Aquatic Therapy

Deanna M. Errico, PT, DPT, ATC Clarkson University January 10, 2009 EATA Workshop Objectives

„ Relate the principles of physics to aquatic therapy „ Identify the physiological benefits of exercising in water „ Identify the precautions and contraindications to aquatic therapy „ Apply the therapeutic effects of aquatic exercise Principles of Water

„ Aquatic Physics „ Density/Specific Gravity „ Hydrostatic Pressure „ Buoyancy „ Refraction „ Thermodynamics Density and Specific Gravity

„ Density „ Mass per unit volume (kg/m3)

„ Specific Gravity/relative density „ Ratio of the density of a particular substance to the density of water. Hydrostatic Pressure

„ Pressure = force per unit area (N/m2)

„ Fluid pressure exerted on all surface areas of an immersed object

„ Directly proportional to depth of body part below surface of water. Buoyancy

„ Upward force generated by the volume of water displaced.

„ Immersed objects have less apparent weight than the same object on land.

„ Buoyancy increases with volume Buoyancy

„ Gravity is not eliminated in water but the impact of gravity is reduced.

„ Simply adjust the amount of human body immersed to therapeutically alter the Buoyancy Factor. Center of Buoyancy

„ = Center of gravity of a fluid „ T2-T4 = center of buoyancy for human standing in neck-deep water. „ Effects are greatest as the limb approaches the surface of the water „ Upward force of buoyancy decreases the effect of body weight and the weight bearing forces on the muscles and joints of the body. Buoyancy and Weight Bearing

„ Increasing depth of water decreases weight-bearing stresses up to C7.

„ Generally: „ Immersion to neck = 10% WB „ Immersion to chest = 25-35% WB „ Immersion to waist = 50% WB Refraction

„ When light passes from one medium to another it encounters a boundary layer and undergoes a transformation at this interface

„ Part of the incident light is reflected at the boundary and the portion passing into the new medium may change direction Thermodynamics

„ Specific Heat/Thermal Energy Transfer „ Keep in mind the transfer of heat:

„ water or body transfers heat in dynamic system. „ Conduction, convection, radiation Principles of Water

„ Water in Motion „ Flow „ Viscosity „ Laminar Flow „ Turbulent Flow „ Drag Contribution „ Resistance Effects Viscosity

„ = Magnitude of internal friction specific to a fluid

„ Friction „ Resistance to movement

„ Energy must be exerted to create movement Resistance

„ Surface tension „ force exerted among surface molecules of water „ Frontal tension „ the more surface area facing the water, the greater the resistance „ Drag Newton’s Laws of Motion „ Inertia „ Tendency of masses to resist changes in motion

„ Acceleration „ Depends on object’s mass and on the applied forces „ Faster movements require greater force

„ Apply these properties to increase exercise intensity Leverage

„ Shorter objects vs. longer objects when moved the same amount of distance through same resistance

„ To increase work load, lengthen the resistance arm Physiologic Effects of Water

„ Cardiorespiratory System „ Musculoskeletal System „ Center of Buoyancy/Center of Balance „ Joint Effects Physiologic Responses during Water Exercise

„ Aerobic Energy Metabolism „ Water Temperature Effect „ Maximal Oxygen Uptake „ Anaerobic Energy Metabolism „ Circulation „ Ventilation „ Thermoregulation „ Endocrine Therapeutic Aquatic Exercise

„ Benefits „ Precautions „ Contraindications „ Treatment „ Other Benefits

„ Increases circulation (superficial and peripheral) „ Increases blood supply in muscles „ Muscle relaxation „ Promotes inhibition of spastic muscles by decreasing gamma fiber activity „ Prepares connective tissues for stretching „ Improves flexibility as muscles are able to work through a greater ROM when supported by water Benefits (Cont)

„ Decreases joint compression forces „ Hydrostatic pressure improves lung capacity „ Hydrostatic pressure decreases pooling of blood in LE’s „ Improved strength of agonist/antagonist „ Decreased osteoporotic effects secondary to muscle contraction „ Decreased sensitivity of sensory nerve endings (and usually less pain) Precautions

