Aquatic Therapy for Lower Aquatic Therapy for Lower Quarter Dysfunction and Quarter Dysfunction and

WellnessWellness

Paula Paula RichleyRichley GeigleGeigle PT, PhDPT, PhDDawn T. Dawn T. GulickGulick PT, ATC, PhD, PT, ATC, PhD,

CSCSCSCS

Background InformationBackground Information

Properties of H2OProperties of H2O

•• Buoyancy: Archimedes: a body entirely or Buoyancy: Archimedes: a body entirely or partially in fluid at rest, has a force acting partially in fluid at rest, has a force acting upward and opposite gravity, equal to the upward and opposite gravity, equal to the weight of fluid displaced.weight of fluid displaced.

•• Clinical Importance: allows movement of Clinical Importance: allows movement of painful or weak body parts that might be painful or weak body parts that might be limited on land.limited on land.

Buoyancy ContinuedBuoyancy Continued

•• Buoyancy may act to:Buoyancy may act to:–– Provide passive movementProvide passive movement–– Support for exercise or assistive exerciseSupport for exercise or assistive exercise–– Provide resisted exerciseProvide resisted exercise

•• Longer lever arm greater torque with buoyancy Longer lever arm greater torque with buoyancy principleprinciple——be careful that is what you want: be careful that is what you want: hamstring stretch, forceful knee extensionhamstring stretch, forceful knee extension——post post acute injury or surgery could be deleteriousacute injury or surgery could be deleterious

Relative DensityRelative Density

•• Density of H2O=1Density of H2O=1•• If density < 1 you will float, air trapped in If density < 1 you will float, air trapped in

lungs (exhalation compromised), lungs (exhalation compromised), increased body fat. Who would you increased body fat. Who would you expect to float more, less?expect to float more, less?

•• If density > 1, you will sink, low body fat, If density > 1, you will sink, low body fat, or respiratory inhalation compromised or respiratory inhalation compromised individualsindividuals

Density ContinuedDensity Continued

•• Upper extremities less dense than lower Upper extremities less dense than lower extremities in general, so upper extremities in general, so upper extremities tend to float better in general extremities tend to float better in general population than lower extremities. Keep population than lower extremities. Keep in mind there are always exceptions.in mind there are always exceptions.

Unloading of Body WeightUnloading of Body Weight

•• Water height at ASIS: unloaded 40% Water height at ASIS: unloaded 40% body weightbody weight

•• Water height at nipple line: unloaded Water height at nipple line: unloaded 70%70%

•• Water height at C7: 90% unloadedWater height at C7: 90% unloaded

Hydrostatic PressureHydrostatic Pressure

•• Pascal’s LawPascal’s Law•• Frank Starling Reflex: (HR x SV =CO); stroke Frank Starling Reflex: (HR x SV =CO); stroke

volume increases secondary to increased volume increases secondary to increased peripheral return from hydrostatic pressure; peripheral return from hydrostatic pressure; therefore, to keep CO stable HR must decrease. therefore, to keep CO stable HR must decrease. For cardiac patients can be beneficial or harmful For cardiac patients can be beneficial or harmful depending upon pathology limitation.depending upon pathology limitation.

Hydrostatic pressure clinical Hydrostatic pressure clinical implicationsimplications

•• Deeper H2O greater hydrostatic Deeper H2O greater hydrostatic pressurepressure

•• Can increase Can increase diuresisdiuresis•• Can decrease edemaCan decrease edema•• Vital capacity must be at least 1500 Vital capacity must be at least 1500

cm3cm3——to avoid lung collapseto avoid lung collapse

Fluid DynamicsFluid Dynamics

•• Laminar flow: provides least resistance Laminar flow: provides least resistance proportional to velocity (faster speed in proportional to velocity (faster speed in water there is more resistance)water there is more resistance)

•• Turbulent flow: high pressure in front of Turbulent flow: high pressure in front of body; low pressure behind bodybody; low pressure behind body

•• Drag: result of turbulent flow pressure Drag: result of turbulent flow pressure differentialsdifferentials——use as intervention principle. use as intervention principle.

Indications for Aquatic Indications for Aquatic InterventionIntervention

•• Aquatics must be used to increase land Aquatics must be used to increase land function, rarely would you prescribe only function, rarely would you prescribe only aquatic program. Some type of land aquatic program. Some type of land program must parallel/support aquatic program must parallel/support aquatic intervention plan. Outcome measures of intervention plan. Outcome measures of success need to include land outcome success need to include land outcome measure.measure.

