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Aquatic Therapy for Lower Quarter Dysfunction and Wellness Paula Richley Geigle PT, PhD Dawn T. Gulick PT, ATC, PhD, CSCS Background Information Properties of H2O • Buoyancy: Archimedes: a body entirely or partially in fluid at rest, has a force acting upward and opposite gravity, equal to the weight of fluid displaced. • Clinical Importance: allows movement of painful or weak body parts that might be limited on land. Buoyancy Continued • Buoyancy may act to: – Provide passive movement – Support for exercise or assistive exercise – Provide resisted exercise • Longer lever arm greater torque with buoyancy principle—be careful that is what you want: hamstring stretch, forceful knee extension—post acute injury or surgery could be deleterious Relative Density • Density of H2O=1 • If density < 1 you will float, air trapped in lungs (exhalation compromised), increased body fat. Who would you expect to float more, less? • If density > 1, you will sink, low body fat, or respiratory inhalation compromised individuals Density Continued • Upper extremities less dense than lower extremities in general, so upper extremities tend to float better in general population than lower extremities. Keep in mind there are always exceptions. Unloading of Body Weight • Water height at ASIS: unloaded 40% body weight • Water height at nipple line: unloaded 70% • Water height at C7: 90% unloaded Hydrostatic Pressure • Pascal’s Law • Frank Starling Reflex: (HR x SV =CO); stroke volume increases secondary to increased peripheral return from hydrostatic pressure; therefore, to keep CO stable HR must decrease. For cardiac patients can be beneficial or harmful depending upon pathology limitation. Hydrostatic pressure clinical implications • Deeper H2O greater hydrostatic pressure • Can increase diuresis • Can decrease edema • Vital capacity must be at least 1500 cm3—to avoid lung collapse Fluid Dynamics • Laminar flow: provides least resistance proportional to velocity (faster speed in water there is more resistance) • Turbulent flow: high pressure in front of body; low pressure behind body • Drag: result of turbulent flow pressure differentials—use as intervention principle. Indications for Aquatic Intervention • Aquatics must be used to increase land function, rarely would you prescribe only aquatic program. Some type of land program must parallel/support aquatic intervention plan. Outcome measures of success need to include land outcome measure. Aquatic Therapy (AT) Use • Decreased weight bearing • To increase/early mobility • Overall rehabilitation:coordination, balance, etc • Decrease pain • Increase circulation (local and systemic) AT Use Continued • Increase sensory input • Motivational/Psychological • Slow movements to work on recruitment/timing for training purposes then return to ‘real’ time efforts on land Precautions • Cardiac conditions • Unstable vital signs • Incontinence • Severe/chronic ear infection (not a pblm if head out of water) • Braces, assistive devices: no plaster casts, fibroglass if liner water tolerant • COPD Precautions Continued • Involved pregnancies • Any land exercise precaution • Overworking is easy because it feels good to • • • exercise in water--be careful Anxiety of water If decrease in body core temperature will put client at risk for chilling (low body fat, decreased ability to generate heat with movement) Open dermis Contraindications • Uncontrolled seizure activity • Unstable medical condition(timing) • Behavior that facilitates client, staff or other patient safety issues • Phobia of water • Fragile medical condition(systemic) that places client at risk in aquatic environment Water Temperature • Ideal water temperature: body in H2O cools 4x • • faster than in air if less than body temp. Range-my opinion: 87-89 degrees for general populations able to generate own active movements If air temperature >90 degrees and humidity >60% aerobic exercise should be monitored closely, patient and therapist High level performance 80 degrees Postural Control Postural Control/Core Stability • I. Horizontal – crunches (semi reclined or full) – Bad ragaz--passive – Bad ragaz--active – Extremity resistance w/wo increased surface area Postural Control/Core Stability • II. Upright – Sitting • Cube position (Halliwick) • Balance board/waist belt/noodle – Standing • Crunches (Sahrmann levels--subtle movements) • Larger amplitude movements of extremities: – against wall, parallel to wall, away from wall Balance Control/Core Stability • II. Upright Continued – Dynamic • nordic track • jumping jacks • jump twist • bounding – With all of above: two leg/one leg/no resistance on extremities/resistance on extremities/w/wo additional turbulence Balance Control/Core Stability • III. Deep Water (open chain) – Small amplitude w importance of core stability emphasized – Mid-range amplitude – Large amplitude w/wo resistance can use extremity floats, external turbulence as tolerated BAD RAGAZ Bad Ragaz Ring Method • Developed originally Bad Ragaz, Switzerland • Horizontal treatment • Uses properties of water creating program of • • progressive resistance Strengthening, muscle re-education, trunk elongation, relaxation, tone inhibition Uses spiral/diagonal patterns similar to PNF Similarities Bad Ragaz and PNF • Maximal resistance • Specific hand holds • Approximation • Traction • Short, precise commands • Rhythmic initiation and stabilization • Irradiation Positioning • T10 most optimal • Flotation devices head, neck, pelvis; ankle and wrist supports as needed • Therapist positioning requires neutral body alignment: wide stance, power from legs, core stability--no rotation so spine is not exposed to as much torque OUTCOME MEASURES Cardiovascular/pulmonary • Dyspnea: vital signs, EEG, exertion scales • Decreased endurance: Physiologic responses to position changes – HR, BP, observations – Lab values • Increased CV responses to low load: CV signs/symptoms – – – BP, HR, rhythm, sounds Angina, claudication, dyspnea EEG Cardiovascular/pulmonary • Increased CP responses to low load: breath/voice sounds, cyanosis, respiratory pattern/rate/rhythm, ventilatory flow/force/volume (spirometry,oximetry) • Impaired ventilation: gas analyses from chart, observations, oximetry, airway clearance tests, pulmonary function tests Integumentary • Observation – Light touch, hot/cold – Sensory integration – Inspection of integument – Augmented photography – Thermography Musculoskeletal • Manual Muscle Test (MMT) • Dynamometry • Performance tests • Technology assisted analysis • Activities Daily Living Scales • Postural analysis grids • Videography Neuromuscular • Seizure: Client/caregiver/medical record for • • • seizure information (review current medications) Altered Sensory: Stereognosis, tactile discrimination, kinesthesiometry, observations, vibration tests, hot/cold Altered vestibular:Response to vestibular provocation tests, chart review, patient report Decreased strength: dynamometry, MMT, timed activities, physical capacity scales, EMG Neuromuscular • Dysfunction of recruitment/timing/sequencing: coordination tests, motor proficiency test, motor planning screens, postural challenge tests • Deconditioning: vital signs, perceived exertion screens, spirometer, aerobic capacity assessment Neuromuscular • Postural Control: observations, technology assisted analyses, grid measurement, functional assessment in pool (reposition head out of water independently) • Peripheral nerves: motor and sensory tests for integrity