Aquatic Therapy Deanna M. Errico, PT, DPT, ATC Clarkson University - PowerPoint PPT Presentation

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/m 3 ) � 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/m 2 ) � 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 � Remember � Aqua jogging pulmonary and � walking cardiac impacts of � Swimming water � Bicycling � THR is 10-15 BPM lower � Aerobics � Dehydration � Warm-up and Cool- down

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

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