Aquatic Rehabilitation
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AQUATIC THERAPY / EXERCISE / REHABILITATION Loganathan Chandrasekar PHT 328 – 1st Sem – 1435 – 1436H Lecture Outline 2 Overview of Aquatic therapy Goal of Aquatic therapy Therapeutic Ex’s – Key points Brief about benefits of water Equipment's used in Hydrotherapy Types of aquatic activity / intervention Specialized techniques Contraindications & precautions Summary PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Lecture Objective 3 At the end of the lecture, the student will be able to; Define aquatic therapy. Recall some of the goals of hydrotherapy, Key points & importance of equipment's used in hydrotherapy. Demonstrate some of the aquatic interventions & some of the specialized techniques. List down some of the contraindications & precautions of aquatic rehabilitation / ex’s PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Overview of Aquatic Therapy 4 Definition:- Aquatic therapy is a form of physical therapy that is performed in a pool. The goal of this particular form of therapy is to assist in restoring the person's strength and movement through the use of buoyancy, resistance, and heat. It aims to rehabilitate patients after injury or those with chronic illness. PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Goals of Aquatic Physical Therapy 5 Aquatic Physical Therapy interventions are designed to improve or maintain: ► function ► aerobic capacity/endurance conditioning ► balance, coordination and agility ► body mechanics and postural stabilization ► flexibility ► gait and locomotion ► Hydrotherapy power, 1434 - 1435H - 1st endurance SEM 7/1/2016 3:26 AM muscle strength, and PHT 328 Therapeutic Pools – Key Points 6 It vary in size & shape. – Rectangular shape is widely used. The traditional pools can be – 12 x 16 feet, with a depth of 3 – 4 feet or larger, usually with a maximum depth of 8 – 10 feet. This type of pool can be used for groups of patients. Access to the traditional pool is by; 1. ramp 2. stairs 3. ladders 4. Mechanical overhead lift PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Therapeutic Pools – Key Points 7 Each pool has an in-built filtration & chlorination system. The rooms should be adequately ventilated to avoid condensation. A private area for changing the cloths, showering & cool down should be available to the patient following therapeutic ex’s sessions. PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM 7/1/2016 3:26 AM PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 8 Benefits of water ex’s Water Quality Benefit Buoyancy: The feeling of being lighter in the water; of floating. • Provides support for weak limbs. • Movement takes less effort. A greater range of motion can be achieved. • Promotes muscle relaxation. Viscosity: The sensation that there is resistance to your movements; that you move slower through the water. • The resistance of water can be used to improve muscle strength. • Slower movement in water provides an opportunity to work on skills such as balance and coordination which may be harder to do on land. Hydrostatic pressure: The sensation of compression while the body is in the water. Pressure increases with depth. • Compression can provide support for standing activities, such as walking, with less effort than on land. Temperature Control 9 PHT 328 • Cooler water can help maintain lower core body temperature even during vigorous activity. This is especially helpful for people with heat sensitivity Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM issues. Physical Properties of Water – Buoyancy 10 Main Controlling Variables: 1. Position or direction of movement in water 2. Water depth 3. Lever arm length 4. Flotation or weighted equipment use PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Position and Direction of Movement 11 Movements toward the surface – Buoyancy assisted. Movements parallel to the bottom of the pool – Buoyancy supported (gravity minimized). Movements toward the bottom of pool – Buoyancy resisted. PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Depth, Lever Arm Length, or Buoyant Equipment Can Alter Resistance or Assistance 12 Shallower water – Less support. Deeper water – More support, but increased frontal resistance. Modifications can be made through use of buoyant equipment. PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Buoyancy and Lever Arm 13 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Buoyancy and Flotation 14 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Resistance Is Influenced By: 15 1. Velocity of movement (mean muscle activity alters when velocity reaches a threshold). 2. Surface area 3. Water depth 4. Direction of movement PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Equipment's used in Hydrotherapy 16 Foam dumbbells Fins/Flippers Float Cuffs Resistance paddles Floatation belt Weights Jug (air filled) Swim noodle Kickboard PHT 328 Hydrotherapy Neck collar Resistance boots 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM 17 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Equipment: Foam Dumbbells 18 Purpose: Strengthening Upper extremity Trunk Floatation PHT 328 support Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Equipment: Fins/Flippers 19 Purpose: Strengthening Lower extremities Abdomen Low back Propulsion PHT 328 when swimming Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Equipment: Float Cuffs 20 Purpose: Strengthening Upper extremity Lower extremity The further away from your body the cuff is placed, the more difficult the exercise PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Equipment: Floatation belt 21 Purpose: Floatation support Strengthening Resistance against vertical in pool improves trunk & hip strength to maintain upright position for “running” or “walking” while floating. PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Equipment: Jug (air filled) 22 Purpose: Strengthening Upper extremity Trunk PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Equipment: Kickboard 23 Purpose Floatation support Balance Attempting to maintain prone PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Equipment: