Midterm_7 POOL Therapy

Prepared by: SONIA C. CASTRO, PTRP

Aquatic exercise refers to the use of multidepth immersion pools or

tanks that facilitate the application of various established therapeutic interventions, including stretching, strengthening, joint mobilization, balance and gait training, and endurance training.


Goals of Aquatic Exercise The specific goals include: Facilitate range of motion (ROM) exercise Initiate resistance training Facilitate weight-bearing activities Enhance delivery of manual techniques Provide three-dimensional access to the patient Facilitate cardiovascular exercise Initiate functional activity replication Minimize risk of injury or reinjury during rehabilitation Enhance patient relaxationPrepared by: SONIA C. CASTRO, PTRP

Why do Aquatic Exercises? The specific purpose of aquatic exercise is to facilitate

functional recovery by providing an environment that augments a patients and/or practitioners ability to perform various therapeutic interventions.


Advantages of Aquatic Therapy Early activity with non-weight bearing status Reduction of joint compressive forces Warmth of water

Relaxation of muscles Gate theory mechanisms Psychological factors


Precautions Fear of Water Fear of water can limit the effectiveness of any immersed activity. Fearful patients often experience increased symptoms during and after immersion because of muscle guarding, stress response, and improper form with exercise. Neurological Disorders Ataxic patients may experience increased difficulty controlling purposeful movements. Patients with heatintolerant multiple sclerosis may fatigue with immersion in temperatures greater than 33C.51 Seizures Patients with controlled epilepsy require close monitoring during immersed treatment and must be compliant with medication prior to treatmentPrepared by: SONIA C. CASTRO, PTRP

Precautions Cardiac Dysfunction Patients with angina and abnormal blood pressure also require close monitoring. For patients with cardiac disease, low-intensity aquatic exercise may result in lower cardiac demand than similar land exercise. 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 fixation.


Contraindications Incipient cardiac failure and unstable angina.

Respiratory dysfunction; vital capacity of less than 1

liter. Severe peripheral vascular disease. Danger of bleeding or hemorrhage. Severe kidney disease: Patients are unable to adjust to

fluid loss during immersion. Open wounds, colostomy, and skin infections such as

tinea pedis and ringworm.Prepared by: SONIA C. CASTRO, PTRP

Contraindications Uncontrolled bowel or bladder: Bowel accidents

require pool evacuation, chemical treatment, and possibly drainage. Water and airborne infections or diseases: Examples

include influenza, gastrointestinal infections, typhoid, cholera, and poliomyelitis. Uncontrolled seizures: They create a safety issue for

both clinician and patient if immediate removal from the pool is necessary.


BUOYANCY Definition. Buoyancy is the upward force that works opposite to gravity. Properties. Archimedes principle states that an immersed body experiences upward thrust equal to the volume of liquid displaced. Clinical Significance Buoyancy provides the patient with relative weightlessness and joint unloading, allowing performance of active motion with increased ease. Buoyancy allows the practitioner three-dimensional access to the patient.Prepared by: SONIA C. CASTRO, PTRP


Hydrostatic Pressure Definition. Hydrostatic pressure is the pressure exerted

on immersed objects. Properties Pascals law states that the pressure exerted by fluid on an

immersed object is equal on all surfaces of the object. As the density of water and depth of immersion increase, so does hydrostatic pressure.

Clinical Significance Increased pressure reduces or limits effusion, assists venous return, induces bradycardia, and centralizes peripheral blood flow. The proportionality of depth and pressure allows patients to perform exercise more easily when closer to the surface.Prepared by: SONIA C. CASTRO, PTRP

Viscosity Definition. Viscosity is friction occurring between

molecules of liquid resulting in resistance to flow. Properties. Resistance from viscosity is proportional to the velocity of

movement through liquid.

Clinical Significance Waters viscosity creates resistance with all active movements. A shorter lever arm results in increased resistance. During manual resistance exercises stabilizing an extremity proximally require the patient to perform more work. Stabilizing an extremity distally requires the patient to perform less work. Increasing the surface area moving through water increases resistance.Prepared by: SONIA C. CASTRO, PTRP

Surface Tension Definition. The surface of a fluid acts as a membrane

under tension. Surface tension is measured as force per unit length. Properties The attraction of surface molecules is parallel to the

surface. The resistive force of surface tension changes proportionally to the size of the object moving through the fluid surface.

Clinical Significance An extremity that moves through the surface performs more work than if kept under water. Using equipment at the surface of the water increases the resistance. by: SONIA C. CASTRO, PTRP Prepared

Hydromechanics Definition. Hydromechanics comprise the physical properties and characteristics of fluid in motion. Components of Flow Motion Laminar flow. Movement where all molecules

move parallel to each other, typically slow movement. Turbulent flow. Movement where molecules do not move parallel to each other, typically faster movements. Drag. The cumulative effects of turbulence and fluid viscosity acting on an object in motion.Prepared by: SONIA C. CASTRO, PTRP

Clinical Significance of Drag As the speed of movement through water increases, resistance to motion increases. Moving water past the patient requires the patient to work harder to maintain his/her position in pool. Application of equipment (glove/paddle/boot) increases drag and resistance as the patient moves the extremity through water.


