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Aquatic Therapy. Useful tool to facilitate training
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1. Aquatic Therapy in Rehabilitation
2. Aquatic Therapy Useful tool to facilitate training & fitness
Movement skill & strength can be enhanced
Effects
? joint compression
Reduces muscular guarding
Useful in improving movement and fitness
Basic Concepts as Land-based Rehab
Warm-up
Strengthening/mobility activities
Endurance/cardiovascular
Cool down/stretch
3. Goals Specific Goals:
Facilitate ROM
Initiate resistance training
Facilitate weight-bearing activities
Enhance delivery of manual techniques
Provide 3-dimensional access to patient
Facilitate cardiovascular fitness
Initiate functional activity
Minimize risk of injury/re-injury during rehab
Enhance patient relaxation
4. Precautions & Contraindications Precautions
Fear of water
Neurologic disorders
Seizures
Cardiac dysfunction
Small open wounds & intravenous lines
Contraindications
Onset of cardiac failure & unstable angina
Respiratory dysfunction
Severe peripheral vascular disease
Danger of bleeding or hemorrhage
Severe kidney disease
Open wounds, skin infections
Uncontrollable bowel/bladder
Water & airborne infections or diseases
Uncontrolled seizures
5. Advantages & Benefits Buoyancy allows active exercise while providing a sense of security and minimizing discomfort
Water provides environment in which more can be accomplished than on land
Useful in early stages of rehabilitation
Provides for earlier movement due to ? compressive forces
Supportive environment allows for extra time to control movement proprioception enhancement
Turbulence functions as a destabilizer & as a tactile sensory stimulus
Provides gradual transition from non-WB to full WB
6. Psychologically may allow for increased confidence due to increased ability of function allowed by water
Strengthening & muscle re-education
Strength gains are dependent on effort put forth by athlete
Energy expenditure may be ?
Must perform activity & maintain stability of body within the water
Cardiovascular maintenance
7. Disadvantages Cost
Building & maintaining a rehabilitation pool
Space & personnel
Thermoregulation
Impact on core body temperature
May impact tolerance for participation in heat
Contraindications involved with injuries & potential of open wound
Additional contraindications
Fear of water, fever, urinary tract infection, allergies to pool chemicals, cardiac dysfunction or uncontrolled seizures
If lacking in ability to stabilize body, aquatic training can be challenging
9. Facilities & Equipment Facility must have certain characteristics
Should be at least 10 ft. x12 ft.
Adequate access (either above or below ground pool)
Shallow & deep areas to perform various exercises
Flat pool bottom with marked gradients - optional
Adequate temperature (79-82)
Ancillaries
Prefabricated pools with treadmill or current producing device
Pool toys limited by imagination (gloves, hand paddles, belts, kickboards)
Clothing & attire
10. Equipment Safety equipment
Exercise equipment
Assistive Devices flotation devices
Resistive devices paddles, water shoes, webbed gloves
11. Water Properties Specific Gravity
Buoyancy
Hydrostatic Pressure
Viscosity
12. Specific Gravity Also known as Relative Density:
The density of an objective relative to that of water
The density of a substance divided by density of H2O.
Specific gravity of water = 1
If objects s.g. is > 1, object will sink
If objects s.g. is < 1, object will float
If objects s.g. is = 1, object will float just below water surface
S.G. of fat = 0.8
S.G. of bone = 1.5-2
S.G. of lean muscle = 1.0
Human Body = 0.95-0.97 (Less than 1 - enables the body to float)
13. Buoyancy is partially dependent on body weight
Different body parts will vary
On average, human S.G. is less than water
Doesnt mean body will float due to body part make-up
Factors that determine the specific gravity of the individual body part:
ratio of bone weight to muscle weight
the amount & distribution of fat
depth & expansion of chest
Air in lungs vs. extremities
Lungs filled with air can ? the specific gravity of the chest (allows head & chest to float higher in the water)
14. Buoyancy Upward force that works opposite to gravity
Counterforce that supports submerged or partially submerged object against pull of gravity
Assists motion toward waters surface
Sense of weight loss (equal to amount of water that is dissipated)
Changes relative to level of submersion
Differing levels in males & females due to relative CoG
Allows for ambulation & vigorous exercise with little impact & friction reduction between articular surfaces
Archimedes principle an immersed body experiences upward thrust equal to the volume of liquid displaced
15. Center of Buoyancy Center of buoyancy, rather than center of gravity, affects the body in water
Reference point of an immersed object upon which buoyant (vertical) forces of fluid predictably act
In the vertical position, the human center is located at the sternum
In the vertical position, posteriorly placed buoyancy devices will cause the patient to lean forward (anterior causes patient to lean back)
16. Hydrostatic Pressure Pressure exerted on immersed objects
Pascals Law pressure exerted by fluid on an immersed object is equal on all surfaces of the object
As density of water & depth of immersion ? so does hydrostatic pressure
17. Friction occurring between molecules of liquid resulting in resistance to flow
A fluids thickness
Resistance is proportional to the velocity of movement through liquid
Increasing the surface area moving through water will ? resistance
Viscosity
18. Hydromechanics Physical properties & 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 (also known as Wave Drag) movement where molecules do not move parallel to each other (typically faster movements)
Drag cumulative effects of turbulence & fluid viscosity acting on an object in motion
As speed of movement through H20 ?, resistance to motion will ?. (? speed = ? drag; velocity2)
Moving H20 past the patient will require the patient to work harder to maintain position in pool.
