Katie St. Mars, PT, DPT
Table of Contents
 Fundamentals of Aquatics
 Properties of water
 Precautions
 Contraindications
 Types of Aquatic Therapy
 Equipment used
 Exercises
 HSP / PLS implications
 Research
 Resources
Fundamentals of Aquatics
Properties of water:
 Buoyancy
 Viscosity
 Hydrostatic pressure
 Turbulence
Contributing factors:
 Temperature
 Depth
Buoyancy
Definition:
 The power of a liquid to keep
something afloat
 Any object, wholly or partially
immersed in fluid, is buoyed up
by a force equal to the weight of
the fluid displaced by the object
(Archimedes principle).
Benefits:
 Decreases weight which makes
movement easier
 Reduces strain on joints due to
body weight pressure
Buoyancy
Qualifiers:
 Depth:

Increased depth = Increased buoyancy
 Salt vs. Chlorinated water
 Salt water is more dense than chlorinated water. This
increases the buoyancy force in salt water, thus making
floating easier and swimming downwards more difficult.
 Lung capacity:
 Increased lung capacity – Increased buoyancy.
Buoyancy
So what?
 Muscle weakness

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Using floats will make it more difficult
to run, walk or push downward with
arms or legs in the water, creating
more resistance for strengthening.
Don’t exhale when diving underwater
to increase difficulty.
 Muscle Spasticity
 Easier to work in the shallow end at 3’
depth to avoid muscle fatigue when
performing standing exercises.
Viscosity
Definition:
 The resistance of a liquid
Benefits:
 Resistance of water (viscosity) acts as a resistance weight
particularly when directed downward due to buoyancy
 Strengthen without straining joints.
 Low viscosity of water (as opposed to honey which has a high
viscosity) allows for freedom of movement.
 Combination of the above two cannot be found in any other
environment for exercise!
H20 leg press vs. leg press on land
Hydrostatic Pressure
Definition:
 Fluid pressure exerted equally on all surface areas
Benefits:
 Helps return blood to the heart
 More efficient with less pressure on cardiovascular system
 Decreases swelling in extremities
 Improves proprioception (awareness and adjustment of
body position) & coordination
 Through increased sensory input
Turbulence
Definition:
 Random motion of water as it responds to a disturbance
Benefits:
 Massaging effect reduces pain
 Provides varying levels of resistance
 Bernoulli’s principle = increased speed of flow; decreased
pressure
“Gate control theory”
Imagine an elevator …
 Elevator – travels along neural pathways from
the skin to spinal cord to brain
 Full of Passengers – signals from water
temperature and pressure
 Passenger attempts to board the crowded
elevator… but no room! – tries to signal pain
 The brain interprets the temperature &
pressure of the water, overriding the pain
message attempting to get through.
Temperature
 for aerobic conditioning,
water temp at 26-29ºC
 to reduce spasticity &
pain, water temp at 3337ºC
 Note: MS patients should
have aquatic therapy no
higher than 29ºC at most.
Depth
Level of immersion:
 to pelvis = 60% of weight bearing in air
 to belly button = 50%
 to mid-ribs = 40%
 to shoulders = 20-30%
 to neck = 10%
 full immersion = roughly zero
Caution – if there is loss of respiratory function:
 do not immerse deeper than the belly button to avoid increased
pressure on chest and respiratory muscles
Precautions for Aquatic Therapy:
 Bowel incontinence with firm stools
 Communicable diseases (cold, flu, hepatitis)
 Sensitivity to disinfection chemicals
 Sensitivity to heat/ humidity (e.g Multiple Sclerosis)
 Rashes, skin conditions with flaking or open areas (psoriasis)
 Orthostatic hypotension (decreased blood pressure)
 Hydrophobia (fear of water)
 Combative or difficult to control person or group
 Poor cognition
 Dependence in ambulation
 Controlled seizures, exercise-induced angina, controlled diabetes
 Open wounds with bio-occlusive dressing
 Compromised immune system (e.g. low T-cell count)
 On chemotherapy
 On dialysis for renal/kidney dysfunction
When not to do Aquatic Therapy
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Fever
Bowel or bladder incontinence
Open wounds, incisions, or skin lesions/infections that are oozing or bleeding
Blistering
Boils
Infectious processes such as hepatitis A, strep throat, vaginal or urinary
infection, staphylococcus infection or other communicable diseases
Uncontrolled seizure disorder
Uncontrolled cardiac problems
Acute lung infections
Catheters or IV lines
Tracheotomies
Menstruation (unless internal protection is used)
Excessively high or low blood pressure
Extreme fear, inappropriate or disruptive behaviors
Therapies
that can be
done in water:
 Ai Chi
 Feldenkrais
 BackHab
 Proprioceptive Neuromuscular Facilitation
 Water Pilates
 Bad Ragaz
 Watsu
 Halliwick
 Wassertanzen
Equipment
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Foam dumbbells
Fins/Flippers
Float Cuffs
Floatation belt
Jug (air filled)
Kickboard
Neck collar
Resistance boots
Resistance paddles
Weights
Swim noodle
Equipment: Foam Dumbbells
 Purpose:
 Strengthening