„ Risk of overexertion and dehydration „ Prone swimming decreases O2 intake by 20% „ HR is 10-15 bpm lower with water exercise than land exercise, when exercising at same MET level (use RPE) „ Chlorine/Bromine can cause skin and respiratory problems „ Causes a 10% decrease in pulmonary function when submerged to neck level „ Easy to over stimulate vestibular system Contraindications

„ Fever over 100 „ Uncontrolled epilepsy „ Incontinence „ Respiratory disease with vital capacity below 1L „ Infectious disease „ Open wounds „ Skin infections „ Uncontrolled blood pressure Contraindications

„ Severe cardiac complications „ Acute cerebral hemorrhage „ MS (in warm water) „ Chlorine sensitivity „ Repeated syncope „ Absent cough reflex „ UTI’s „ Isolation precautions Treatment

„ Land versus Pool based treatment „ inconvenience of pool and increased liability „ Applicable to wide range of diagnoses and patient populations „ Can be used at several points in rehabilitation process „ Entering and Exiting pool issues „ ladder vs steps vs lift Mobility

„ Benefits of decreased weight bearing „ Gait training while still under precautions „ Decreased pain in arthritic joints while performing cardiovascular exercise „ Proprioceptive awareness in early recovery stages Mobility (cont)

„ Benefits of buoyancy „ Decreased need for assistance „ Assistance with hip flexion and knee flexion in gait „ Provides supportive environment Mobility (cont)

„ Water mobility tasks (similar to land based) „ Parallel bars „ Steps „ Assistive devices „ Dumbbells „ Weights „ Buoyancy belts Mobility (cont)

„ Increase challenge: „ Increase speed „ Add resistance „ Increase surface area „ Quick reversals „ Add drags and turbulence „ Decrease depth Balance Activities

„ Constant use of abdominal/trunk musculature for stabilization „ Sitting, kneeling, standing on noodle, dumbbell (with or without a belt) „ Ball activities, standing with narrow base of support/one leg Back stabilization/ strengthening exercises

„ Maintain pelvic tilt and good posture during UE/LE exercises and with ambulation activities „ Noodle activities in sitting or kneeling (bicycle with arm and leg movement) „ Side bend and trunk rotation stretches „ Golf swing, kickboard presses, scapular retraction, „ Deep end activities of scissoring, thrusts, and pendulums Stretching

„ Calf „ Quad „ Hamstring „ LB/upper back „ Buttocks „ Upper extremity (triceps/post shoulder/ant) UE/LE strengthening

„ Remember physical properties of water when designing program (buoyancy supported, assisted, or eliminated)

„ Increase difficulty by increasing speed, reps, resistance, and position in water, and depth of water. Cardiovascular exercise

„ Aqua jogging „ Remember pulmonary and „ walking cardiac impacts of „ Swimming water „ Bicycling „ THR is 10-15 BPM „ Aerobics lower „ Dehydration „ Warm-up and Cool- down Other

„ Bad Ragaz „ Warm vs cool pool „ Watsu „ CPT codes „ Mechanical traction „ 97110: ther-ex „ Manual techniques „ 97113: Aquatic ex „ Plyometrics „ Lifeguard „ Sports „ Consent form/waiver „ Pregnant patients „ Pool costs/ (benefits) maintenance „ Other specific „ High risk populations environment References

„ Ruoti RG, Morris DM, Cole AJ. Aquatic Rehabilitation. Lippincott Williams & Wilkins Publishers: Philadelphia PA. 1997. „ Sova R. Aquatics: the Complete Reference Guide for Aquatic Fitness Professionals. DSL, Ltd.: Port Washington, WI. 2000 „ Marocco S. Aquatic Therapy Inquiry Seminar, Clarkson University 2005. „ McNamara C. Aquatic PT for LE Injuries. CE Course. „ Whisher D, Lebel C. Aquatic PT: An Orthopedic Approach. CE course