Application of equipment will ? drag & resistance as the patient moves the extremity through H20.
19. 3 Resistive forces at work in H20:
Cohesive force - Runs parallel to the direction of the H20 surface
Result of H20 molecule surface tension
Bow force - Force generated at front end of object during movement
When object moves, ? in H20 pressure at the front and ? pressure in the rear
Creates a pressure gradient, resulting in low pressure zones swirling = eddies (turbulence) create a drag force
Drag force waters resistance to movement within a fluid that is caused by the friction of the fluids molecules
Form Drag resistance that an object encounters in a fluid and is determined by the objects shape & size
Wave Drag waters resistance as a result of turbulence
Frictional Drag result of waters surface tension
Can be changed by shape and speed of object
? streamline = ? drag
Must be considered carefully when attempting to protect a limb during rehabilitation
Drag forces can ? torque at a given joint which may be contraindicated
20. Thermodynamics Water temp. will have an effect on the body & performance
Specific Heat amount of heat (calories) required to raise the temp of 1 gram of substance by 1C.
Rate of temp change is dependent upon mass & specific heat of object
Water retains heat 1000 times more than air
Temperature transfer water conducts temp 25 times faster than air
Heat transfer increases with velocity (patient moving will lose body temp faster than patient at rest)
21. Aquatic Techniques Program can be designed to have active assistive movements & progress to strengthening
Can perform exercises in various positions including:
Supine, prone, side-lying, seated, vertical
Things to consider when performing aquatic techniques:
Type of injury/surgery
Treatment protocols if appropriate
Results/muscle imbalances found in evaluation
Goals/expected return to activity
Program design (similar to land-based programs)
Warm-up
Strengthening/mobility activities
Endurance/cardiovascular
Cool down/stretch
22. Spine Dysfunction Initial Level
Instruct athlete on neutral position in partial squat with back against wall
Wall will provide feedback to monitor ability to maintain position
Progression of upper/lower extremity activity can be incorporated with stabilization exercises
If dealing with sciatica-type symptoms, deep water traction may be beneficial
Work on normalization of gait pattern and increasing ability to bear weight (performed in deep end)
Increasing pelvic mobility through stretching
23. Intermediate Level
Move athlete away from wall
Incorporate equipment to simulate pulling/pushing motions
Can also perform activities that incorporate single leg stance and lunging while challenging dynamic stabilization of core
Supine and prone activity can also be utilized to train core
24. Advanced Level
Must be sure to incorporate activities that mirror challenges of sport and provide higher level of trunk stabilization
Train bilateral activity integrate opposite movement patterns
Athlete should be integrated back to training on land
Water does not allow for normal speeds and forces during sports specific activities
25. Lower Extremity Injuries Initial Level
Goal - restore normal motion & early strengthening
Restore normal gait patterns
Can work on active joint motion (hip, knee, ankle)
Utilize cuffs, noodles, or kickboards under foot will assist with increasing motion
Incorporate conditioning & balance activities
Utilize good postural mechanics while challenging balance/neuromuscular control
Deep-water activities allows for conditioning & cross-training
It also provides an opportunity for non-weight bearing secondary to injury
Incorporate of supine activities
Resistance against uninvolved leg will also allow for strengthening of injured extremity
26. Intermediate Level
Challenge athlete with weights & flotation devices
Be aware if you need to use proximal or distal resistance
Utilize straight & diagonal plane activities
Balance training
Standing on cuff, noodle, uneven surfaces
Deep water tethering for running/sprinting
Continue integrating supine & prone exercises as athletes strength & ability ?
Integrate sports specific activity & jumping progression
27. Final Level
Athlete should be engaged in high level strengthening & conditioning
Program should compliment land-based program
Decrease use of floatation devices, alter use of buoyancy cuffs (minus floatation belt)
Endurance training in aquatic environment is a good alternative for athletes conditioning program
May be useful in preventing recurrence of injury
28. Conclusions Should not be exclusive treatment option for athlete
Many physical & psychological benefits during early stages of rehabilitation
Sports specific training utilize land & water based training to achieve goals
Must be sure to engage in activity at normal speeds and force levels prior to return to play
29. References Houglum, P. (2001). Therapeutic exercise for musculoskeletal injuries, 2nd ed.
Prentice, W. (2004). Rehabilitation techniques for sports medicine and athletic training, 4th ed.
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