Upper extremity
Trunk
 Floatation support
Equipment: Fins/Flippers
 Purpose:
 Strengthening

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Lower extremities
Abdomen
Low back
 Propulsion when swimming
Equipment: Float Cuffs
 Purpose:
 Strengthening


Upper extremity
Lower extremity
 The further away from your body the cuff is placed, the
more difficult the exercise
Equipment: Floatation belt
 Purpose:
 Floatation support
 Strengthening

Resistance against
vertical in pool improves
trunk & hip strength to
maintain upright
position for “running” or
“walking” while floating.
Equipment: Jug (air filled)
 Purpose:
 Strengthening


Upper extremity
Trunk
Equipment: Kickboard
 Purpose
 Floatation support
 Balance

Attempting to
maintain prone
Equipment: Neck collar
 Purpose
 Floatation support
 To prevent strain to
cervical spine
Equipment: Resistance boots
 Purpose
 Strengthening

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Lower extremity
Abdomen
Low back
Equipment: Resistance paddles
 Purpose
 Strengthening

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Upper extremity
Trunk
Equipment: Weights
 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
Equipment: Swim noodle
 Purpose
 Floatation assistance
 Strengthening


Upper extremity
Lower extremity
Always check with your health care practitioner before
beginning any exercise program. Working with a
Physiotherapist is best.
Aquatic Exercises
• Strengthening
– Using hydrostatic pressure, buoyancy & turbulence to
increase resistance & thereby increase strength
• Stretching
– Using hydrostatic pressure & buoyancy to improve static hold
stretches with increased temperature for muscle relaxation
• Cardiovascular endurance
– Using hydrostatic pressure & turbulence to improve
diaphragmatic breathing and cardiovascular endurance
• Neuromuscular coordination
– Using hydrostatic pressure to improve proprioception with
dynamic movements, which improves motor planning &
output coordination
Strengthening
 Active strengthening
 Upper Extremity Strengthening

Begin with 10-20 reps x 1 set; progress to 20-30 reps x 2-3 sets
 Lower Extremity Strengthening

Begin with 10-20 reps x 1 set; progress to 20-30 reps x 2-3 sets
 Trunk Strengthening

Begin with 2-3 min. duration; progress to 15 min. duration
 Passive strengthening
 e.g. Bad Ragaz therapy (buoyancy supported)
Upper Extremity Strengthening
 Arm Circles
 Shoulder depressions
 Shoulder retractions
 Pool side push-ups
Lower Extremity Strengthening
 Leg circles
 Kicking
 Seated outside of pool
 Seated on pool step
 On kickboard
 Side-stepping
 Jumping forward (1 leg or both)
 Stepping up/down pool steps
 Jumping jacks
Trunk Strengthening
 Diving underwater for rings
 Balancing on kickboard
 Straddle sit on swim noodle
 Plank + kick on pool step
 Abdominal twists
Stretching
 Active stretching
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Begin with 10-30” hold x 1-3x
Progress to 30” hold x 3
 Upper extremity
 Lower extremity
 Passive stretching
 Partner performs passive range of motion (PROM) or
proprioceptive neuromuscular facilitation (PNF)
 Best performed by a Physiotherapist
Upper extremity Stretching
 Chest / biceps stretch
 Clasp hands behind back or grab
handrails / pool side if unable to
reach behind back
 Triceps / shoulder stretch
 Use swim noodle
Lower Extremity Stretching
 Calf stretch
 Hamstring stretch
 Place heel on pool step
Cardiovascular endurance
 Treading water
 Begin with 10-30” trials x 3
 Progress to 1-2 min. trials x 2-3
 Walking in chest-waist deep water
 Begin with 2-3 min. trials x 3
 Progress to 5-10 min. trials x 2-3
 Progress to 20-30 min. x 1
 Aqua jogging (use Flotation Belt)
Neuromuscular coordination
 Exercises that improve the brain-body connection with
coordinated movement!
 Shooting basketball
 Stepping up/down pool step
 Side-stepping
 Walking backwards
 Dribbling weighted soccer ball
 To improve balance
 Karate kicks on one leg
 Making “waves”

