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Transcript of Astri dr. tz - aquatic
AQUATIC EXERCISEPembimbing:
DR. dr. Tirza Tamin, SpKFR-K
Presentan:Setia Wati Astri Arifin
Introduction DEFINITION
The use of multidepth immersion pools or tanks that facilitate the application of various established therapeutic interventions
Schrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5 th ed. Philadelphia: F. A. Davis Company, 2007. p. 273
PURPOSEfacilitate functional recovery by providing an environment that augments a patient’s ability to perform various therapeutic interventions
Goals
Schrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5th ed. Philadelphia: F. A. Davis Company, 2007. p. 273
ROM exercise Resistance training
Weight-bearing activities
Delivery of manual
techniques
Access to the patient
Cardiovascular exercise
Functional activity
replication
Minimize risk of injury or reinjury Relaxation
Principles And Properties Of Water
Buoyancy Hydrostatic Pressure
Viscosity Flow•Laminar flow parallel•Turbulent flow not move parallelThermodynamics
Schrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5 th ed. Philadelphia: F. A. Davis Company, 2007. p. 273Becker BE, Cole AJ. Aquatic Rehabilitation. In: DeLisa JA, Frontera RW, Gans BM, Robinson L, Walsh NE, editors. Physical medicine and rehabilitation: principle and practice
Adva
ntag
es
Buoyancy weightlessness and joint unloading increase active motionHydrostatic pressure reduces or limits effusion, assists venous return, induces bradycardia, and centralizes peripheral blood flowViscosity resistance with all active movementsTurbulence destabilizer & tactile sensory stimulusReduces stress and reduces pain to a great extent
Disa
dvan
tage
sCost• Cost of building and
maintaining a rehabilitation pool
Specified personnel• Physiatrists and therapies
must be trained in aquatic safety and therapy procedures
Thermoregulation
Mobility
• Buoyant equipment may assist the movement initially• Warm temperature may increase soft tissue extensibility• Stretch techniques are used in two ways: active & passive
Trunk stabilization
• Consist of 6 steps: walking and marching; jumping in high duck position; arm circling and straight arm pulls; arm supported open chain hip, knee and ankle flexion and extension in backward position; arm supported open chain hip, knee and ankle flexion and extension in forward position; aqua jogging
Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.
Beginning Aquatic Rehabilitation
• As early as possible after the injury to minimize effect of immobilization
• Start with walking in water patient learns to move in this new therapy-medium, feels quite relaxed and pain and fear are reduced
Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.
Design Similar to land-based programsDepends on:• Type of injury/surgery • Treatment protocols• Results/muscle imbalances found in
evaluation • Goals
Hoogenboom B, Lomax N. Aquatic therapy in rehabilitation. In: Prentice WE, editor. Rehabilitation techniques for sports medicine and athletic training. 4th ed. New York: McGraw Hill, 2004. p. 326
Exercise Technique
The four variables that can be manipulated to alter resistance or assistance
1. Position or direction of movement in the water
2. Water depth 3. Lever arm length 4. Use of flotation or
weighted equipment
Brody LT. Aquatic physical therapy. In: Hall CM, Brody LT, editors. Therapeutic exercise , moving toward function. 2nd ed. Philadelphia: Lippincott Williams & Wilkins. p. 330
Temperature Regulation
• Maintain between 26⁰C and 33⁰C for mobility exerciseBecause,– Patients are unable to maintain adequate core warmth
during immersed exercise at temperatures less than 25⁰C– Hot water immersion (> 37⁰C) may increase the
cardiovascular demands at rest and with exercise
• Cardiovascular training and aerobic exercise should be performed in water temperatures between 26⁰C and 28⁰C
Schrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5th ed. Philadelphia: F. A. Davis Company, 2007. p. 273
Similar with land-based exercise, except for its mechanic-kinematic
Water will provide additional resistance to the body core Upper
extremity
Strengthening exercises can be performed completely non weight bearing in the open chainWeight bearing can be increased by reducing the depth or by using weight belts
Lower extremity
Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.
Special Equipment
Pools in-ground swimming pool minimum range 4–5 m depth 1.2 - 1.4 m
Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.
