Aquatic Rehabilitation

Matt McGraw MS, ATC, PES, CES

March 2, 2019

Overview

• History of Aquatic Rehabilitation

• Principles of Water

• Aquatic Therapy Techniques

• Contraindications and Precautions

• Indications and Advantages

• Things to think about

History of Aquatic Rehab

• Early Civilizations - early 20th Century

• Belief that hot springs/spas provided

therapeutic and medicinal value

• Social activity

• Hot air/water and cold plunge

• Limited use of submerged exercise

History of Aquatic Rehab

• 1830: Vincenz Priessnitz

• Combined cold water with exercise to strengthen ill

patients

• Dr. Winternitz

• Researched varying water temps on sick patients

• U.S. treatment modality during smallpox

outbreak for Neurological Rehab

• 1913: Dr. Charles Leroy Lowman

• 1924: Hubbard Tank

History of Aquatic Rehab• 1930’s Underwater PT with Physical Exercise in

Warm Water

• 1937: Dr. Lowman

• Technique of Underwater Gymnastics: A Study

in Practical Application

• Dr. Rebekah Wright: Mental Diseases

• 1960’s and 70’s: Space Age

• 1980’s: American Physical Therapy Association

• Aquatic Therapy and Rehabilitation Institute

Aquatic Therapy Today

• Used to Improve

• Balance

• Coordination

• Weight Bearing

• Strength

• Endurance

• Pain management

• ROM

• Motor Control

• Circulatory Function

Principles of Water

• Buoyancy

• Archimedes' principle:

• Buoyant force on an object submerged in a fluid is equal to the weight of the fluid that is displaced by the object

• 50% Umbilicus

• 60% Xiphoid process

Principles of Water

• Benefits include:

• Decrease:

• Joint compressive forces

while weight bearing

• Stress on connective tissue

• Fear of falling

• Blood pooling

• Increase:

• Supports weak muscles

• Enhance flexibility

• ROM

• Easier to handle patient

• Changes the

Biomechanical Stress

Principles of Water

• Hydrostatic Pressure (HP): Water exerts a pressure of 22.4 mm Hg/ft of

water depth equally in all directions.

• 12” = 22.4 mm Hg/ft

• 24” = 44.8 mm Hg/ft

• 36” = 67.2 mm Hg/ft

• 48” = 89.6 mm Hg/ft

Principles of Water

• Effects of Hydrostatic Pressure on systems of the body:

• Cardiovascular system:

• Forces blood from the legs into the chest

• Heart pumps excess blood

• Causing it to stretch

• Increased heart muscle contraction

• Causes heart to empty more completely

• Starlings law: Heart requires fewer heart beats to pump the

same volume of blood, decreasing the HR in the water.

Principles of Water

• Respiratory system

• Increased blood flow, makes breathing harder

• HP on the chest causes pressure on the diaphragm

• pressure=resistance, forcing air out of the lungs

• Improves inhalation and assist exhalation

Principles of Water

• Nervous system:

• Interprets sensory information about the

bodies position in space, temperature,

pressure, and sensations

• Receives sensory stimulation which aids

in decreasing pain

Principles of Water

• Viscosity: Resistance of a fluid to change in shape or movement

• Accommodating resistance: Resistance that

matches the patients applied force of effort

• Variable resistance: the ability to change the

speed, velocity, &/or direction of the movement

• Works opposing muscle groups equally, unlike

the equivalent on land

Principles of Water

• Assist patients by dampening

involuntary movements

• Parkinson’s

• Cerebral Palsy

Principles of Water

• Thermodynamics: More efficient at transferring heat than air.

• Recommended Temp Therapy Pool

• 33.5-35.5 C (92.3-95.9 F)

• Recommended Temp Vigorous

Exercise

• 26-29.5 C (78.8-85.1 F)

Aquatic Therapy Techniques

• Aquatic Therapist use principles and interactions with

patients to create progressive exercises that are:

• Passive to active

• Isometric

• Isotonic

• Isokinetic

• Incorporate fundamental PNF

Aquatic Therapy Techniques

• Bad Ragaz Ring Method (BRRM):

• 1957 Dr. Knupfer

• 3 rings to keep client supported in horizontal supine or prone position

• Watsu:

• 1980’s

• Gentle rhythmic moves

• Viscera

• Limbic system

• Nervous system

• Musculoskeletal system

• Psyche

Aquatic Therapy Techniques

• Ai Chi

• 1990 Jun Konno

• Fluid movement

• Long axis

• Posture

• Breathing

• Visualization

• Imagery

• Benefits:

• Increased

• Flexibility

• ROM

• Mobility

• Improves

• Insomnia

• Depression

Aquatic Therapy Techniques

• Other current therapy techniques

• Backhab

• Burdenko method

• Feldenkrais

• Halliwick

• PNF

• Unpredictable command technique

Contraindications

• Phobia of water

• Trouble breathing

• Pulmonary disease

• Weak chest muscles

• Unstable cardiac conditions

• Unstable vital signs

• Uncontrolled hypertension

• Uncontrolled seizures

• Uncontrolled diabetes

Contraindications

• Open wounds

• Infected wounds

• Active infections

• ex: GI virus causing diarrhea, vomiting, or

exposure to other bodily fluids

• Fever

• Kidney Failure

Examples of Precautions

• Severe or chronic ear infections

• Chronic UTI

• Yeast Infection

• Chronic skin diseases

• Dermatitis

• Psoriasis

• At risk of Hyper or Hypothermia

Indications and Advantages

• Patient needs can be addressed by principles of water

• Patients that require the physical properties of water to increase function

• Extreme pain against gravity, buoyancy may help (neurological disease or disorder)

