46 difﬁcult to reach a ﬁrm conclusion regarding the efﬁcacy of this exercise intervention for such patients. These two studies, however, do suggest that Pilates has beneﬁcial effects in terms of decreasing pain and disability in patients with nonspeciﬁc CLBP. Similar to yoga, the exact mech- anism by which Pilates exerts these beneﬁts has not been elucidated. The Pilates method does, however, utilize principles of various accepted rehabilitation methods that have scientiﬁc support for LBP including core strength- ening [10, 11]. Core weakness has been increasingly recognized as a biomechanical deﬁcit in patients with LBP; however, muscle dysfunction here may not simply be a problem of muscle strength. Instead, the problem appears to involve poor neuromuscular control, or recruitment patterns of core musculature, which negatively affects spinal stability. Therefore, speciﬁcally designed therapeu- tic exercise approaches that modulate neuromuscular control and enhance spinal stability have been investigated for patients with LBP. For example, O’Sullivan et al. evaluated the efﬁcacy of a rehabilitation technique that enhances lumbar spine stabilization via muscle activation directed at the intervertebral segment in patients with CLBP who also had signs of radiological instability [10]. Signiﬁcant reductions in pain and functional disability were shown in these patients; these effects were maintained at 30-month follow-up. It follows the Pilates method would be beneﬁcial for patients with LBP because it improves absolute core strength and moreover encourages proper activation patterns of core musculature. For example, the foundation of the mat program is a group of exercises that train core stabilization; when proper recruitment patterns are demonstrated, more challenging exercises are pro- gressively added to improve core strength. In addition, the modiﬁed Pilates approach developed by Rydeard et al. with its emphasis on speciﬁc muscle activation strategies to stabilize the lumbar–pelvic region is supported within this theoretical context of neuromuscular control and spinal stability. The effects of this approach on decreasing pain and improving function in patients with CLBP who also have dysfunction in control of muscles stabilizing the lumbar–pelvic region are in agreement with the O’Sullivan ﬁndings. Finally, in addition to the role core strengthening plays in beneﬁting patients with CLBP, one must also consider the impact of the mental component of Pilates. Like yoga, the Pilates’ principles of breathing and con- centration are no doubt intricately tied to the mechanism behind its effectiveness for the CLBP population. Conclusion In conclusion, the studies outlined in this chapter are an important start in the evaluation of how yoga and Pilates Curr Rev Musculoskelet Med (2008) 1:39–47 may be helpful in managing patients with LBP. It is important to note, however, that all of the above trials focus on nonspeciﬁc LBP. Future studies should therefore examine the efﬁcacy of postures and exercises geared speciﬁcally for different LBP diagnoses as there may be varying clinical effect. For example, an individual with ﬂexion mediated low back and leg pain secondary to lumbar radiculopathy from a herniated disc may beneﬁt more from movements that emphasize extension versus those that involve ﬂexion and/or twisting. In addition, trials should incorporate larger sample sizes to obtain more power for statistical signiﬁcance. Different clinical arms should be employed comparing for example, yoga or Pi- lates to physical therapy. Control groups should include group and individualized formats to detect any beneﬁt that may be derived from group support including socialization context. Longer follow-up should be assessed for outcome measures to determine the long-term effects of these exercise interventions. Finally, studies should attempt to elucidate the mechanisms that underlie the beneﬁts of these exercise interventions for patients with LBP. Given the interest of the general population in yoga and Pilates and the emergence of information supporting their use for CLBP, it appears these mind–body exercise thera- pies may be helpful tools in managing patients with LBP. Health care providers who treat LBP and consider recom- mending yoga and/or Pilates to these patients should therefore have a basic understanding of these exercise regimens. For yoga, one should be familiar with the core postures of a typical yoga class. One should also under- stand that different styles of yoga exist and some, i.e. Iyengar yoga and Viniyoga, may be better suited for the LBP patient. For Pilates, one should be aware of the basic exercises in a mat class as well as the potential for pro- gression to more challenging exercises on specialized apparatus. Finally, because instructors are not required to obtain a speciﬁc license in order to teach yoga or Pilates, one should direct the patient to seek out instructors who have at least several years of teaching experience including working with LBP patients. With this information, the health care provider will be well equipped when recom- mending yoga or Pilates as a management tool for this often challenging group of patients. References 1. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of nonspeciﬁc low back pain. Cochrane Database Syst Rev. 2000; CD000335. 2. Saper RB, Eiseberg DM, Davis RB, Culpepper L, Phillips RS. Prevalence and patterns of adult yoga use in the United States: results of a national survey. Altern Ther Health Med 2004;10:44– 9.