Inflatable Cervical Collar maintain head
Floatation Ring positioning and relaxation
Buoyancy Belt supine, prone, or vertically for shallow and deep water position
Special Equipment
Special Equipment
Swim Bars/ Buoyant
dumbbells maintain head
Gloves generates resistance
Hand Paddles generates resistance
Special Equipment
Hydro-tone® Bells and Boots
generates resistance
Kickboards generates resistance
Ergocycle generates resistance
PrecautionsFear of Water
• need an orientation period
Neurological Disorders
Seizures
• patients with controlled epilepsy require close monitoring
Cardiac Dysfunction
• angina and abnormal blood pressure need close monitoring
Small Open Wounds and Lines• Small, open wounds and tracheotomies may be covered by waterproof dressings• Patients with intravenous lines, Hickman lines, and other open lines require proper
clamping and fixationSchrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5 th ed. Philadelphia: F. A. Davis Company, 2007. p. 273
Contraindication
Schrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5 th ed. Philadelphia: F. A. Davis Company, 2007. p. 273
seizures
Incipient cardiac failure and unstable angina.
Respiratory dysfunction; vital capacity of less than 1liter.
Severe peripheral vascular disease.
Danger of bleeding or hemorrhage.
Severe kidney disease
Open wounds, colostomy, and skin infections such as tinea-pedis and ringworm.
METHODS
Bad Ragaz Ring Method• Technique– The therapist provide stability for the client– 3 action ways: isometrically, isokinetically, isotonically
aquaticsintl.com
Garret G. Bad Ragaz Ring method. In: Ruoti RG, Morris DM, Cole AJ, editors. Aquatic rehabilitation. Philadelphia: Lippincott; 1997. p. 289
• The client wears neck ring float, body ring at the L5-S2 level and extremity rings•The water level should not exceed axillary (T8-T10) level of therapist• Minimal pool area 15,8 m2
• Water depth usually 0,9-1,2 m• Temperature 33,3⁰C – 36,6⁰C
Bad Ragaz Ring Method
• Aim:– Tone reduction– Relaxation– Increasing ROM– Muscle re-education– Strengthening– Spinal
traction/elongation– Improving alignment and
trunk stability
– Preparation of the LE for weight-bearing
– Restoration of normal pattern of LE&UE movement
– Improve general endurance
– Training the body functional capacity
Garret G. Bad Ragaz Ring method. In: Ruoti RG, Morris DM, Cole AJ, editors. Aquatic rehabilitation. Philadelphia: Lippincott; 1997. p. 289
Indication
• Orthopedic & rheumatologic conditions
• Neurologic disorders• Pain syndrome• Sensory
desensitization• Developmental delay
symptoms
Contraindication
• Precaution to excessive fatique
• Vestibular problems• Acute conditions
Garret G. Bad Ragaz Ring method. In: Ruoti RG, Morris DM, Cole AJ, editors. Aquatic rehabilitation. Philadelphia: Lippincott; 1997. p. 289
Bad Ragaz Ring Method
• Trunk Pattern– Stabilization– Rotation– Rotation with flexion– Rotation with
extension• Arm Pattern• Leg Pattern
• Isokinetic/Isotonic/Isometric• Bilateral/Unilateral• Starting Position• Therapist hold• Verbal Commands• Finishing Position• Progression
Bad Ragaz Ring Method
Halliwick Method
BALANCE AND
POSTURE
Can be used for patients with neurologically or developmental impaired
Focusing on patients ability in water and NOT disability on land
Mental AdaptationMaintaining posture and balance with buoyant force influenceOvercome breathing difficultyAdjustment to therapist dis-engagement Balance
RestorationUse primitive reflex activities to control vertical, lateral, and combined rotation movement
InhibitionTeaches clients to hold a posture when challenges are applied on body
FacilitationControlling movement through the waterMaintain balanced posture while being moved passivelySwim stroke
Halliwick Method
AQUATIC REHABILITATION FOR OSTEOARTHRITIS
Aquatic Therapy With Knee Osteoarthritis
• Purpose Prevent atrophy and motion loss and abnormal movement pattern development
Aquatic rehabilitation richaed g.ruoti, david m.morris, andrew j.cole. LIPPINCOT Philadhelpia New york 1997
Limitations of Weight bearing with Buoyancy effect
Aquatic Therapy With Knee Osteoarthritis
Condition associated with weight bearing limitations
Can use exercise according to early phase , intermediate phase and late phase
Limited weight bearing using buoyancy can be initiated early to prevent athropy and motion loss and abnormal movement pattern development
Primary goal : Restore normal gait mechanics• Proper heelstrike• Proper weight
transfer• Proper knee and
hip flexion• Proper knee
ekstensionAquatic rehabilitation richaed g.ruoti, david m.morris, andrew j.cole. LIPPINCOT Philadhelpia New york 1997. pg 79-81
Primary goal:• Increased endurance in
gait• Restoration of full motion• Return of muscle
function.
