Students: Jordan Amodeo , Nick Bresso, John Calati , Aaron Duca Mentor: Jon Nettie, PT

1. AquaLogix vs. “Standard” Aquatic Equipment In Cardinal and Multiplanar(PNF) Patterns with Patients Who Have Non-Descript Low Back Pain Students: Jordan Amodeo, Nick Bresso, John Calati, Aaron Duca Mentor: Jon Nettie, PT Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences

2. Introduction • Epidemiological studies show that about 80% of the population will suffer from some sort of back pain in their lives, and that low back pain is one of the most frequent complaints among patients • It has been estimated that low back pain costs the economy more than 20 million dollars through medical costs and lost work days

3. Introduction • Conservative interventions can include: • Spinal manipulative therapy • Exercise • Advice and education • Transcutaneous electrical nerve stimulation (TENS) • Aquatic therapy

4. Introduction • Benefits of Aquatic Therapy • Objects in water weigh substantially less so there is less intervertebral disc pressure, allowing for an earlier start to treatment and a more aggressive program. • Buoyancy: force that acts in the opposite direction of earth’s gravity • Hydrostatic pressure: pressure that the water exerts on the immersed object • Water temperature desensitizes the patient from pain

5. AquaLogix Fitness Systems • A multi-patented, diverse array of aquatic exercise equipment that can be utilized to treat a wide variety of patient conditions • Principle of “Omni-directional drag resistance” • The AquaLogix system consists of two devices: bells and fins

6. AquaLogix Bells • The bells are a drag resistance device that encloses the hand of the user in a perforated and finned cage • Provides resistance through all directions of movement • 3 different resistance levels available: • Low – “cardio bells” • Medium – “cross trainers” • High – “sculptors”

7. AquaLogix Bells Low Resistance Medium Resistance High Resistance

8. AquaLogix Fins • The fins are designed similar to an ankle cuff weight. • However, instead of weight plates or sand being placed inside the cuff weight, there are four different fins attached to the outside. • A Velcro strap is used to secure the device round the patient’s lower leg • On each of the four fins there isa transverse fin on the vertical fin • Two different levels of resistance available: low and high

9. AquaLogix Fins

10. Research on AquaLogix Technology • There is currently no research available regarding the use of AquaLogix Fitness Systems to treat patients of any condition or disorder • The only research performed using the AquaLogix technology was by Prins et al. in 2006 • The study examined the use of kinematic motion analysis in the evaluation of selected exercises used in the treatment of patients for whom aquatic physical therapy has proved beneficial • The patients used the AquaLogix bells and fins during the analysis of the resistive force of water and how limb velocities vary as a function of the different cross-sectional areas of each level of AquaLogix bells

11. Call For Research • Aquatic foam dumbbells and ankle weights are typically used for aquatic rehabilitation programs in the treatment of patients with low back pain • Affordable, practical, and widely accepted throughout the physical therapy world • AquaLogix has been gaining notoriety among the fitness world in recent years • Must be brought to the attention of physical therapists implementing aquatic rehabilitation programs • Accurate and reliable research must be performed to determine the effectiveness of the AquaLogix technology compared to standard aquatic dumbbells

12. Purpose • This investigation sought to determine the efficacy of an aquatic therapy protocol using AquaLogix technology in order to improve function and reduce symptoms in patients with non-descript low back pain

13. Hypothesis • It is hypothesized that an aquatic rehabilitation protocol involving AquaLogix technology will provide increased function and a reduction of symptoms related to low back pain when compared to an aquatic rehabilitation protocol without AquaLogix technology.

14. Methods • Sample recruitment: • 90 chronic low back, male and female patients. • 18-65 years of age referred by their physician to the DMC RIM OP PT Brasza Clinic. • Voluntary consent forms. • Participants will be tested for 50 minutes in 8 treatment sessions over a period of 4 weeks. • Twice a week

15. Methods • Participants will undergo a social/medical history and physical examination to determine if they meet the eligibility requirements set by the inclusion and exclusion criteria.

16. Inclusion Criteria • Age 18-65 years • Chronic Low Back Pain (2-6 months).

17. Exclusion Criteria • Inability to participate due to fear of the water. • Any uncontrolled cardiac problems. • Incontinent. • Any uncontrolled diabetes. • Receiving any other treatment for their low back pain.

18. Testing Protocol • There will be two experimental groups, participants will participate in a series of exercise routines. • Participants will be randomly designated to participate in the AquaLogix group (Group 1) or Standard Foam Dumbbell group (Group 2) on the first session. • The subjects selected for Group 1 or 2 will stay in their designated groups through out the entire study. • The same aquatic exercises “protocol” will be used by both groups.

19. Outcome Measures • Oswestry Disability Index (ODI): • The Oswestry Disability Index (ODI) will be used to assess functional outcomes of each subject at the beginning and end of this study. • Numeric Pain Rating Scale (NPRS): • The Numeric Pain Rating Scale (NPRS) will be used by each participant to rate his/her pain levels before and after each physical therapy aquatic class.

