Download Aquatic Therapy for Lower Quarter Dysfunction and Wellness

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