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

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

3. 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.

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

5. 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.

6. 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.

7. 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

8. 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)

9. 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.

10. 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

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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

17. 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.

18. 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

19. 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.

20. 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

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

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

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

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

25. 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.

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

27. Equipment: Kickboard Purpose Floatation support Balance
Attempting to maintain prone

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

29. Equipment: Resistance boots
Purpose
Strengthening
Lower extremity
Abdomen
Low back

30. Equipment: Resistance paddles
Purpose
Strengthening
Upper extremity
Trunk

31. 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

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

33. 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.

34. 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.

35. 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…

36. 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

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

38. 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

39. 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.

40. 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

41. 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

42. 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

43. 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.