• Patients with edema in LE may benefit from hydrostatic pressure

• Patients with Arthritis

Indications and Advantages

• Patient can practice in reduced load before land equivalent

• Patient needs variety in rehabilitation

• Respiratory strengthening and efficiency

• Strengthens heart

• Improves pain due to over sensory stimulation

Things to think about

• Align your Aquatic policies and procedures

with local and state bathing codes, and federal

regulations

• Post appropriate signage in pool area

• Therapist in the pool?

• Assisting patient (safety)

• Challenge patient

• Calling for help in an emergency

Things to think about

• Patient safety

• Slip resistance mats

• Wear appropriate footwear out of the pool

• Adequate overhead lighting

• Handicap accessible

• Appropriate changing room

• Restroom easily accessible

• Shower available

Things to think about

• Variety of aquatic exercise modalities

• Appropriate storage

References- Gianfaldoni, S., Tchernev, G., Wollina, U., Roccia, M. G., Floranelli, M., Gianfaldoni, R., & Lotti, T. (2017). History of Baths and Thermal Medicine. Journal of Medical Sciences, 5(4), 566-568. doi:10.3889/oamjms.2017.126

- Hydrotherapy. (2017, April 26). In Encyclopedia Britannica, Inc. Retrieved from https://www.britannica.com/science/hydrotherapy

- Becker, B. E. (2009). Aquatic Therapy: Scientific Foundations and Clinical Rehabilitation Applications. Pm&r, 1(9), 859-872. doi:10.1016/j.pmrj.2009.05.017

- Thein, J. M., & Brody, L. T. (1998). Aquatic-Based Rehabilitation and Training for Elite Athlete. The Journal of Orthopedic and Sports Physical Therapy, 27(1), 32-41. doi:https://doi.org/10.2519/jospt.1998.27.1.32

- Waller, B., Lambeck, J., & Daly, D. (2009). Therapeutic aquatic exercise in the treatment of low back pain: A systematic review. Clinical Rehabilitation, 23(1), 3-14. doi:10.1177/0269215508097856

- Prins, J., & Cutner, D. (1999). Aquatic Therapy in the rehabilitation of athletic injuries. Clinics of Sports Medicine, 18(2), 447-461.

- Marinho-Buzelli, A. R., Bonnyman, A. M., & Verrier, M. C. (2014). The effects of aquatic therapy on mobility of individuals with neurological diseases: A systematic review. Clinical Rehabilitation, 29(8), 741-751. doi:10.1177/0269215514556297

- Valtonen, A., Pöyhönen, T., Sipilä, S., & Heinonen, A. (2010). Effects of Aquatic Resistance Training on Mobility Limitation and Lower-Limb Impairments After Knee Replacement. Archives of Physical Medicine and Rehabilitation, 91(6), 833-839. doi:10.1016/j.apmr.2010.03.002

- Becker, Bruce E., and Andrew J. Cole. Comprehensive Aquatic Therapy. Washington State University, 2011.

References- Ultimate Guide to Aquatic Therapy & Water Therapy - HydroWorx®. (n.d.). Retrieved from https://www.hydroworx.com/research-education/additional-resources/aquatic-therapy-guide/

- An Introduction to Aquatic Therapy. (2016, June 15). Retrieved from http://www.rainbowrehab.com/introduction-aquatic-therapy/

- The History of Aquatic Therapy. (2015, September 12). Retrieved from https://www.physicalrehabstl.com/the-history-of-aquatic-therapy/

- Kauffman, B. E., & Kauffman, B. W. (2014). Aquatic Therapy. In A Comprehensive Guide to Geriatric Rehabilitation (pp. 517-519). Churchill Livingstone Elsevier.

- Aquatic Therapy: A Viable Therapeutic Recreation Intervention. (n.d.). Retrieved from https://www.researchgate.net/publication/234563482_Aquatic_Therapy_A_Viable_Therapeutic_Recreation_Intervention

- Wyatt, F. B., Milam, S., Manske, R. C., & Deere, R. (2001). The Effects of Aquatic and Traditional Exercise Programs on Persons With Knee Osteoarthritis. Journal of Strength and Conditioning Research, 15(3), 337-340. doi:10.1519/00124278-200108000-00013

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- Meyler, J., Moss, R., & Skinner, B. (n.d.). Going with the flow: The use of aquatic therapy in sports injury rehabilitation. https://www.co-kinetic.com/content/going-with-the-flow-the-use-of-aquatic-therapy-in-sports-injury-rehabilitation

- Norton, Charlotte O., and Lynette Jamison. A Team Approach to the Aquatic Continuum of Care. Butterworth-Heinemann, 2000.