Download Chapter 16: Aquatic Therapy in Rehabilitation

Aquatic Therapy in
Rehabilitation
Chapter 15
Aquatic Therapy
• Useful tool to facilitate training & fitness
• Movement skill & strength can be enhanced
• Effects
•  joint compression
• Reduces muscular guarding
• Useful in improving movement and fitness
• Basic Concepts as Land-based Rehab
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Warm-up
Strengthening/mobility activities
Endurance/cardiovascular
Cool down/stretch
Goals
• Specific Goals:
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Facilitate ROM
Initiate resistance training
Facilitate weight-bearing activities
Enhance delivery of manual techniques
Provide 3-dimensional access to patient
Facilitate cardiovascular fitness
Initiate functional activity
Minimize risk of injury/re-injury during rehab
Enhance patient relaxation
Precautions & Contraindications
• Precautions
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Fear of water
Neurologic disorders
Seizures
Cardiac dysfunction
Small open wounds &
intravenous lines
• Contraindications
• Onset of cardiac failure &
unstable angina
• Respiratory dysfunction
• Severe peripheral vascular
disease
• Danger of bleeding or
hemorrhage
• Severe kidney disease
• Open wounds, skin infections
• Uncontrollable bowel/bladder
• Water & airborne infections
or diseases
• Uncontrolled seizures
Advantages & Benefits
• Buoyancy allows active exercise while providing a
sense of security and minimizing discomfort
• Water provides environment in which more can be
accomplished than on land
• Useful in early stages of rehabilitation
• Provides for earlier movement due to  compressive forces
• Supportive environment – allows for extra time to control
movement – proprioception enhancement
• Turbulence functions as a destabilizer & as a tactile sensory
stimulus
• Provides gradual transition from non-WB to full WB
• Psychologically – may allow for increased
confidence due to increased ability of function
allowed by water
• Strengthening & muscle re-education
• Strength gains are dependent on effort put forth by
athlete
• Energy expenditure may be 
• Must perform activity & maintain stability of body
within the water
• Cardiovascular maintenance
Disadvantages
• Cost
• Building & maintaining a rehabilitation pool
• Space & personnel
• Thermoregulation
• Impact on core body temperature
• May impact tolerance for participation in heat
• Contraindications involved with injuries & potential of open
wound
• Additional contraindications
• Fear of water, fever, urinary tract infection, allergies to pool chemicals,
cardiac dysfunction or uncontrolled seizures
• If lacking in ability to stabilize body, aquatic training can be challenging
• Facility must have certain
characteristics
• Should be at least 10 ft. x12 ft.
• Adequate access (either above or
below ground pool)
• Shallow & deep areas to perform
various exercises
• Flat pool bottom with marked
gradients - optional
• Adequate temperature (79°-82°)
• Ancillaries
• Prefabricated pools with treadmill or
current producing device
• Pool toys – limited by imagination
(gloves, hand paddles, belts,
kickboards)
• Clothing & attire
Facilities &
Equipment
Equipment
• Safety equipment –
• Exercise equipment –
• Assistive Devices –
flotation devices
• Resistive devices –
paddles, water shoes,
webbed gloves
Water Properties
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Specific Gravity
Buoyancy
Hydrostatic Pressure
Viscosity
Specific Gravity
• Also known as “Relative Density:
• The density of an objective relative to that of
water
• The density of a substance divided by density of H2O.
• Specific gravity of water = 1
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If object’s s.g. is > 1, object will sink
If object’s s.g. is < 1, object will float
If object’s s.g. is = 1, object will float just below water surface
S.G. of fat = 0.8
S.G. of bone = 1.5-2
S.G. of lean muscle = 1.0
Human Body = 0.95-0.97 (Less than 1 - enables the body to float)
• Buoyancy is partially dependent on body weight
• Different body parts will vary
• On average, human S.G. is less than water
• Doesn’t mean body will float due to body part make-up
• Factors that determine the specific gravity of the
individual body part:
• ratio of bone weight to muscle weight
• the amount & distribution of fat
• depth & expansion of chest
• Air in lungs vs. extremities
• Lungs filled with air can  the specific gravity of the chest (allows
head & chest to float higher in the water)
Buoyancy
• Upward force that works opposite to gravity
• Counterforce that supports submerged or partially
submerged object against pull of gravity
• Assists motion toward water’s surface
• Sense of weight loss (equal to amount of water that is
dissipated)
• Changes relative to level of submersion
• Differing levels in males & females due to relative CoG
• Allows for ambulation & vigorous exercise with little
impact & friction reduction between articular surfaces
• Archimedes principle – an immersed body experiences upward
thrust equal to the volume of liquid displaced
Center of Buoyancy
• Center of buoyancy, rather than center of gravity,
affects the body in water
• Reference point of an immersed object upon which
buoyant (vertical) forces of fluid predictably act
• In the vertical position, the human center is located at
the sternum
• In the vertical position, posteriorly placed buoyancy
devices will cause the patient to lean forward (anterior
causes patient to lean back)
Hydrostatic Pressure
• Pressure exerted on immersed
objects
• Pascal’s Law – pressure exerted by fluid on an
immersed object is equal on all surfaces of the
object
• As density of water & depth of immersion  so
does hydrostatic pressure
Viscosity
• Friction occurring between molecules
of liquid resulting in resistance to flow
• A fluid’s “thickness”
• Resistance is proportional to the velocity of movement
through liquid
• Increasing the surface area moving through water
will  resistance
Hydromechanics
• Physical properties & characteristics of fluid in motion
• Components of Flow motion:
• Laminar flow – movement where all molecules move parallel to each
other (typically slow movement)
• Turbulent flow (also known as “Wave Drag”) – movement where
molecules do not move parallel to each other (typically faster movements)
• Drag – cumulative effects of turbulence & fluid viscosity acting on an
object in motion
• As speed of movement through H20 , resistance to motion will . ( speed =
 drag; velocity2)
• Moving H20 past the patient will require the patient to work harder to
maintain position in pool.
