The Benefits of Water: Seen & Unseen Benefits of Aquatic Therapy
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Transcript The Benefits of Water: Seen & Unseen Benefits of Aquatic Therapy
Katie St. Mars, PT, DPT
Table of Contents
Fundamentals of Aquatics
Properties of water
Precautions
Contraindications
Types of Aquatic Therapy
Equipment used
Exercises
HSP / PLS implications
Research
Resources
Fundamentals of Aquatics
Properties of water:
Buoyancy
Viscosity
Hydrostatic pressure
Turbulence
Contributing factors:
Temperature
Depth
Buoyancy
Definition:
The power of a liquid to keep
something afloat
Any object, wholly or partially
immersed in fluid, is buoyed up
by a force equal to the weight of
the fluid displaced by the object
(Archimedes principle).
Benefits:
Decreases weight which makes
movement easier
Reduces strain on joints due to
body weight pressure
Buoyancy
Qualifiers:
Depth:
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.
Buoyancy
So what?
Muscle weakness
Using floats will make it more difficult
to run, walk or push downward with
arms or legs in the water, creating
more resistance for strengthening.
Don’t exhale when diving underwater
to increase difficulty.
Muscle Spasticity
Easier to work in the shallow end at 3’
depth to avoid muscle fatigue when
performing standing exercises.
Viscosity
Definition:
The resistance of a liquid
Benefits:
Resistance of water (viscosity) acts as a resistance weight
particularly when directed downward due to buoyancy
Strengthen without straining joints.
Low viscosity of water (as opposed to honey which has a high
viscosity) allows for freedom of movement.
Combination of the above two cannot be found in any other
environment for exercise!
H20 leg press vs. leg press on land
Hydrostatic Pressure
Definition:
Fluid pressure exerted equally on all surface areas
Benefits:
Helps return blood to the heart
More efficient with less pressure on cardiovascular system
Decreases swelling in extremities
Improves proprioception (awareness and adjustment of
body position) & coordination
Through increased sensory input
Turbulence
Definition:
Random motion of water as it responds to a disturbance
Benefits:
Massaging effect reduces pain
Provides varying levels of resistance
Bernoulli’s principle = increased speed of flow; decreased
pressure
“Gate control theory”
Imagine an elevator …
Elevator – travels along neural pathways from
the skin to spinal cord to brain
Full of Passengers – signals from water
temperature and pressure
Passenger attempts to board the crowded
elevator… but no room! – tries to signal pain
The brain interprets the temperature &
pressure of the water, overriding the pain
message attempting to get through.
Temperature
for aerobic conditioning,
water temp at 26-29ºC
to reduce spasticity &
pain, water temp at 3337ºC
Note: MS patients should
have aquatic therapy no
higher than 29ºC at most.
Depth
Level of immersion:
to pelvis = 60% of weight bearing in air
to belly button = 50%
to mid-ribs = 40%
to shoulders = 20-30%
to neck = 10%
full immersion = roughly zero
Caution – if there is loss of respiratory function:
do not immerse deeper than the belly button to avoid increased
pressure on chest and respiratory muscles
Precautions for Aquatic Therapy:
Bowel incontinence with firm stools
Communicable diseases (cold, flu, hepatitis)
Sensitivity to disinfection chemicals
Sensitivity to heat/ humidity (e.g Multiple Sclerosis)
Rashes, skin conditions with flaking or open areas (psoriasis)
Orthostatic hypotension (decreased blood pressure)
Hydrophobia (fear of water)
Combative or difficult to control person or group
Poor cognition
Dependence in ambulation
Controlled seizures, exercise-induced angina, controlled diabetes
Open wounds with bio-occlusive dressing
Compromised immune system (e.g. low T-cell count)
On chemotherapy
On dialysis for renal/kidney dysfunction
When not to do Aquatic Therapy
Fever
Bowel or bladder incontinence
Open wounds, incisions, or skin lesions/infections that are oozing or bleeding
Blistering
Boils
Infectious processes such as hepatitis A, strep throat, vaginal or urinary
infection, staphylococcus infection or other communicable diseases
Uncontrolled seizure disorder
Uncontrolled cardiac problems
Acute lung infections
Catheters or IV lines
Tracheotomies
Menstruation (unless internal protection is used)
Excessively high or low blood pressure
Extreme fear, inappropriate or disruptive behaviors
Therapies
that can be
done in water:
Ai Chi
Feldenkrais
BackHab
Proprioceptive Neuromuscular Facilitation
Water Pilates
Bad Ragaz
Watsu
Halliwick
Wassertanzen
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
Always check with your health care practitioner before
beginning any exercise program. Working with a
Physiotherapist is best.
