The Benefits of Water: Seen & Unseen Benefits of Aquatic Therapy

1. The Benefits of Water:Seen & Unseen Benefits of Aquatic Therapy Katie St. Mars, PT, DPT

2. Table of Contents • Fundamentals of Aquatics • Properties of water • Precautions • Contraindications • Types of Aquatic Therapy • Equipment used • Exercises • HSP / PLS implications • Research • Resources

3. Fundamentals of Aquatics Properties of water: • Buoyancy • Viscosity • Hydrostatic pressure • Turbulence Contributing factors: • Temperature • Depth

4. 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

5. 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.

6. Buoyancy So what? • Muscle weakness • 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.

7. 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!

8. H20 leg press vs. leg press on land

9. 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

10. 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

11. “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.

13. Temperature • for aerobic conditioning, water temp at 26-29ºC • to reduce spasticity & pain, water temp at 33-37ºC • Note: MS patients should have aquatic therapy no higher than 29ºC at most.

14. 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

15. 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

16. When not to do Aquatic Therapy • 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

17. Therapies that can be done in water: • Ai Chi • Feldenkrais • BackHab • Proprioceptive Neuromuscular Facilitation • Water Pilates • Bad Ragaz • Watsu • Halliwick • Wassertanzen

18. Equipment • Foam dumbbells • Fins/Flippers • Float Cuffs • Floatation belt • Jug (air filled) • Kickboard • Neck collar • Resistance boots • Resistance paddles • Weights • Swim noodle

19. Equipment: Foam Dumbbells • Purpose: • Strengthening • Upper extremity • Trunk • Floatation support

20. Equipment: Fins/Flippers • Purpose: • Strengthening • Lower extremities • Abdomen • Low back • Propulsion when swimming

21. Equipment: Float Cuffs • Purpose: • Strengthening • Upper extremity • Lower extremity • The further away from your body the cuff is placed, the more difficult the exercise

22. 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.

23. Equipment: Jug (air filled) • Purpose: • Strengthening • Upper extremity • Trunk

24. Equipment: Kickboard • Purpose • Floatation support • Balance • Attempting to maintain prone

25. Equipment: Neck collar • Purpose • Floatation support • To prevent strain to cervical spine

26. Equipment: Resistance boots • Purpose • Strengthening • Lower extremity • Abdomen • Low back

27. Equipment: Resistance paddles • Purpose • Strengthening • Upper extremity • Trunk

28. 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

29. Equipment: Swim noodle • Purpose • Floatation assistance • Strengthening • Upper extremity • Lower extremity

30. Exercises you can do! Always check with your health care practitioner before beginning any exercise program. Working with a Physiotherapist is best.

31. 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

32. 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)

33. Upper Extremity Strengthening • Arm Circles • Shoulder depressions • Shoulder retractions • Pool side push-ups

34. 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

35. Trunk Strengthening • Diving underwater for rings • Balancing on kickboard • Straddle sit on swim noodle • Plank + kick on pool step • Abdominal twists

36. Stretching • Active stretching • 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

37. 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

38. Lower Extremity Stretching • Calf stretch • Hamstring stretch • Place heel on pool step

39. 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)

40. 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

41. Case Examples: • Primary Lateral Sclerosis • Hereditary Spastic Paraplegia

42. 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.

43. for HSP symptoms… • Difficulty walking • Negotiating obstacles • Balance on one leg • Progressive spasticity • Water temp more than 35ºC • Muscle weakness • Strengthening exercises

44. 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

45. 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).

46. 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).

47. 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),

48. 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)

49. Resources • 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

50. Resources cont’d • Books / Videos • Free at your local library or on youtube.com • http://www.youtube.com/watch?v=A80fpkGHBpU&feature=related • http://www.youtube.com/watch?v=FHphTmeZV-g