• Application of equipment will  drag & resistance as the patient moves the
extremity through H20.
• 3 Resistive forces at work in H20:
• Cohesive force - Runs parallel to the direction of the H20 surface
• Result of H20 molecule surface tension
• Bow force - Force generated at front end of object during movement
• When object moves,  in H20 pressure at the front and  pressure in the
rear
• Creates a pressure gradient, resulting in low pressure zones swirling =
eddies (turbulence) create a drag force
• Drag force – water’s resistance to movement within a fluid that is caused by
the friction of the fluid’s molecules
• Form Drag – resistance that an object encounters in a fluid and is
determined by the object’s shape & size
• Wave Drag – water’s resistance as a result of turbulence
• Frictional Drag – result of water’s surface tension
• Can be changed by shape and speed of object
•  streamline =  drag
• Must be considered carefully when attempting to protect a limb during
rehabilitation
• Drag forces can  torque at a given joint which may be contraindicated
Thermodynamics
• Water temp. will have an effect on the body &
performance
• Specific Heat – amount of heat (calories) required
to raise the temp of 1 gram of substance by 1°C.
• Rate of temp change is dependent upon mass & specific
heat of object
• Water retains heat 1000 times more than air
• Temperature transfer – water conducts temp 25
times faster than air
• Heat transfer increases with velocity (patient moving
will lose body temp faster than patient at rest)
Aquatic Techniques
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Program can be designed to have active assistive movements & progress to
strengthening
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Can perform exercises in various positions including:
• Supine, prone, side-lying, seated, vertical
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Things to consider when performing aquatic techniques:
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Type of injury/surgery
Treatment protocols if appropriate
Results/muscle imbalances found in evaluation
Goals/expected return to activity
Program design (similar to land-based programs)
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Warm-up
Strengthening/mobility activities
Endurance/cardiovascular
Cool down/stretch
Spine Dysfunction
• Initial Level
• Instruct athlete on neutral position in partial squat with
back against wall
• Wall will provide feedback to monitor ability to maintain position
• Progression of upper/lower extremity activity can be
incorporated with stabilization exercises
• If dealing with sciatica-type symptoms, deep water traction
may be beneficial
• Work on normalization of gait pattern and increasing
ability to bear weight (performed in deep end)
• Increasing pelvic mobility through stretching
• Intermediate Level
• Move athlete away from
wall
• Incorporate equipment to
simulate pulling/pushing
motions
• Can also perform
activities that incorporate
single leg stance and
lunging while challenging
dynamic stabilization of
core
• Supine and prone activity
can also be utilized to
train core
• Advanced Level
• Must be sure to incorporate activities that mirror
challenges of sport and provide higher level of trunk
stabilization
• Train bilateral activity – integrate opposite movement
patterns
• Athlete should be integrated back to training on land
• Water does not allow for normal speeds and forces during sports
specific activities
Lower Extremity Injuries
• Initial Level
• Goal - restore normal motion & early strengthening
• Restore normal gait patterns
• Can work on active joint motion (hip, knee, ankle)
• Utilize cuffs, noodles, or kickboards under foot will assist with
increasing motion
• Incorporate conditioning & balance activities
• Utilize good postural mechanics while challenging
balance/neuromuscular control
• Deep-water activities allows for conditioning & cross-training
• It also provides an opportunity for non-weight bearing secondary to
injury
• Incorporate of supine activities
• Resistance against uninvolved leg will also allow for
strengthening of injured extremity
• Intermediate Level
• Challenge athlete with weights & flotation
devices
• Be aware if you need to use proximal or distal
resistance
• Utilize straight & diagonal plane activities
• Balance training
• Standing on cuff, noodle, uneven surfaces
• Deep water tethering for running/sprinting
• Continue integrating supine & prone exercises as
athlete’s strength & ability 
• Integrate sports specific activity & jumping
progression
• Final Level
• Athlete should be engaged in high level strengthening &
conditioning
• Program should compliment land-based program
• Decrease use of floatation devices, alter use of buoyancy
cuffs (minus floatation belt)
• Endurance training in aquatic environment is a good
alternative for athlete’s conditioning program
• May be useful in preventing recurrence of injury
Conclusions
• Should not be exclusive treatment option for
athlete
• Many physical & psychological benefits during
early stages of rehabilitation
• Sports specific training – utilize land & water
based training to achieve goals
• Must be sure to engage in activity at “normal” speeds
and force levels prior to return to play