Aquatic Therapy in Rehabilitation Chapter 15

Aquatic Therapy Useful tool to facilitate training & fitness Movement skill & strength can be enhanced Effects  joint compression Reduces muscular guarding Useful in improving movement and fitness Basic Concepts as Land-based Rehab Warm-up Strengthening/mobility activities Endurance/cardiovascular Cool down/stretch

Goals Specific Goals: Facilitate ROM Initiate resistance training Facilitate weight-bearing activities Enhance delivery of manual techniques Provide 3-dimensional access to patient Facilitate cardiovascular fitness Initiate functional activity Minimize risk of injury/re-injury during rehab Enhance patient relaxation

Precautions & Contraindications Precautions Fear of water Neurologic disorders Seizures Cardiac dysfunction Small open wounds & intravenous lines Contraindications Onset of cardiac failure & unstable angina Respiratory dysfunction Severe peripheral vascular disease Danger of bleeding or hemorrhage Severe kidney disease Open wounds, skin infections Uncontrollable bowel/bladder Water & airborne infections or diseases Uncontrolled seizures

Advantages & Benefits Buoyancy allows active exercise while providing a sense of security and minimizing discomfort Water provides environment in which more can be accomplished than on land Useful in early stages of rehabilitation Provides for earlier movement due to  compressive forces Supportive environment – allows for extra time to control movement – proprioception enhancement Turbulence functions as a destabilizer & as a tactile sensory stimulus Provides gradual transition from non-WB to full WB

Psychologically – may allow for increased confidence due to increased ability of function allowed by water Strengthening & muscle re-education Strength gains are dependent on effort put forth by athlete Energy expenditure may be  Must perform activity & maintain stability of body within the water Cardiovascular maintenance

Disadvantages Cost Building & maintaining a rehabilitation pool Space & personnel Thermoregulation Impact on core body temperature May impact tolerance for participation in heat Contraindications involved with injuries & potential of open wound Additional contraindications Fear of water, fever, urinary tract infection, allergies to pool chemicals, cardiac dysfunction or uncontrolled seizures If lacking in ability to stabilize body, aquatic training can be challenging

Facilities & Equipment Facility must have certain characteristics Should be at least 10 ft. x12 ft. Adequate access (either above or below ground pool) Shallow & deep areas to perform various exercises Flat pool bottom with marked gradients - optional Adequate temperature (79°-82°) Ancillaries Prefabricated pools with treadmill or current producing device Pool toys – limited by imagination (gloves, hand paddles, belts, kickboards) Clothing & attire

Equipment Safety equipment – Exercise equipment – Assistive Devices – flotation devices Resistive devices – paddles, water shoes, webbed gloves

Water Properties Specific Gravity Buoyancy Hydrostatic Pressure Viscosity

Specific Gravity Also known as “Relative Density: The density of an objective relative to that of water The density of a substance divided by density of H 2 O. Specific gravity of water = 1 If object’s s.g. is > 1, object will sink If object’s s.g. is < 1, object will float If object’s s.g. is = 1, object will float just below water surface S.G. of fat = 0.8 S.G. of bone = S.G. of lean muscle = 1.0 Human Body = (Less than 1 - enables the body to float)

Buoyancy is partially dependent on body weight Different body parts will vary On average, human S.G. is less than water Doesn’t mean body will float due to body part make-up Factors that determine the specific gravity of the individual body part: ratio of bone weight to muscle weight the amount & distribution of fat depth & expansion of chest Air in lungs vs. extremities Lungs filled with air can  the specific gravity of the chest (allows head & chest to float higher in the water)

Buoyancy Upward force that works opposite to gravity Counterforce that supports submerged or partially submerged object against pull of gravity Assists motion toward water’s surface Sense of weight loss (equal to amount of water that is dissipated) Changes relative to level of submersion Differing levels in males & females due to relative CoG Allows for ambulation & vigorous exercise with little impact & friction reduction between articular surfaces Archimedes principle – an immersed body experiences upward thrust equal to the volume of liquid displaced

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)

Hydrostatic Pressure Pressure exerted on immersed objects Pascal’s Law – pressure exerted by fluid on an immersed object is equal on all surfaces of the object As density of water & depth of immersion  so does hydrostatic pressure

Friction occurring between molecules of liquid resulting in resistance to flow A fluid’s “thickness” Resistance is proportional to the velocity of movement through liquid Increasing the surface area moving through water will  resistance Viscosity

Hydromechanics Physical properties & 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 (also known as “Wave Drag”) – movement where molecules do not move parallel to each other (typically faster movements) Drag – cumulative effects of turbulence & fluid viscosity acting on an object in motion As speed of movement through H 2 0 , resistance to motion will . (  speed =  drag; velocity 2 ) Moving H 2 0 past the patient will require the patient to work harder to maintain position in pool. Application of equipment will  drag & resistance as the patient moves the extremity through H 2 0.