Neck collar 24 Purpose Floatation support To prevent strain to cervical spine PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Equipment: Resistance boots 25 Purpose Strengthening Lower extremity Abdomen Low back PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Equipment: Resistance paddles 26 Purpose Strengthening Upper extremity Trunk PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Equipment: Weights 27 Purpose Assistance to maintain vertical positioning Strengthening Will be easier than performing weighted exercise on land Coordination Using medicine ball to dribble like soccer ball PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Equipment: Swim noodle 28 Purpose Floatation assistance Strengthening Upper extremity Lower extremity PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Examination and Evaluation for Aquatic Rehabilitation 29 Full land-based examination must be performed. Also consider: Basic safety (ability to enter water, comfort, etc.) Precautions (cardiac history, etc.) Contraindications to aquatic environment (fever, infections, rashes, etc.) PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Aquatic Techniques 30 Must consider Type of injury/surgery Treatment protocols if appropriate Results/muscle imbalances found in evaluation Goals/expected return to activity Program design Warm-up Strengthening/mobility activities Endurance/cardiovascular Cool down/stretch PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Types of Aquatic Activity 31 Balance exercises Relaxation and stretching Ai Chi (Water Tai Chi) Halliwick techniques Stretching Ai chi Aquatic body work: Watsu, Jahara, or Healing Dance Strengthening exercises Deep or shallow water techniques Bad Ragaz Ring Method Use of drag or resistance equipment PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Sample Aquatic Exercises 32 Marching—stand with your side to the pool wall. Hold onto the wall if needed for balance. Lift one leg up and down, then the other. Repeat 5 to 8 times. Side leg lifts—stand facing the side of the pool. Hold onto the edge of the pool if needed for balance. Lift leg out to the side 5 to 8 times. Do the other leg. Back leg lifts—stand facing the side of the pool. Hold onto the edge of the pool if needed for balance. Lift leg straight back 5 to 8 times. DO NOT arch the back. Do the other leg. Runner's stretch—stand facing the side of the pool. Hold the edge of pool for balance. Step one leg back. Both feet flat on floor. Keep the heel of the back leg on the floor. Bend the knee of the forward leg. Lean forward from the ankles. You should feel a stretch in the lower leg or calf muscles. Hold for 20-30 seconds. Do 1 to 2 times. Switch legs. PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Other Benefits… 33 PHT 328 Decreases stress Pain relief Improved flexibility Ease depression Boost self-esteem Improved posture Increased circulation Increased cardiovascular functioning Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Upper Extremity Injuries 34 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) PHT 328 and PNF Hydrotherapy 1434 - 1435H - 1st SEM Pendulum diagonal plane activity 7/1/2016 3:26 AM Upper Extremity Injuries 35 Intermediate Level Goal: Develop strength and eccentric control throughout ROM Strengthening progression Maintain good postural mechanics Use equipment to resist motion, increase surface area, or increase lever arm 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 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM 7/1/2016 3:26 AM PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 36 Upper Extremity Injuries Final Level Goal: Functional strengthening and training Transition from aquatic to landbased treatment Increase the use of equipment to maintain motivation levels of athlete 7/1/2016 3:26 AM PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 37 Spine Dysfunction 38 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 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM 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 Hydrotherapy 7/1/2016 3:26 AM PHT 328 1434 - 1435H - 1st SEM 39 Spine Dysfunction 40 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 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Lower Extremity Injuries 41 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 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Lower Extremity Injuries 42 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 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Lower Extremity Injuries 43 Intermediate Level Goal: Use Develop strength and eccentric control throughout ROM weights and flotation devices to increase difficulty Proximal Utilize resistance may be necessary due to the injury straight and diagonal plane activities Balance Stand training on cuff, noodle, uneven surfaces PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Lower Extremity Injuries 44 Integrate Double Deep eccentric activity and single leg reverse squats water running/sprinting Continue to integrate supine and prone exercises as athlete’s strength and ability increase Jumping progression Integration PHT 328 of sports-specific activity Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Lower Extremity Injuries 45 Final Level Goal: Functional strengthening and conditioning Program should compliment land-based program Decrease Aquatic May use of floatation devices endurance training be useful in preventing recurrence of injury PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Therapeutic Exercise Intervention - Mobility Impairment 46 Progress simple ROM exercises toward functional limitations. Use lever arm length and buoyant equipment to alter resistance. Observe land mechanics before pool exercise to ensure proper technique. PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM ROM (Hamstrings and Shoulder Extensors) 47 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Aquatic-Based Rehabilitation and Training for the Shoulder Thein & Thein 7/1/2016 3:26 AM PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 48 Aquatic-Based Rehabilitation and Training for the Shoulder 7/1/2016 3:26 AM PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM Thein & Thein 49 Muscle Strength/Power/Endurance Impairment 50 Principles and progressions are the same as on land. Resistance is influenced by surface area (SA) and direction. Consider gloves, etc. to increase SA. Be aware of groups providing stability. Leg and trunk stabilizers are necessary to counter many upper extremity movements. PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Balance Impairment 51 Ideal environment for balance training. Variety of activities can be performed. Loss of balance is slowed dramatically. Allows for increased reaction time. PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Aquatic Therapy to Improve Balance 52 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Aquatic Rehab to Treat Functional Limitations 53 As patient improves, modify activities to address functional limitations. E.g., decrease level of water as sitting activities improve. As normal mechanics improve, decrease water levels to replicate land-based environments. PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Land-Based Functional Activities in Water 54 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM 55 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM 56 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Contraindications/Precautions for pool therapy 57 Individuals with excessive fear Open wounds Rashes Active infections Incontinence Tracheostomy PHT 328 Hydrotherapy CV changes Diuresis Over exercise 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Summary 58 Pool provides a unique environment for rehabilitation. The properties aquatic therapy provides can be used in many ways to achieve therapeutic goals. Physiologic responses, temperature, and hydrostatic pressure must be considered for safety.PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Summary (cont.) 59 Aquatic therapy can accommodate activities and progress from early-functional stages. Balance is challenged with most movements and stabilizing muscles must be considered. Pool program should include a land-based program for a well-balanced transition to the land environment. PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Aquatic Exercise 60 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM 61 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM 62 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM A self- contained hydrotherapy unit 63 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM 64 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM 65 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Aquatic Rehabilitation: Advantages 66 AROM exercises supported through buoyancy Minimizes discomfort Sense of security Useful in early stages of rehabilitation Proprioception enhancement Supportive environment Turbulence provides perturbations and tactile sensory stimulus Extremely useful with lower-extremity injuries Provides gradual transition from non to full weight-bearing PHT 328 Hydrotherapydue 1434 - 1435H - 1stcompressive SEM 7/1/2016 3:26 AM May allow earlier locomotion to decreased forces Aquatic Rehabilitation: Advantages 67 Psychological impact Strengthening and muscle re-education Increased confidence due to increased function allowed by water Dependent on effort put forth by athlete Energy expenditure Aerobic workout possible to maintain CV fitness PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Aquatic Rehabilitation: Disadvantages 68 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 PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Conclusions 69 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 levelsPHT prior to return to play1434 - 1435H - 1st SEM 328 Hydrotherapy 7/1/2016 3:26 AM Aquatic Plyometric Training Increases Vertical Jump in Female Volleyball Players – Research evidence 70 PT department University of Maryland Eastern Shore Eccentric loading limited compared to land based plyometrics although concentric have increased loading 6 wks APT x2/wk in addition to traditional pre-season Control teammates X2/week flexibility training and traditional pre-season Warm-up jogging & APT included: power skips, spike approaches, single and double leg bounding, continuous jumping for height, jump squats and depth jumps. Encouraged to perform in an explosive manner and with maximal effort. Isokinetics Peak Torque 60 & 180 deg/sec & Vertical Jump were increased above control No reports injuries PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Effects of aquatics resistance training on neuromuscular performance in healthy women - Research evidence 71 Medicine and Science in Sports Medicine -Tapani Poyhonen Finland 24 healthy women 34.2 y/o +/- 3.9 healthcare workers Study effects of 10 week aquatic resistance training on neuromuscular performance and muscle mass measuring peak torque isometric & isokinetic 60/180 deg/sec, surface EMG quadriceps & hamstrings, lean tissue crosssectional area (LCSA) as measure by CT scan 5-8 min warm up aqua jogger 30-45 min resistance training and 5 cool down Repe3ated one leg knee extension-flexion sitting, repeated extension -flexion standing, reciprocating extension-flexion in sitting, hip extension-flexion with knee extended in standing or kicking alternating at each training session Instructed to perform with maximal effort for highest possible velocity with verbal encouragement Differing sized boots for resistance and varying set, reps and rest through 10 week progression. Showed improved torque, neural activation and LCSA PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Resources 72 Spine Health Water Therapy Exercise Program http://www.spine- health.com/topics/conserv/water/water01.html Aquatic Therapy and Rehab Institute www.atri.org Aquatic Exercise Association (AEA) http://www.aeawave.com/ Aquaticnet.com http://www.aquaticnet.com/index.htm PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM Resources cont’d 73 Books / Videos Free at your local library or on youtube.com http://www.youtube.com/watch?v=A80fpkGHBpU&fe ature=related http://www.youtube.com/watch?v=FHphTmeZV-g PHT 328 Hydrotherapy 1434 - 1435H - 1st SEM 7/1/2016 3:26 AM