Aquatic Exercises
• Strengthening
– Using hydrostatic pressure, buoyancy & turbulence to
increase resistance & thereby increase strength
• Stretching
– Using hydrostatic pressure & buoyancy to improve static hold
stretches with increased temperature for muscle relaxation
• Cardiovascular endurance
– Using hydrostatic pressure & turbulence to improve
diaphragmatic breathing and cardiovascular endurance
• Neuromuscular coordination
– Using hydrostatic pressure to improve proprioception with
dynamic movements, which improves motor planning &
output coordination
Strengthening
Active strengthening
Upper Extremity Strengthening
Begin with 10-20 reps x 1 set; progress to 20-30 reps x 2-3 sets
Lower Extremity Strengthening
Begin with 10-20 reps x 1 set; progress to 20-30 reps x 2-3 sets
Trunk Strengthening
Begin with 2-3 min. duration; progress to 15 min. duration
Passive strengthening
e.g. Bad Ragaz therapy (buoyancy supported)
Upper Extremity Strengthening
Arm Circles
Shoulder depressions
Shoulder retractions
Pool side push-ups
Lower Extremity Strengthening
Leg circles
Kicking
Seated outside of pool
Seated on pool step
On kickboard
Side-stepping
Jumping forward (1 leg or both)
Stepping up/down pool steps
Jumping jacks
Trunk Strengthening
Diving underwater for rings
Balancing on kickboard
Straddle sit on swim noodle
Plank + kick on pool step
Abdominal twists
Stretching
Active stretching
Begin with 10-30” hold x 1-3x
Progress to 30” hold x 3
Upper extremity
Lower extremity
Passive stretching
Partner performs passive range of motion (PROM) or
proprioceptive neuromuscular facilitation (PNF)
Best performed by a Physiotherapist
Upper extremity Stretching
Chest / biceps stretch
Clasp hands behind back or grab
handrails / pool side if unable to
reach behind back
Triceps / shoulder stretch
Use swim noodle
Lower Extremity Stretching
Calf stretch
Hamstring stretch
Place heel on pool step
Cardiovascular endurance
Treading water
Begin with 10-30” trials x 3
Progress to 1-2 min. trials x 2-3
Walking in chest-waist deep water
Begin with 2-3 min. trials x 3
Progress to 5-10 min. trials x 2-3
Progress to 20-30 min. x 1
Aqua jogging (use Flotation Belt)
Neuromuscular coordination
Exercises that improve the brain-body connection with
coordinated movement!
Shooting basketball
Stepping up/down pool step
Side-stepping
Walking backwards
Dribbling weighted soccer ball
To improve balance
Karate kicks on one leg
Making “waves”
Creating turbulence while maintaining sitting or standing
Case Examples:
Primary Lateral Sclerosis
Hereditary Spastic Paraplegia
for PLS (Primary lateral Sclerosis)…
Stiffness, weakness and spasticity in legs
Leg exercises, PROM, water temp more than 35ºC
Decreased balance & increased clumsiness
Picking up swim rings with feet to improve coordination
Trunk weakness
Balancing on swim noodle or kickboard
Hoarseness, reduced rate of speaking, slurred speech and drooling
Blowing bubbles in water to maintain strength
Difficulties with swallowing and breathing
If you have breathing difficulties, do not immerse deeper than the
belly button to avoid increased difficulty.
for HSP symptoms…
Difficulty walking
Negotiating obstacles
Balance on one leg
Progressive spasticity
Water temp more than 35ºC
Muscle weakness
Strengthening exercises
Word of caution…
Avoiding overuse
Overuse can often exacerbate weakness & spasticity
Strengthening can only occur once muscles have
achieved muscle fatigue
This can be difficult to feel in the water
Use caution with muscles < 3+/5 per MMT (manual
muscle test)
Difficult to move against gravity? Don’t isolate muscle in pool!
Signs of overuse: cramps or spasm, pain, extreme fatigue
Research
Aquatic exercise provides increased ease of movement with
less pain than land-based programs.
(Broach & Dattilo, 2001; Cooper, 1976; Mobily, Mobily, Lessard &
Berkenpas, 2000; Mobily & Verburg, 2001).
Participants can typically participate with lower body
temperatures, less muscle stress, less energy expenditure
and less guarded actions associated with fear of failing and
improved performance.
(Broach & Dattilo, 2001).
Research cont’d
The sheer weight of the water provides natural
compression on joints and promotes reduction in
swelling.
(Mobily, Mobily, Lessard, & Berkenpas, 2000).
Water provides a source of graded resistance conducive
to improvement in muscular strength and endurance
when the limbs are moved repeatedly through a range
of motion over the course of an extended period of
time.
(Mobily & Verburg, 2001).
Research cont’d
The physical benefits of activity performed in the water
may include: relief of pain, decreased spasticity and
increased relaxation, improved bone density, improved
pulmonary function, strengthened muscles, improved
endurance and improved range of motion and increased
circulation.
(Broach & Dattilo, 1996)
Participants stated they felt that the most important
outcome of AT included increased freedom of
movement, relaxation, energy and social interactions
Broach and Dattilo (2001),
Research cont’d
Psychological benefits of participation in aquatic therapy
have been identified to include improved mood, enhanced
self-esteem and body image and decreased anxiety and
depression.
(Broach & Dattilo, 1996).
Scuba diving program significantly reduces spasticity
per Modified Ashworth scale for paraplegics.
(Haydn et al. 2007)
Resources
Spine Health Water Therapy Exercise Program
http://www.spinehealth.com/topics/conserv/water/water01.html
Aquatic Therapy and Rehab Institute
www.atri.org
Aquatic Exercise Association (AEA)
http://www.aeawave.com/
Aquaticnet.com
http://www.aquaticnet.com/index.htm
Resources cont’d
Books / Videos
Free at your local library or on youtube.com
http://www.youtube.com/watch?v=A80fpkGHBpU&feat
ure=related
http://www.youtube.com/watch?v=FHphTmeZV-g
About the author:
Graduated from Virginia Commonwealth University’s
Medical College in 2008
Doctor of Physical Therapy (physiotherapy)
Practice experience with: progressive neurological
disorders, sports medicine, post-op orthopaedics,
paediatrics to include autism.
Paediatric Physical Therapist (physiotherapist) with
Himmel Home Health- New Braunfels - San Antonio
area, Texas, USA.