Aquatic Therapy (AT) UseAquatic Therapy (AT) Use

•• Decreased weight bearingDecreased weight bearing•• To increase/early mobilityTo increase/early mobility•• Overall rehabilitation:coordination, Overall rehabilitation:coordination,

balance, etcbalance, etc•• Decrease painDecrease pain•• Increase circulation (local and systemic)Increase circulation (local and systemic)

AT Use ContinuedAT Use Continued

•• Increase sensory inputIncrease sensory input•• Motivational/PsychologicalMotivational/Psychological•• Slow movements to work on Slow movements to work on

recruitment/timing for training purposes recruitment/timing for training purposes then return to ‘real’ time efforts on landthen return to ‘real’ time efforts on land

PrecautionsPrecautions

•• Cardiac conditionsCardiac conditions•• Unstable vital signsUnstable vital signs•• IncontinenceIncontinence•• Severe/chronic ear infection (not a Severe/chronic ear infection (not a pblmpblm if if

head out of water)head out of water)•• Braces, assistive devices: no plaster casts, Braces, assistive devices: no plaster casts,

fibroglassfibroglass if liner water tolerantif liner water tolerant•• COPDCOPD

Precautions ContinuedPrecautions Continued

•• Involved pregnanciesInvolved pregnancies•• Any land exercise precautionAny land exercise precaution•• Overworking is easy because it feels good to Overworking is easy because it feels good to

exercise in waterexercise in water----be carefulbe careful•• Anxiety of waterAnxiety of water•• If decrease in body core temperature will put If decrease in body core temperature will put

client at risk for chilling (low body fat, decreased client at risk for chilling (low body fat, decreased ability to generate heat with movement)ability to generate heat with movement)

•• Open dermisOpen dermis

ContraindicationsContraindications

•• Uncontrolled seizure activityUncontrolled seizure activity•• Unstable medical condition(timing)Unstable medical condition(timing)•• Behavior that facilitates client, staff or Behavior that facilitates client, staff or

other patient safety issuesother patient safety issues•• Phobia of waterPhobia of water•• Fragile medical condition(systemic) that Fragile medical condition(systemic) that

places client at risk in aquatic environmentplaces client at risk in aquatic environment

Water TemperatureWater Temperature

•• Ideal water temperature: body in H2O cools 4x Ideal water temperature: body in H2O cools 4x faster than in air if less than body temp. Rangefaster than in air if less than body temp. Range----my opinion: 87my opinion: 87--89 degrees for general 89 degrees for general populations able to generate own active populations able to generate own active movementsmovements

•• If air temperature >90 degrees and humidity If air temperature >90 degrees and humidity >60% aerobic exercise should be monitored >60% aerobic exercise should be monitored closely, patient and therapistclosely, patient and therapist

•• High level performance 80 degreesHigh level performance 80 degrees

Postural ControlPostural Control

Postural Control/Core StabilityPostural Control/Core Stability

•• I. HorizontalI. Horizontal–– crunches (semi reclined or full)crunches (semi reclined or full)–– Bad Bad ragazragaz----passivepassive–– Bad Bad ragazragaz----activeactive–– Extremity resistance w/Extremity resistance w/wowo increased surface increased surface

areaarea

Postural Control/Core StabilityPostural Control/Core Stability

•• II. UprightII. Upright–– SittingSitting

•• Cube position (Cube position (HalliwickHalliwick))•• Balance board/waist belt/noodleBalance board/waist belt/noodle

–– StandingStanding•• Crunches (Crunches (SahrmannSahrmann levelslevels----subtle movements)subtle movements)•• Larger amplitude movements of extremities:Larger amplitude movements of extremities:

–– against wall, parallel to wall, away from wallagainst wall, parallel to wall, away from wall

Balance Control/Core StabilityBalance Control/Core Stability

•• II. Upright ContinuedII. Upright Continued–– DynamicDynamic

•• nordicnordic tracktrack•• jumping jacksjumping jacks•• jump twistjump twist•• boundingbounding

–– With all of above: two leg/one leg/no With all of above: two leg/one leg/no resistance on extremities/resistance on resistance on extremities/resistance on extremities/w/extremities/w/wowo additional turbulenceadditional turbulence

Balance Control/Core StabilityBalance Control/Core Stability

•• III. Deep Water (open chain)III. Deep Water (open chain)–– Small amplitude w importance of core stability Small amplitude w importance of core stability

emphasizedemphasized–– MidMid--range amplituderange amplitude–– Large amplitude w/Large amplitude w/wowo resistance can use resistance can use

extremity floats, external turbulence as extremity floats, external turbulence as toleratedtolerated