Special equipment for aquatic exerciseCollars, Rings, Belts, and VestsEquipment designed to assist with patient positioning by providing buoyancy assistance can be applied to the neck, extremities, or trunk. Inflatable cervical collars are used for the supine patient to support the neck and maintain the head out of the water


Special equipment for aquatic exerciseSwim Bars Buoyant dumbbells (swim bars) are available in short and long lengths. They are useful for supporting the upper body or trunk in upright positions and the lower extremities in the supine or prone positions. Patients can balance (seated or standing) on long swim bars in deep water to challenge balance, proprioception, and trunk strength.Prepared by: SONIA C. CASTRO, PTRP

Special equipment for aquatic exerciseGloves, Hand Paddles, Fins and Boots

Resistance to upper and lower extremitymovements is achieved by applying webbed gloves or progressively larger paddles to the hands and boots/fins on the leg and feet. These devices are not buoyant and, therefore, only resist motion in the direction of movement.


Special equipment for aquatic exerciseKickboards used to provide buoyancy in the prone or supine positions, create

resistance to walking patternsin shallow water when held

vertically, or used to challengeseated, kneeling, or standing balance in the deep by: SONIA C. CASTRO, PTRP water. Prepared

Exercise Equipment Assistive devices Floatation cuffs Pull buoys Vests and belts

Resistive devices Water shoes Fins Boots

Kickboards Water dumbbells

Webbed gloves Paddles Bells


Aquatic Therapy Techniques Ai Chi: a combination of deep breathing and slow broad movements of the arms, legs and torso using concepts of Tai Chi, Shiatsu and Qigong. Performs standing in shoulder-depth water with an ideal pool temp of 88F to 96F Ai Chi Ne: (pronounced Eye Chee Knee) is a partner stretching program. It involves breathing techniques to increase relaxation and therefore enhance the stretch abilities. BackHab: a program that the individual can do on his own. It is an aquatic walking program using various strides to accomplish a variety of benefits. It is excellent for gait re-training. Bad Ragaz Ring Method: a method of muscle re-education utilizing specific patterns of resistance, endurance, elongation, relaxation, ROM and tonal

reduction. The Burdenko Method: used for athletic training and as a therapeutic methods for people with disabilities. Concept includes integrating land and water therapy, using a vertical position, focusing on the whole body and homework.Prepared by: SONIA C. CASTRO, PTRP

Aquatic Therapy Techniques Feldenkrais: uses gentle movement and directed attention to

improve movement and enhance human functioning. This method aims to increase ease and ROM, improve flexibility and coordination and encourage the individual to rediscover innate capacity for graceful efficient movement. Halliwick: an approach to teaching people with physical and/or

learning difficulties to participate in water activities, to move independently in water and to swim. Lyu Ki Dou: various hands-on healing modalities along with Ai

Chi, Tai Chi and Qi Gong. Massage: water massage used for soft tissue manipulation and

body mobilization techniques in water.Prepared by: SONIA C. CASTRO, PTRP

Aquatic Therapy Techniques Proprioceptive Neuromuscular Facilitation (PNF):

exercises consist of spiral and diagonal patterns and must incorporate three components of motion: flexion or extension, adduction or abduction and rotation. Water Pilates: Pilates exercises adapted for the pool. This

body conditioning program is designed to improved strength, flexibility and range of motion (ROM) and laso encourages musculoskeletal alignment. Unpredictable Command Technique (UCT): has a goal

of progressing the clients so that two or more motor movements are done simultaneously.Prepared by: SONIA C. CASTRO, PTRP

Aquatic Therapy Techniques Wassertanzen: a dynamic movement therapy that

includes work below the water surface with the aid of nose clips. Wassertanzen means water dance Water Yoga: performed in warm, waist-to-chest depth

water to develop strength and static balance simultaneously. Watsu: (water + shiatsu) is cradling, one-on-one program

that is experienced in a very warm water (approx 94F) pool. It is for pain reduction, increase ROM, increased circulation, psychological problems, relaxation and reduction of stress. Yogalates: combines Yoga, Pilates, Ai Chi. The objectives

are increase body awareness, strength, ROM , relaxation and inward focus.Prepared by: SONIA C. CASTRO, PTRP

Exercise Session Format Start with 10 to 15 minutes and increase in 5-minute

intervals Use deep breathing to increase vital capacity Use GRADUAL progressive overload Work on balance Work on strength Work on flexibility Longer cool down



INTRODUCTION TO HALLIWICK METHOD Developed by James McMillan in 1950 10-Point Program began at Halliwick School for Crippled

Girls in London. The Halliwick concept is an approach to teaching all people, in particular, focusing on those with physical and/or learning difficulties, to participate in water activities, to move independently in water, and to swim. Children learned to swim independently with increase in head control, trunk stability, breath control, endurance, and self esteem. Concept one of most widely utilized methods of aquatic therapy.Prepared by: SONIA C. CASTRO, PTRP

PHILOSOPHY OF HALLIWICK Goal: Achieve maximum independence in the water and on land through self reliance. Uses a systems theory to implement a psycho-sensory motor approach in water. Focus is that swimming is a means to independence. Encourages active participation without flotation devises.


