle, through the midline of the knee, through the greater trochanter, lumbar vertebrae, shoulder joint, and lobe of the ear. It would not be unreasonable to hang a plumb line on the pool deck, and check clients for good postural positioning.
You can explain to clients how misalignment will cause all kinds of problems over time, in the body. Many people simply need you to help with awareness. You become their "eyes" and tell them how to adjust positioning to be in good posture. In the water continuously remind them about posture. In a Healthy Back class you will sound like a tape recorder.....repeating the same cues over and over! Posture will feature in all the other back stability exercises you do: neutral position, pelvic control, muscle balance, strengthening and stretching. Posture completes the holistic circle of looking at the whole person.