3 Resistive forces at work in H 2 0: Cohesive force - Runs parallel to the direction of the H 2 0 surface Result of H 2 0 molecule surface tension Bow force - Force generated at front end of object during movement When object moves,  in H 2 0 pressure at the front and  pressure in the rear Creates a pressure gradient, resulting in low pressure zones swirling = eddies (turbulence) create a drag force Drag force – water’s resistance to movement within a fluid that is caused by the friction of the fluid’s molecules Form Drag – resistance that an object encounters in a fluid and is determined by the object’s shape & size Wave Drag – water’s resistance as a result of turbulence Frictional Drag – result of water’s surface tension Can be changed by shape and speed of object  streamline =  drag Must be considered carefully when attempting to protect a limb during rehabilitation Drag forces can  torque at a given joint which may be contraindicated

Thermodynamics Water temp. will have an effect on the body & performance Specific Heat – amount of heat (calories) required to raise the temp of 1 gram of substance by 1°C. Rate of temp change is dependent upon mass & specific heat of object Water retains heat 1000 times more than air Temperature transfer – water conducts temp 25 times faster than air Heat transfer increases with velocity (patient moving will lose body temp faster than patient at rest)

Aquatic Techniques Program can be designed to have active assistive movements & progress to strengthening Can perform exercises in various positions including: Supine, prone, side-lying, seated, vertical Things to consider when performing aquatic techniques: Type of injury/surgery Treatment protocols if appropriate Results/muscle imbalances found in evaluation Goals/expected return to activity Program design (similar to land-based programs) Warm-up Strengthening/mobility activities Endurance/cardiovascular Cool down/stretch

Spine Dysfunction Initial Level Instruct athlete on neutral position in partial squat with back against wall Wall will provide feedback to monitor ability to maintain position Progression of upper/lower extremity activity can be incorporated with stabilization exercises If dealing with sciatica-type symptoms, deep water traction may be beneficial Work on normalization of gait pattern and increasing ability to bear weight (performed in deep end) Increasing pelvic mobility through stretching

Intermediate Level Move athlete away from wall Incorporate equipment to simulate pulling/pushing motions Can also perform activities that incorporate single leg stance and lunging while challenging dynamic stabilization of core Supine and prone activity can also be utilized to train core

Advanced Level Must be sure to incorporate activities that mirror challenges of sport and provide higher level of trunk stabilization Train bilateral activity – integrate opposite movement patterns Athlete should be integrated back to training on land Water does not allow for normal speeds and forces during sports specific activities

Lower Extremity Injuries Initial Level Goal - restore normal motion & early strengthening Restore normal gait patterns Can work on active joint motion (hip, knee, ankle) Utilize cuffs, noodles, or kickboards under foot will assist with increasing motion Incorporate conditioning & balance activities Utilize good postural mechanics while challenging balance/neuromuscular control Deep-water activities allows for conditioning & cross-training It also provides an opportunity for non-weight bearing secondary to injury Incorporate of supine activities Resistance against uninvolved leg will also allow for strengthening of injured extremity

Intermediate Level Challenge athlete with weights & flotation devices Be aware if you need to use proximal or distal resistance Utilize straight & diagonal plane activities Balance training Standing on cuff, noodle, uneven surfaces Deep water tethering for running/sprinting Continue integrating supine & prone exercises as athlete’s strength & ability  Integrate sports specific activity & jumping progression

Final Level Athlete should be engaged in high level strengthening & conditioning Program should compliment land-based program Decrease use of floatation devices, alter use of buoyancy cuffs (minus floatation belt) Endurance training in aquatic environment is a good alternative for athlete’s conditioning program May be useful in preventing recurrence of injury

Conclusions Should not be exclusive treatment option for athlete Many physical & psychological benefits during early stages of rehabilitation Sports specific training – utilize land & water based training to achieve goals Must be sure to engage in activity at “normal” speeds and force levels prior to return to play