TEN POINT PROGRAM Motor learning sequence that focuses on postural

control to teach swimming. Three phases make up the ten-point program:


Phase 1: Mental Adaptation (1) Breath control includes holding breath in water and

control in expiration to prevent inhaling or swallowing water. Facilitates forward head movement and head control. Support is given at shoulder girdle, never at head. Gradually support is decreased. Final stages of mental adaptation include, jumping, walking, and turning.


Phase 2: Balance Control (2-8) Balance control is ability to independently maintain or

change a position in the water. Involves balance in stillness and turbulent gliding to

challenge balance control. Sagittal rotation occurs in an upright position by

bending to right or left. Transverse rotation involves moving from standing to

supine to standing. Longitudinal rotation produces a roll in supine to

prone to supine 360 degrees.Prepared by: SONIA C. CASTRO, PTRP

Balance control (Continued) Balance in stillness involves the client assuming a

position and maintaining their balance while the instructor introduces turbulence in the water. Phase 2 challenges swimmers to develop postural

control, spinal range of motion, spinal stabilization, strength, greater control in reaching for objects, righting and supportive reactions, trunk dissociation, scapular depression, maintaining neutral pelvic alignment, head righting reactions, control over lateral rotation, and moving in three dimensional patterns.


Phase 3: Movement (Steps 9-10) Movement phase involves a simple progression

towards creating an effective swimming movement. Movement begins with sculling and progresses to a

double sided rowing activity with both arms symmetrically in supine.


The 10 Point Program1. Mental Adjustment being able to respond appropriately to a different environment, situation or task. The learning of breath control is an important aspect of this work. 2. Disengagement an ongoing process throughout the learning by which the swimmer becomes physically and mentally independent.

3. Transversal Rotation Control (formerly Vertical Rotation) the ability to control any rotation made about a fronto-transversal axis.4. Sagittal Rotation Control the ability to control any rotation made about a sagittotransversal (anterior/posterior) axis. 5. Longitudinal Rotation Control (formerly Lateral Rotation) the ability to control any rotation made about a sagitto-frontal (longitudinal) axis.Prepared by: SONIA C. CASTRO, PTRP

The 10 Point Program6. Combined Rotation Control the ability to control any combination of rotations. 7. Up thrust trusting the water will support you. Sometimes called mental inversion (because the swimmer must invert their thinking and realize they will float and not sink). 8. Balance in stillness floating still and relaxed in the water. This is dependent on both mental and physical balance control. When balanced, other activities can be performed more easily. 9. Turbulent Gliding a floating swimmer is moved through the water by an instructor without any physical contact between them. The swimmer has to control unwanted rotations but makes no propulsive movements. 10. Simple Progression and Basic Swimming Stroke the development from simple propulsive movements made by the swimmer to a stroke which may be individual to each swimmer.Prepared by: SONIA C. CASTRO, PTRP


Exercises for the Spine (Shallow Water)








Exercises for the Spine (Deep Water)


Exercises for the Lower Extremity Ambulation and Balance Activities (Shallow Water) Forward Walking Backward Walking Toe Walking

Heel Walking Lunges Carioca Running


Exercises for the Lower Extremity Ambulation and Balance Activities (Shallow Water)


Hip Exercises (Shallow Water)


Hip Exercises (Shallow Water)


Knee Exercises (Shallow Water)


Knee Exercises (Shallow Water)


Ankle Exercises (Shallow Water)


Exercises for the Lower Extremity Ambulation and Balance Activities (Deep Water)


Hip Exercises (Deep Water)


Hip Exercises (Deep Water)


Knee Exercises (Deep Water)


Upper Extremity Exercises in Shallow Water Shoulder








Upper Extremity Exercises in Shallow Water Elbow


Upper Extremity Exercises in Deep Water






Examples of Manual Stretching Techniques


Examples of Manual Resistance Techniques








For arthritis (hip and knee)

Forward Kick Leg Side Lift Hamstring Curl Kick Out exercise Side Kick Out Small Squats Flamingo Toes exercises Leg Circles Side Weight Shifting Front Weight Shifting MarchingPrepared by: SONIA C. CASTRO, PTRP

Midterm_7 POOL Therapy

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