Download Chapter 16: Aquatic Therapy in Rehabilitation

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
– Not a new form of therapy  revisited
• Effects:
– Decreases joint compression
– Reduces muscle guarding
– Improves movement and fitness
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
Physical Properties
• Buoyancy
– Counteracts downward pull of gravity
• Upward force that supports submerged or partially submerged
object
• Assists motion toward water’s surface
– Sense of weight loss
• Changes relative to level of submersion
• Differs in males and females due to relative CoG
– Allows for ambulation and vigorous exercise
• Reduces joint impact
• Reduces friction between articular surfaces
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
Physical Properties cont.
• Specific Gravity
– Buoyancy is partially dependent on body weight
• Weight of different body parts will vary
– Determined by:
• Ratio of bone weight to muscle weight
• Amount and distribution of fat
• Depth and expansion of chest
– Specific gravity of humans is slightly less than water
• Enables the body to float
• Does not mean that body will float horizontally
• Different segments have different specific gravities
• Air in lungs vs. extremities
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
Resistive Forces
• Cohesive force
– Runs parallel to the direction of the water surface
– Due to surface tension of water molecules
• Bow force
– Force generated at the front of an object during
movement
• Increased water pressure at the front
• Decreased water pressure in the rear
– Creates a pressure gradient
• Low pressure zones swirl = eddies (turbulence)
• Creates a drag force
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
Resistive Forces cont.
• Drag force
– Modified by shape and speed of object
• Increase streamline of object = decrease 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
(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
• Progression: deep to shallow
– Take advantage of buoyancy property
• 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
– Minimizes discomfort
– Sense of security
• Useful in early stages of rehabilitation
– Supportive environment
• Proprioception enhancement
– Turbulence provides perturbations and tactile sensory stimulus
• 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
Aquatic Rehabilitation: Advantages
• Psychological impact
– Increased confidence due to increased function
allowed by water
• Strengthening and muscle re-education
– Dependent on effort put forth by athlete
• Energy expenditure
– Aerobic workout possible to maintain CV fitness
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
Aquatic Rehabilitation:
Disadvantages
• Building and maintaining a rehabilitation pool
– Space and personnel
• Aquatic training may be too challenging if
•
athlete unable to stabilize body
Thermoregulation
– May impact tolerance for participation in heat
• 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
–
–
–
–
–
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
– Prefabricated pools with treadmill or current
producing device
– Pool toys – limited by imagination
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
Aquatic Techniques
• Must consider
–
–
–
–
Type of injury/surgery
Treatment protocols if appropriate
Results/muscle imbalances found in evaluation
Goals/expected return to activity
–
–
–
–
Warm-up
Strengthening/mobility activities
Endurance/cardiovascular
Cool down/stretch
• Program design
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
Upper Extremity Injuries
• 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
– Prone positioning (w/ snorkel)
• Pendulum and PNF diagonal plane activity
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
Upper Extremity Injuries
• Intermediate Level
– Goal: Develop strength and eccentric control
throughout ROM
– Strengthening progression
• 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
– Land-based program and aquatic program should be
coordinated to assure continued improvement of
strength, endurance, and function
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
Upper Extremity Injuries
• 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
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
Spine Dysfunction
• 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
– Progression
• Upper/lower extremity activity can be incorporated with
stabilization exercises
• 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
– 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
Spine Dysfunction
• Final Level
– Goal: Functional strengthening and training
– Incorporate sport-specific activities to challenge core
stabilization
– Train bilateral activity
• Integrate opposite movement patterns
– Incorporate land-based training
• Water does not allow for normal speeds and forces during
sports-specific activities
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
Lower Extremity Injuries
• 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
– Balance activities
• Enforce proper postural mechanics while challenging
balance/neuromuscular control
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
Lower Extremity Injuries
– NWB conditioning and cross-training in deep water
• Running
• Bicycling
• Cross country skiing
• Incorporation of sports specific skills
– Incorporation of supine activities
• Work on active hip and knee motion within pain-free range
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
Lower Extremity Injuries
• 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
– Utilize straight and diagonal plane activities
– Balance training
• Stand on cuff, noodle, uneven surfaces
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
Lower Extremity Injuries
– Integrate eccentric activity
• 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
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
Lower Extremity Injuries
• 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
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved
Conclusions
• Should be utilized in conjunction with land-based
•
•
rehabilitation exercises
Many physical and psychological benefits during
early stages of rehabilitation
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
(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved