(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Chapter 16: Aquatic Therapy in Rehabilitation Jenna Doherty-Restrepo, MS, ATC, LAT Entry-Level ATEP Rehabilitation Techniques in Athletic Training

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Aquatic Therapy Rapidly becoming popular Rapidly becoming popular –Not a new form of therapy  revisited Effects: Effects: –Decreases joint compression –Reduces muscle guarding –Improves movement and fitness

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Physical Properties Buoyancy Buoyancy –Counteracts downward pull of gravity Upward force that supports submerged or partially submerged object Upward force that supports submerged or partially submerged object Assists motion toward water’s surface Assists motion toward water’s surface –Sense of weight loss Changes relative to level of submersion Changes relative to level of submersion Differs in males and females due to relative CoG Differs in males and females due to relative CoG –Allows for ambulation and vigorous exercise Reduces joint impact Reduces joint impact Reduces friction between articular surfaces Reduces friction between articular surfaces

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Specific Gravity Specific Gravity –Buoyancy is partially dependent on body weight Weight of different body parts will vary Weight of different body parts will vary –Determined by: Ratio of bone weight to muscle weight Ratio of bone weight to muscle weight Amount and distribution of fat Amount and distribution of fat Depth and expansion of chest Depth and expansion of chest –Specific gravity of humans is slightly less than water Enables the body to float Enables the body to float Does not mean that body will float horizontally Does not mean that body will float horizontally Different segments have different specific gravities Different segments have different specific gravities Air in lungs vs. extremities Air in lungs vs. extremities Physical Properties cont.

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Cohesive force Cohesive force –Runs parallel to the direction of the water surface –Due to surface tension of water molecules Bow force Bow force –Force generated at the front of an object during movement Increased water pressure at the front Increased water pressure at the front Decreased water pressure in the rear Decreased water pressure in the rear –Creates a pressure gradient Low pressure zones swirl = eddies (turbulence) Low pressure zones swirl = eddies (turbulence) Creates a drag force Creates a drag force Resistive Forces

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Drag force Drag force –Modified by shape and speed of object Increase streamline of object = decrease drag Increase streamline of object = decrease drag Increase speed of object = increase drag Increase speed of object = increase drag –Must be considered carefully when attempting to protect a limb during rehabilitation Drag forces = increased torque at a given joint Drag forces = increased torque at a given joint Resistive Forces cont.

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Archimedes's Principle A gradual increase in weight bearing can be achieved with aquatic therapy A gradual increase in weight bearing can be achieved with aquatic therapy Progression: deep to shallow Progression: deep to shallow –Take advantage of buoyancy property Closed kinetic chain exercises Closed kinetic chain exercises –Proprioceptive benefits –Reduces joint compression/friction forces

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Aquatic Rehabilitation: Advantages AROM exercises supported through buoyancy AROM exercises supported through buoyancy –Minimizes discomfort –Sense of security Useful in early stages of rehabilitation Useful in early stages of rehabilitation –Supportive environment Proprioception enhancement Proprioception enhancement –Turbulence provides perturbations and tactile sensory stimulus Extremely useful with lower-extremity injuries Extremely useful with lower-extremity injuries –Provides gradual transition from non to full weight-bearing –May allow earlier locomotion due to decreased compressive forces

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Psychological impact Psychological impact –Increased confidence due to increased function allowed by water Strengthening and muscle re-education Strengthening and muscle re-education –Dependent on effort put forth by athlete Energy expenditure Energy expenditure –Aerobic workout possible to maintain CV fitness Aquatic Rehabilitation: Advantages

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Aquatic Rehabilitation: Disadvantages Building and maintaining a rehabilitation pool Building and maintaining a rehabilitation pool –Space and personnel Aquatic training may be too challenging if athlete unable to stabilize body Aquatic training may be too challenging if athlete unable to stabilize body Thermoregulation Thermoregulation –May impact tolerance for participation in heat Contraindications: Contraindications: –Open wounds, fear of water, fever, urinary tract infection, allergies to pool chemicals, cardiac dysfunction or uncontrolled seizures

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Facilities and Equipment Facility must have certain characteristics Facility must have certain characteristics –Should be at least 10 x 12 –Adequate access –Shallow and deep areas –Flat pool floor with marked gradients –Adequate temperature (79-82 degrees) Ancillaries Ancillaries –Prefabricated pools with treadmill or current producing device –Pool toys – limited by imagination

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Aquatic Techniques Must consider Must consider –Type of injury/surgery –Treatment protocols if appropriate –Results/muscle imbalances found in evaluation –Goals/expected return to activity Program design Program design –Warm-up –Strengthening/mobility activities –Endurance/cardiovascular –Cool down/stretch

