BY: Dr. Gehan Shaalan Physical Therapy Lecturer Aquatic Exercises BY: Dr. Gehan Shaalan Physical Therapy Lecturer

Aquatic Therapy (AT) Definition: An active intervention that utilizes principles of hydrostatics &hydrodynamics to design interventions to target specific impairments &functional limitations

Aquatic exercise Aquatic exercise refers to the use of multi-depth immersion pools or tanks that facilitate the application of various established therapeutic interventions, including stretching, strengthening, joint mobilization, balance and gait training, and endurance training.

Physical Properties of Water Buoyancy Hydrostatic Pressure Viscosity Surface Tension Hydromechanics Thermodynamics

Buoyancy 1. As the body is gradually immersed,water is displaced, creating the force of buoyancy. 2. Buoyancy: (a) reduces the gravitational forces making it feel easier to complete movements and activities in the water. (b)Allows patients to find positions of comfort allowing rehabilitation to occur that is not possible on land.

Buoyancy 3. Archimedes Principle a. When a body is fully or partially submerged in a fluid at rest, it experiences an upward thrust equal to the weight of the fluid displaced. b. Influenced by volume and density influenced by hydrostatic pressure. c. Relative Density (how well objects float) = density/volume. 4. Position/Size of an object influences how well it floats.

Buoyancy 5. Buoyancy can be used to assist, support or resist movement. Depends on patients’ position – standing, supine, sitting, etc. - When immersed to pubic symphysis=60% weight bearing (WB) - To umbilicus = 50% WB - To xiphoid = 40% WB - To shoulders = 20-30% WB

Center of Buoyancy Center of buoyancy, rather than center of gravity, affects the body in water Reference point of an immersed object upon which buoyant (vertical) forces of fluid predictably act In the vertical position, the human center is located at the sternum In the vertical position, posteriorly placed buoyancy devices will cause the patient to lean forward (anterior causes patient to lean back)

Buoyancy Qualifiers: Depth: Salt vs. Chlorinated water Lung capacity: Increased depth = Increased buoyancy Salt vs. Chlorinated water Salt water is more dense than chlorinated water. This increases the buoyancy force in salt water, thus making floating easier and swimming downwards more difficult. Lung capacity: Increased lung capacity – Increased buoyancy.

Clinical benefits Buoyancy Help exercise when weight bearing is contraindication (decrease stress and compression on weight bearing joints, muscles and connective tissues). Can be used as assistive or resistive force Raise weakened body parts against gravity. Combination of Buoyancy and Hydrostatic pressure help in balance exercises

Hydrostatic pressure Definition. Hydrostatic pressure is the pressure exerted on immersed objects. Properties Pascal’s law states that the pressure exerted by fluid on an immersed object is equal on all surfaces of the object. As the density of water and depth of immersion increase, so does hydrostatic pressure.

Clinical benefits Immersion in water can assist in promoting circulation or alleviating peripheral edema due to venous or lymphatic insufficiency. Facilitate cardiovascular function Support provided by hydrostatic pressure may help to brace unstable joints or weak muscles. The greatest effect will occur with vertical positioning. The effect will be less pronounced if the patient is swimming in more horizontal position close to the water surface.

Viscosity Definition. Viscosity is friction occurring between molecules of liquid resulting in resistance to flow. Properties. Resistance from viscosity is proportional to the velocity of movement through liquid. Clinical Significance Water’s viscosity creates resistance with all active movements.

Surface Tension Definition. The surface of a fluid acts as a membrane under tension. Surface tension is measured as force per unit length. Properties The attraction of surface molecules is parallel to the surface. The resistive force of surface tension changes proportionally to the size of the object moving through the fluid surface. Clinical Significance An extremity that moves through the surface performs more work than if kept under water. Using equipment at the surface of the water increases the resistance.

Hydromechanics Definition. Hydromechanics comprise the physical properties and characteristics of fluid in motion. Components of Flow Motion Laminar flow. Movement where all molecules move parallel to each other, typically slow movement. Turbulent flow. Movement where molecules do not move parallel to each other, typically faster movements. Drag. The cumulative effects of turbulence and fluid viscosity acting on an object in motion.

Hydromechanics Clinical Significance of Drag As the speed of movement through water increases, resistance to motion increases. Moving water past the patient requires the patient to work harder to maintain his/her position in pool. Application of equipment (glove/paddle/boot) increases drag and resistance as the patient moves the extremitythrough water

Thermodynamics Water temperature has an effect on the body and, therefore, performance in an aquatic environment. Specific Heat Definition. Specific heat is the amount of heat (calories) required to raise the temperature of 1 gram of substance by 1C. Properties. The rate of temperature change is dependent on the mass and the specific heat of the object. Clinical Significance Water retains heat 1000 times more than air. Differences in temperature between an immersed object and water equilibrate with minimal change in the temperature of the water.

GOALS AND INDICATIONS FOR AQUATIC EXERCISE Facilitate range of motion (ROM) exercise Initiate resistance training Facilitate weight-bearing activities Enhance delivery of manual techniques Provide three-dimensional access to the patient Facilitate cardiovascular exercise Minimize risk of injury or re-injury during rehabilitation Enhance patient relaxation

Contraindications Water and airborne infections or diseases: Examples include influenza, gastrointestinal infections, typhoid, cholera, and poliomyelitis. Uncontrolled seizures: They create a safety issue for both clinician and patient if immediate removal from the pool is necessary.

Contraindications Incipient cardiac failure and unstable angina. Respiratory dysfunction; vital capacity of less than 1 liter. Severe peripheral vascular disease. Danger of bleeding or hemorrhage. Severe kidney disease: Patients are unable to adjust tofluid loss during immersion. Open wounds, colostomy, and skin infections such as tinea pedis. Uncontrolled bowel or bladder

Equipment Foam dumbbells Fins/Flippers Float Cuffs Floatation belt Jug (air filled) Kickboard Neck collar Resistance boots Resistance paddles Weights Swim noodle

Equipment: Foam Dumbbells Purpose: Strengthening Upper extremity Trunk Floatation support

Equipment: Fins/Flippers Purpose: Strengthening Lower extremities Abdomen Low back Propulsion when swimming

Equipment: Float Cuffs Purpose: Strengthening Upper extremity Lower extremity The further away from your body the cuff is placed, the more difficult the exercise

Equipment: Floatation belt Purpose: Floatation support Strengthening Resistance against vertical in pool improves trunk & hip strength to maintain upright position for “running” or “walking” while floating.

Equipment: Jug (air filled) Purpose: Strengthening Upper extremity Trunk

Equipment: Kickboard Purpose Floatation support Balance Attempting to maintain prone

Equipment: Neck collar Purpose Floatation support To prevent strain to cervical spine

Equipment: Resistance boots Purpose Strengthening Lower extremity Abdomen Low back

Equipment: Resistance paddles Purpose Strengthening Upper extremity Trunk

Equipment: Weights Purpose Assistance to maintain vertical positioning Strengthening Will be easier than performing weighted exercise on land Coordination Using medicine ball to dribble like soccer ball

Equipment: Swim noodle Purpose Floatation assistance Strengthening Upper extremity Lower extremity

Exercise Guidelines Start exercising gently and increase persistently within pain tolerance. It is crucial to individualize programs based upon fitness levels, nature of symptoms, level of progress, and symptoms on a given day: give lots of personal attention; provide lots of options. The best time to exercise is when feeling energetic. For many, this is late morning /mid-day. Teach, and constantly reinforce “Power Posture”. Constantly draw attention to functional posture and alignment and always emphasize postural musculature training in and outside of the class.

Exercise Guidelines Frequent rest breaks between intervals of gentle activity are important, especially when starting a program. Many clients will experience a longer recovery period and more post-exercise discomfort than ‘normals’. Be careful not to overdo it. Start by having clients do less than they feel they can do. Keep reminding clients to self-monitor (BORG’s RPE scale) and respect their limitations.

Exercise Guidelines Reinforce the benefits in quality of life that are to be gained by being active. Some people get light headed, dizzy, or lose balance easily. Highly coordinated movements will not be appropriate, nor will moves requiring lots of strength (eg: propulsion or rapid direction changes). Highlight mental focus: teach participants to use deep breathing and relaxation techniques (especially effective while stretching); emphasize the difference in sensation between a stretching versus a strengthening exercise…

Examination for aquatic rehab Full land based exam Consideration of Contraindications: Excessive fear of water. Open wounds, Rashes Active infections Incontinence Tracheostomy Post ops may require a Bioclusive dressing Fevers > 100F

Precautions in Aquatics CV changes Pulmonary impairments Over exercise- reduced gravity environment, support of buoyancy, m relaxation with immersion, HP and water temperature

Treating Impairments with Aquatics Mobility impairments: Progress activities to enhance function and reduce disability ASAP. Considerations: Force of buoyancy Position and available ROM at the jt. Direction of desired movement Need for floatation or weighted equipment

Mobility impairments Con’t Buoyancy will facilitate ROM. Change the lever length and equipment as pt. improves Static stretches can be done using steps, pool sides and bars Observe the exercise on land first. Observe closely once in the water secondary to refraction Ie. Standing at poolside you won’t get a true indication of how your pt is moving. Refraction causes what looks like trunkel shortening. Muscle performance and endurance- use your knowledge of viscosity and hydrodynamic properties to increase the challenge to strength AND ENDURANCE WORK. Use ckc, okc, pnf, motor control ex.

Balance impairment Supportive medium with destabilizing forces make this approach ideal Falls are dramatically slowed, inc. pt.s time for response Single Leg Support activities Single Leg Support with arm mvt. Single toe raises Step ups Example fibromyalgia

Aquatic Rehab to treat Functional Limitations Functional limitations are restrictions in performance affecting the whole person. Good situation for working on posture or position. Chairs can be submerged, buoyancy sitting equipment. As sitting tolerance improves, water depth is decreased. Forward reach

Coordinating Land and Water Land based activity should begin as soon as tolerated It is difficult to produce eccentric m contractions in the pool With pain, aquatics may be most of the program Sometimes alternating the pool with land based interventions works best Remember when CV training endurance can be increased by exercise at sufficient intensity, duration, using large m groups 3-5x/week

Patient education Before entering the pool, explain the fundamental properties of H2O to the pt. Make sure the pt. is aware of the entrances and exits from the pool, drop offs, gutters, and bars. Show the pt. the exercises on land first.