Creating turbulence while maintaining sitting or standing
Case Examples:
 Primary Lateral Sclerosis
 Hereditary Spastic Paraplegia
for PLS (Primary lateral Sclerosis)…
 Stiffness, weakness and spasticity in legs
 Leg exercises, PROM, water temp more than 35ºC
 Decreased balance & increased clumsiness
 Picking up swim rings with feet to improve coordination
 Trunk weakness
 Balancing on swim noodle or kickboard
 Hoarseness, reduced rate of speaking, slurred speech and drooling
 Blowing bubbles in water to maintain strength
 Difficulties with swallowing and breathing
 If you have breathing difficulties, do not immerse deeper than the
belly button to avoid increased difficulty.
for HSP symptoms…
 Difficulty walking
 Negotiating obstacles
 Balance on one leg
 Progressive spasticity
 Water temp more than 35ºC
 Muscle weakness
 Strengthening exercises
Word of caution…
 Avoiding overuse
 Overuse can often exacerbate weakness & spasticity
 Strengthening can only occur once muscles have
achieved muscle fatigue
 This can be difficult to feel in the water
 Use caution with muscles < 3+/5 per MMT (manual
muscle test)

Difficult to move against gravity? Don’t isolate muscle in pool!
 Signs of overuse: cramps or spasm, pain, extreme fatigue
Research
 Aquatic exercise provides increased ease of movement with
less pain than land-based programs.
 (Broach & Dattilo, 2001; Cooper, 1976; Mobily, Mobily, Lessard &
Berkenpas, 2000; Mobily & Verburg, 2001).
 Participants can typically participate with lower body
temperatures, less muscle stress, less energy expenditure
and less guarded actions associated with fear of failing and
improved performance.
 (Broach & Dattilo, 2001).
Research cont’d
 The sheer weight of the water provides natural
compression on joints and promotes reduction in
swelling.
 (Mobily, Mobily, Lessard, & Berkenpas, 2000).
 Water provides a source of graded resistance conducive
to improvement in muscular strength and endurance
when the limbs are moved repeatedly through a range
of motion over the course of an extended period of
time.
 (Mobily & Verburg, 2001).
Research cont’d
 The physical benefits of activity performed in the water
may include: relief of pain, decreased spasticity and
increased relaxation, improved bone density, improved
pulmonary function, strengthened muscles, improved
endurance and improved range of motion and increased
circulation.
 (Broach & Dattilo, 1996)
 Participants stated they felt that the most important
outcome of AT included increased freedom of
movement, relaxation, energy and social interactions
 Broach and Dattilo (2001),
Research cont’d
 Psychological benefits of participation in aquatic therapy
have been identified to include improved mood, enhanced
self-esteem and body image and decreased anxiety and
depression.
 (Broach & Dattilo, 1996).
 Scuba diving program significantly reduces spasticity
per Modified Ashworth scale for paraplegics.
 (Haydn et al. 2007)
Resources
 Spine Health Water Therapy Exercise Program
 http://www.spinehealth.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
Resources cont’d
 Books / Videos
 Free at your local library or on youtube.com
 http://www.youtube.com/watch?v=A80fpkGHBpU&feat
ure=related
 http://www.youtube.com/watch?v=FHphTmeZV-g
About the author:
 Graduated from Virginia Commonwealth University’s
Medical College in 2008
 Doctor of Physical Therapy (physiotherapy)
 Practice experience with: progressive neurological
disorders, sports medicine, post-op orthopaedics,
paediatrics to include autism.
 Paediatric Physical Therapist (physiotherapist) with
Himmel Home Health- New Braunfels - San Antonio
area, Texas, USA.