Primary goal:• Progression to full weight
bearing on ground• Impact loading, plyometric
exercise and functional activities in the pool (optional)
Early Phase
Intermediate Phase
Late Phase
Special Requirement• Water temperature 27-30°C• Depth– Subacute phase: xyphoid level– Chronic phase: SIAS level
• Modify:– Patient’s position– Lever arm length – Direction of movement– Use of flotation or weighted
equipment
Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.
Sample Training Program for Knee Problem
Trunk stabilization Flexion/extension in
floating supine and prone position
Balance training Single leg standing on
heels (up to toes - down to heels - repeat)
Upper extremity training Straight arm pull
Lower extremity training
Walking (forward, backward, sideways)
Endurance training Jogging in deep water Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli
LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.
Activities to improve posture
Activities to increase ROM and flexibility
Activities to increase muscular strength and endurance
Cardiovascular training
Musculosceletal Conditions Of The SpineGOAL :
Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.
Activities To Improve Posture
• Spinal stabilization exercise • Forward walking with a
resistance board• Trunk strengthening
with paddles• Advance spinal
stabilization exercise • Balancing (sitting) on a
kickboard
Activities To Increase ROM And Flexibility
• Hamstring strech with use of floatation bouyance• Forward walking exercise
Passive Trunk Flexion And ExtensionFlexion
Extension Wall slide /squats
Supine lap work, holding kickboard at chest
Hanging in corner, lower extremity flexed, back to wall
Posterior pelvic tilt with back to wall, vertical stabilization with lower
extremities flexion
Activities To Increase Muscular Strength And Endurance
Increase the strength and endurance of the paraspinal and abdominal musculature (important)
Cardiovascular Training
Important in completing the rehabilitation process and facilitating the transtition to a regular fitness regime
1. Walking2. Jogging 3. Swimming strokes4. Immersed cycling 5. Immersed treadmill
Impairment Oriented Rehabilitation
• Mechanical back pain• Soft tissue injuries• Postural dysfunction• Other imparment
oriented considerations
Phase :• Early• Intermediate• Late
Mechanical Back Pain • Include : – discogenic pain, – facet syndrome ,– degenerative joint
disease,– obesity
• Goal : reduction of pain– Unloading the spine by
means of immersion into the shallow/deep end of the pool
– Sensory input from flow along the body
– Water’s warmth
Early PhaseGOALS:1. Reduction of pain2. Correction of any
postural faults (lateral shift, lumbar spine flexion)
3. The establishment of normal movement patterns.
• Variety of positions:– Bad Ragaz techniques for
passive lateral trunk flexion– Passive trunk flexion and
extension– Gentle traction for
lumbar/cervical spine (supine by stabilizing distally or proximally at the trunk then traction force at the head or hips)
– Vertical traction in deeper water by using ankle weight and flotation vest
Intermediate Phase
GOAL :• Increasing the pain-free ROM• Improving ability to generate torque in the trunk
musculature for extended periods of time • Increasing the number of activities performed
without pain.
Technique
Exercise by resistive trunk rotation : • Stabilizing the feet on the bottom of the pool and
rotating the trunk • Stabilizing the trunk by holding on to a stationary
object with the arms and rotating the legs.
Exercise in the pool allows the person to
increase the exercise time and repetition
without increasing joint compression
Patient usually can demonstrate proper
posture when cued, but has difficulty
maintaining the posture for any length of time
Late phase
• Pain free ROM• Dynamic control of posture• Muscular endurance
Functional Needs
NEUROLOGIC DISORDER
Aquatic Rehabilitation Of Clients With Neurologic Disorder
Neurorehabilitation modelMotor learningEnchancing motor skill throught
task analysis
Balance dysfunction • Biomechanical aspect• Motor coordination
• Sensory integration and aquatic solution for balance dysfuntion
Voluntary movement deficit • Central mechanism dysfunction• Periferal mechanism dysfunction
• Aquatic solution for voluntary movement deficit
Gait dysfunction • stance and swing phase
• aquatic solution to gait dysfunction
STROKE
Stroke Aquatic Program
GOAL :
Produce a positive influence on participants over all endurance, strength and flexibility
Provide a convenient, regularly scheduled opportunity for participant to exercise and socialize in a positive, fulfilling manner.