20. Design and Procedures • The ODI will be completed prior to the first and following the last intervention. • The subject’s self report of pain using the NPRS will be completed at the beginning and end of each of the (8 or 16) physical therapy aquatic classes.

21. Intervention • Place ankle equipment on prior to entering the pool.

22. Intervention • Warm up: • Walk (width of the pool) for 3 minutes with aquatic equipment on ankles. • General squats: 3 sets of 10 • Submersing body to shoulder height in the water. • May rest hands on side rail for balance.

23. Intervention • UE work: 3 sets of 10 for each. • Alternating shoulder flexion • Bilateral shoulder abduction • Internal/External rotation: arms at the side • (both sides at the same time.) • Horizontal abduction/adduction • (both sides at the same time.) • Shoulder flexion: Bilaterally • PNF D1: Bilaterally • (both sides at the same time.) • PNF D2: Bilaterally • (both sides at the same time.) • Punches: • Grasp equipment, thumbs up, elbows bent then fully extend the arm as if punching

24. Intervention • LE work: 3 sets of 10 for each • Hip extension: Bilaterally • One side at a time. • Hip abduction: Bilaterally • One side at a time. • Hamstring curl: Bilaterally • One side at a time. • Cool down: • Walk (width of the pool) for 3 minutes with aquatic equipment on ankles.

25. Power Analysis • The power analysis for the number of subjects our study will need in each group consists of a t test with a difference between two independent means of the two groups. • With an effect size of 0.60 and an alpha of 0.05 at 80% power, we will need approximately 45 subjects per group (N=90). • The number of subject required might not be practical because we are limited by the occurrences of LBP patients that are referred to RIM and by the possible apprehension of the patients’ willingness to participate in the research.

26. References • Koes BW, Bouter LM, Beckerman H, van der Heijden GJ, Knipschild PG. Physiotherapy exercises and back pain: a blinded review. Brit Med J. 1991;302(6792):1572-6. • Pengel HM, Maher CG, Refschauge KM. Systematic review of conservative interventions for subacute low back pain. ClinRehabil. 2002;16(8):811-20. • Macedo LG, Latimer J, Maher CG, et al. Effect of motor control exercises versus graded activity in patients with chronic nonspecific low back pain: a randomized controlled trial. PhysTher. 2012;92(3):363-77. • Hayden JA, van Tulder MW, Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med. 2005;142(9):776-85. • Konlian C. Aquatic therapy: making a wave in the treatment of low back injuries. OrthopNurs. 1999;18(1):11-8. • Becker BE. Aquatic therapy: scientific foundations and clinical rehabilitation applications. Phys Med RehabilCli. 2009;1(9):859-72. • Waller B, Lambeck J, Daly D. Therapeutic aquatic exercise in the treatment of low back pain: a systematic review. ClinRehabil. 2009;23(1):3-14. • Dundar U, Solak O, Yigit I, Evcik D, Kavuncu V. Clinical effectiveness of aquatic exercise to treat chronic low back pain: a randomized controlled trial. Spine. 2009;34(14):1436-40. • Stout T. AquaLogix Fitness. AquaLogix. 2012. Available at http://www.aqualogixfitness.com/. Accessed March 29, 2012.

27. References • Benson T. National Aeronautics and Space Administration. What is drag? 10 September 2010. Availabe at http://www.grc.nasa.gov/WWW/k-12/airplane/drag1.html. Accessed April 1, 2012. • Kopansky C. Canadian Aquafitnesss Leaders Allianace Inc. Aqua Bells and Fins. 27 September 2011. Available at http://www.calainc.org/Merchandise/belt_and_fins.htm. Accessed April 1, 2012. • Stout T. TLM Enterprises. AquaLogix. 2006. Available at http://www.aqualogixfitness.com/out.php?id=4&page=links.html. Accessed April 2, 2012. • Prins JH, Kimura I, Turner M, Weisbach M, Lehoullier L. The application of kinematic motion analysis in the evaluation of therapeutic exercises used in aquatic rehabilitation. Arch Phys Med Rehabil. 2006;87. • Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine. 2000;25(22):2940-52. • Roland M, Fairbank J. The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire. Spine. 2000;25(24):3115-24. • Finch E, Brooks D, Stratford P, Mayo N. Physical rehabilitation outcome measures: a guide to enhanced clinical decision making. J NeuroEngRehabil. 2005;2(2):1-4. • Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. J ClinNurs. 2005;14:798-804. • Young IA, Cleland JA, Michener LA, Brown C. Reliability, construct validity, and responsiveness of the neck disability index, patient-specific functional scale, and numeric pain rating scale in patients with cervical radiculopathy. Am J Phys Med Rehabil. 2010;89(10):831-9. • Jensen MP, Miller L, Fisher LD. Assessment of pain during medical procedures: a comparison of three scales. Clin J Pain. 1998;14(4):343-9.

28. Questions?