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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