Provide effective, worthwhile educational program
b) Streching (10’- held @15 “) with active streches preferred :1. Hip flexor2. Hip adduction 3. Heel cord4. Back extension5. Shoulder flexion6. Shoulder horizontal
abduction
activities
a) warm up (5 ‘ )for perform increasing blood circulation :
1. Slow walking2. Slow marching at wall3. Slow cycling
c) Movement control (10‘) Aimed : improving control of muscular contractions to enchance smooth, effective joint movement
d) Aerobic activities (15’)to increase heart rate to 50 % to 70 % of maximum heart rate :1. Water walking2. Water running3. Marching at the
side of the pool4. Cycling in the
innertube5. Cycling while held
by a partner
e) Cool down (15’)to return the heart rate gently to a resting level :1. Slow walking2. Slow marching
at the wall3. Slow cycling
PEDIATRIC
Aquatic Rehabilitation In Pediatric
General Safety Consideration :• Oral Motor Control• Ear Chronic Infection• Hiponatremi• Flotation device for
safety
Behavioral considerationsAge guidelines
Cognitive status
Behavioral concerns related to diagnosis.
Aquatic rehabilitation richaed g.ruoti, david m.morris, andrew j.cole. LIPPINCOT Philadhelpia New york 1997
Using Water To Address Problem Area
Alteration in stiffness:
• Hypotonia • Hypertonia • Weakness
ROM
Respiratory problems
Arousal problems
Sensory perseptual difficulties
Aquatic rehabilitation richaed g.ruoti, david m.morris, andrew j.cole. LIPPINCOT Philadhelpia New york 1997
Parent/ Guardian/Caregiver Instruction
• Children require more intense supervision• The assisting enter the water with the child
and therapist to learn the necessary skills• A demonstration by the therapist followed by
a return demonstration by the learner.
Adapted Bad Ragaz
• Requires : the patient respond to a verbal command by the therapist.
• Modified the therapist’s hands become the
vehicle of communication and slight pressure or traction to move.
The therapist’s may be able to hold the child without using flotation if she is small enough or buoyancy enough.
Example • To activate the lateral trunk and legs by
beginning in supported supine, holding at the shoulders, elbows or rib cage to provide stability.• By quickly moving the upper trunk and
shoulders side to side, the child can be helped to move her lower trunk and legs to the side.
Adapted WATSUVery useful :
The severely or profoundly mentally retarded child
Child with increased stiffnessNot indication :
Children who are significantly hypotonic
• Can be used early in the session to “loosen up” the child in preparation for more active work.
Cerebral Palsy, Spastic Diplegia With Minimal Severity Sesion Plan
1. Enter via jumping off deck from a sitting position near therapist
2. Turn around to place hands and feet on the wall, push off the wall with feet and continue with supine flutter kick
3. Supine recovery to do prone flutter kick back to the wall
4. Repeat steps 2 and 3 several times for trunk and lower extremity strengthening.
5. Race across the pool using kickboards for upper extremity stability and flutter kick in either prone or supine.6. Perform an obstacle course with object to retrive from the pool floor using a surface dive7. Trunk and lower extremity exercise in suspended vertical with arms in two kickboards8. Practice with simple hand stands9. Handstands with controlled lower extremity movements into flexion / extension and abduction / adduction10. Exit pool via staircase using two rails and assist as needed
ATHLETE
Aquatic Rehabilitation Of The Athlete
Benefit of aquatic programming for the athlete The Principle of Unloading
The aquatic medium provide the athlete with the opportunities for injury prevention and for immediate onset of safe and functional rehabilitation
Aquatic rehabilitation richaed g.ruoti, david m.morris, andrew j.cole. LIPPINCOT Philadhelpia New york 1997
Purpose
Aquatic rehabilitation richaed g.ruoti, david m.morris, andrew j.cole. LIPPINCOT Philadhelpia New york 1997
To negate or lessen any force that would interfere with a
final goal
unloaded articular cartilage and the cortical and cancellanous bone
Protection of the ligaments and muscle-tendon from
excessive torque or damaging vibrational forces
Exercise prescription
The general principle1. Work in the most shallow water tolerated2. Functional activities should be practice as a whole3. Sytematically remove external stabilization provided for
clients4. Encourage stabilizing contractions in upright positions with
movement of selected body segment5. Encourage quick, reciprocal movement6. Encourage active movement problem solving7. Gradually increase the difficulty of the task.
Type training to improve gait dysfunction
• Standing weight shift• One leg up• Marcing• Kick back• Side kick
• Straight leg kick• Walking with front
support• Walking with side
support
Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.
Hoogenboom B, Lomax N. Aquatic therapy in rehabilitation. In: Prentice WE, editor. Rehabilitation techniques for sports medicine and athletic training. 4th ed. New York: McGraw Hill, 2004. p. 326
Application
Application
Noodle Water