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Upper Extremity Injuries Initial Level Initial Level –Start at chest depth –Warm-up: Walking with natural arm swing in an effort to restore normal scapulothoracic motions –Goal: Shoulder movement without compensation –Supine positioning Stretching, mobilization and range of motion Stretching, mobilization and range of motion –Prone positioning (w/ snorkel) Pendulum and PNF diagonal plane activity Pendulum and PNF diagonal plane activity

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Intermediate Level Intermediate Level –Goal: Develop strength and eccentric control throughout ROM –Strengthening progression Use equipment to resist motion, increase surface area, or increase lever arm Use equipment to resist motion, increase surface area, or increase lever arm –Maintain good postural mechanics Work on scapular mechanics in prone and supine positions Work on scapular mechanics in prone and supine positions –Land-based program and aquatic program should be coordinated to assure continued improvement of strength, endurance, and function Upper Extremity Injuries

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Final Level Final Level –Goal: Functional strengthening and training –Transition from aquatic to land-based treatment –Increase the use of equipment to maintain motivation levels of athlete Upper Extremity Injuries

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Spine Dysfunction Initial Level Initial Level –Goal: Proper biomechanics (gait pattern), ROM, proprioception, pain modulation –Wall squats used to find pelvic neutral position Wall provides sensory feedback to maintain position Wall provides sensory feedback to maintain position –Progression Upper/lower extremity activity can be incorporated with stabilization exercises Upper/lower extremity activity can be incorporated with stabilization exercises Increase ability to bear weight by progressing from deep end to shallow end Increase ability to bear weight by progressing from deep end to shallow end –Traction provided by deep water –Increase pelvic mobility through stretching

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Spine Dysfunction Intermediate Level Intermediate Level –Goal: Core strengthening –Move away from wall –Incorporate pulling/pushing motions –Incorporate single leg stance and lunges to challenge dynamic stabilization of core –Supine and prone activity can also be utilized to train core

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Final Level Final Level –Goal: Functional strengthening and training –Incorporate sport-specific activities to challenge core stabilization –Train bilateral activity Integrate opposite movement patterns Integrate opposite movement patterns –Incorporate land-based training Water does not allow for normal speeds and forces during sports-specific activities Water does not allow for normal speeds and forces during sports-specific activities Spine Dysfunction

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Lower Extremity Injuries Initial Level Initial Level –Goal: Proper biomechanics, ROM, proprioception, and strengthening –Work to restore normal gait patterns –Initiate AROM exercises (hip, knee, ankle) Progression: utilize cuffs, noodles, or kickboards under foot Progression: utilize cuffs, noodles, or kickboards under foot –Balance activities Enforce proper postural mechanics while challenging balance/neuromuscular control Enforce proper postural mechanics while challenging balance/neuromuscular control

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved –NWB conditioning and cross-training in deep water Running Running Bicycling Bicycling Cross country skiing Cross country skiing Incorporation of sports specific skills Incorporation of sports specific skills –Incorporation of supine activities Work on active hip and knee motion within pain-free range Work on active hip and knee motion within pain-free range Lower Extremity Injuries

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Intermediate Level Intermediate Level –Goal: Develop strength and eccentric control throughout ROM –Use weights and flotation devices to increase difficulty Proximal resistance may be necessary due to the injury Proximal resistance may be necessary due to the injury –Utilize straight and diagonal plane activities –Balance training Stand on cuff, noodle, uneven surfaces Stand on cuff, noodle, uneven surfaces Lower Extremity Injuries

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved –Integrate eccentric activity Double and single leg reverse squats Double and single leg reverse squats –Deep water running/sprinting –Continue to integrate supine and prone exercises as athlete’s strength and ability increase –Jumping progression –Integration of sports-specific activity Lower Extremity Injuries

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Final Level Final Level –Goal: Functional strengthening and conditioning –Program should compliment land-based program –Decrease use of floatation devices –Aquatic endurance training May be useful in preventing recurrence of injury May be useful in preventing recurrence of injury Lower Extremity Injuries

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Conclusions Should be utilized in conjunction with land-based rehabilitation exercises Should be utilized in conjunction with land-based rehabilitation exercises Many physical and psychological benefits during early stages of rehabilitation Many physical and psychological benefits during early stages of rehabilitation Sport-specific training Sport-specific training –Utilize land and water based training to achieve goals –Must be sure to engage in activity at “normal” speeds and force levels prior to return to play