BAD RAGAZBAD RAGAZ

Bad Bad RagazRagaz Ring MethodRing Method

•• Developed originally Bad Developed originally Bad RagazRagaz, Switzerland, Switzerland•• Horizontal treatmentHorizontal treatment•• Uses properties of water creating program of Uses properties of water creating program of

progressive resistanceprogressive resistance•• Strengthening, muscle reStrengthening, muscle re--education, trunk education, trunk

elongation, relaxation, tone inhibitionelongation, relaxation, tone inhibition•• Uses spiral/diagonal patterns similar to PNFUses spiral/diagonal patterns similar to PNF

Similarities Bad Similarities Bad RagazRagaz and PNFand PNF

•• Maximal resistanceMaximal resistance•• Specific hand holdsSpecific hand holds•• ApproximationApproximation•• TractionTraction•• Short, precise commandsShort, precise commands•• Rhythmic initiation and stabilizationRhythmic initiation and stabilization•• IrradiationIrradiation

PositioningPositioning

•• T10 most optimalT10 most optimal•• Flotation devices head, neck, pelvis; ankle Flotation devices head, neck, pelvis; ankle

and wrist supports as neededand wrist supports as needed•• Therapist positioning requires neutral Therapist positioning requires neutral

body alignment: wide stance, power from body alignment: wide stance, power from legs, core stabilitylegs, core stability----no rotation so spine is no rotation so spine is not exposed to as much torquenot exposed to as much torque

OUTCOME MEASURESOUTCOME MEASURES

Cardiovascular/pulmonaryCardiovascular/pulmonary

•• Dyspnea: vital signs, EEG, exertion scalesDyspnea: vital signs, EEG, exertion scales•• Decreased endurance: Physiologic responses to Decreased endurance: Physiologic responses to

position changesposition changes–– HR, BP, observationsHR, BP, observations–– Lab valuesLab values

•• Increased CV responses to low load: CV Increased CV responses to low load: CV signs/symptomssigns/symptoms–– BP, HR, rhythm, soundsBP, HR, rhythm, sounds–– Angina, claudication, dyspneaAngina, claudication, dyspnea–– EEGEEG

Cardiovascular/pulmonaryCardiovascular/pulmonary

•• Increased CP responses to low load: Increased CP responses to low load: breath/voice sounds, cyanosis, respiratory breath/voice sounds, cyanosis, respiratory pattern/rate/rhythm, ventilatory pattern/rate/rhythm, ventilatory flow/force/volume (spirometry,oximetry)flow/force/volume (spirometry,oximetry)

•• Impaired ventilation: gas analyses from Impaired ventilation: gas analyses from chart, observations, oximetry, airway chart, observations, oximetry, airway clearance tests, pulmonary function testsclearance tests, pulmonary function tests

IntegumentaryIntegumentary

•• ObservationObservation–– Light touch, hot/coldLight touch, hot/cold–– Sensory integrationSensory integration–– Inspection of integumentInspection of integument–– Augmented photographyAugmented photography–– ThermographyThermography

MusculoskeletalMusculoskeletal

•• Manual Muscle Test (MMT)Manual Muscle Test (MMT)•• DynamometryDynamometry•• Performance testsPerformance tests•• Technology assisted analysisTechnology assisted analysis•• Activities Daily Living ScalesActivities Daily Living Scales•• Postural analysis gridsPostural analysis grids•• VideographyVideography

NeuromuscularNeuromuscular

•• Seizure: Client/caregiver/medical record for Seizure: Client/caregiver/medical record for seizure information (review current medications)seizure information (review current medications)

•• Altered Sensory: Stereognosis, tactile Altered Sensory: Stereognosis, tactile discrimination, kinesthesiometry, observations, discrimination, kinesthesiometry, observations, vibration tests, hot/coldvibration tests, hot/cold

•• Altered vestibular:Response to vestibular Altered vestibular:Response to vestibular provocation tests, chart review, patient reportprovocation tests, chart review, patient report

•• Decreased strength: dynamometry, MMT, timed Decreased strength: dynamometry, MMT, timed activities, physical capacity scales, EMGactivities, physical capacity scales, EMG

NeuromuscularNeuromuscular

•• Dysfunction of Dysfunction of recruitment/timing/sequencing: recruitment/timing/sequencing: coordination tests, motor proficiency test, coordination tests, motor proficiency test, motor planning screens, postural motor planning screens, postural challenge testschallenge tests

•• Deconditioning: vital signs, perceived Deconditioning: vital signs, perceived exertion screens, spirometer, aerobic exertion screens, spirometer, aerobic capacity assessmentcapacity assessment

NeuromuscularNeuromuscular

•• Postural Control: observations, technology Postural Control: observations, technology assisted analyses, grid measurement, assisted analyses, grid measurement, functional assessment in pool (reposition functional assessment in pool (reposition head out of water independently)head out of water independently)

•• Peripheral nerves: motor and sensory Peripheral nerves: motor and sensory tests for integritytests for integrity