Chapter 16: Aquatic Therapy in Rehabilitation

1. Chapter 16: Aquatic Therapy in Rehabilitation Jenna Doherty-Restrepo, MS, ATC, LAT Entry-Level ATEP Rehabilitation Techniques in Athletic Training

2. Aquatic Therapy • Rapidly becoming popular • Not a new form of therapy  revisited • Effects: • Decreases joint compression • Reduces muscle guarding • Improves movement and fitness

3. Physical Properties • Buoyancy • Counteracts downward pull of gravity • Upward force that supports submerged or partially submerged object • Assists motion toward water’s surface • Sense of weight loss • Changes relative to level of submersion • Differs in males and females due to relative CoG • Allows for ambulation and vigorous exercise • Reduces joint impact • Reduces friction between articular surfaces

4. Physical Properties cont. • Specific Gravity • Buoyancy is partially dependent on body weight • Weight of different body parts will vary • Determined by: • Ratio of bone weight to muscle weight • Amount and distribution of fat • Depth and expansion of chest • Specific gravity of humans is slightly less than water • Enables the body to float • Does not mean that body will float horizontally • Different segments have different specific gravities • Air in lungs vs. extremities

5. Resistive Forces • Cohesive force • Runs parallel to the direction of the water surface • Due to surface tension of water molecules • Bow force • Force generated at the front of an object during movement • Increased water pressure at the front • Decreased water pressure in the rear • Creates a pressure gradient • Low pressure zones swirl = eddies (turbulence) • Creates a drag force

6. Resistive Forces cont. • Drag force • Modified by shape and speed of object • Increase streamline of object = decrease drag • Increase speed of object = increase drag • Must be considered carefully when attempting to protect a limb during rehabilitation • Drag forces = increased torque at a given joint

7. Archimedes's Principle • A gradual increase in weight bearing can be achieved with aquatic therapy • Progression: deep to shallow • Take advantage of buoyancy property • Closed kinetic chain exercises • Proprioceptive benefits • Reduces joint compression/friction forces

8. Aquatic Rehabilitation: Advantages • AROM exercises supported through buoyancy • Minimizes discomfort • Sense of security • Useful in early stages of rehabilitation • Supportive environment • Proprioception enhancement • Turbulence provides perturbations and tactile sensory stimulus • Extremely useful with lower-extremity injuries • Provides gradual transition from non to full weight-bearing • May allow earlier locomotion due to decreased compressive forces

9. Aquatic Rehabilitation: Advantages • Psychological impact • Increased confidence due to increased function allowed by water • Strengthening and muscle re-education • Dependent on effort put forth by athlete • Energy expenditure • Aerobic workout possible to maintain CV fitness

10. Aquatic Rehabilitation: Disadvantages • Building and maintaining a rehabilitation pool • Space and personnel • Aquatic training may be too challenging if athlete unable to stabilize body • Thermoregulation • May impact tolerance for participation in heat • Contraindications: • Open wounds, fear of water, fever, urinary tract infection, allergies to pool chemicals, cardiac dysfunction or uncontrolled seizures

11. Facilities and Equipment • Facility must have certain characteristics • Should be at least 10 x 12 • Adequate access • Shallow and deep areas • Flat pool floor with marked gradients • Adequate temperature (79-82 degrees) • Ancillaries • Prefabricated pools with treadmill or current producing device • Pool toys – limited by imagination

13. Aquatic Techniques • Must consider • Type of injury/surgery • Treatment protocols if appropriate • Results/muscle imbalances found in evaluation • Goals/expected return to activity • Program design • Warm-up • Strengthening/mobility activities • Endurance/cardiovascular • Cool down/stretch

14. Upper Extremity Injuries • Initial Level • Start at chest depth • Warm-up: Walking with natural arm swing in an effort to restore normal scapulothoracic motions • Goal: Shoulder movement without compensation • Supine positioning • Stretching, mobilization and range of motion • Prone positioning (w/ snorkel) • Pendulum and PNF diagonal plane activity

15. Upper Extremity Injuries • Intermediate Level • Goal: Develop strength and eccentric control throughout ROM • Strengthening progression • Use equipment to resist motion, increase surface area, or increase lever arm • Maintain good postural mechanics • Work on scapular mechanics in prone and supine positions • Land-based program and aquatic program should be coordinated to assure continued improvement of strength, endurance, and function

17. Upper Extremity Injuries • Final Level • Goal: Functional strengthening and training • Transition from aquatic to land-based treatment • Increase the use of equipment to maintain motivation levels of athlete

18. Spine Dysfunction • Initial Level • Goal: Proper biomechanics (gait pattern), ROM, proprioception, pain modulation • Wall squats used to find pelvic neutral position • Wall provides sensory feedback to maintain position • Progression • Upper/lower extremity activity can be incorporated with stabilization exercises • Increase ability to bear weight by progressing from deep end to shallow end • Traction provided by deep water • Increase pelvic mobility through stretching

19. Spine Dysfunction • Intermediate Level • Goal: Core strengthening • Move away from wall • Incorporate pulling/pushing motions • Incorporate single leg stance and lunges to challenge dynamic stabilization of core • Supine and prone activity can also be utilized to train core

20. Spine Dysfunction • Final Level • Goal: Functional strengthening and training • Incorporate sport-specific activities to challenge core stabilization • Train bilateral activity • Integrate opposite movement patterns • Incorporate land-based training • Water does not allow for normal speeds and forces during sports-specific activities

21. Lower Extremity Injuries • Initial Level • Goal: Proper biomechanics, ROM, proprioception, and strengthening • Work to restore normal gait patterns • Initiate AROM exercises (hip, knee, ankle) • Progression: utilize cuffs, noodles, or kickboards under foot • Balance activities • Enforce proper postural mechanics while challenging balance/neuromuscular control

22. Lower Extremity Injuries • NWB conditioning and cross-training in deep water • Running • Bicycling • Cross country skiing • Incorporation of sports specific skills • Incorporation of supine activities • Work on active hip and knee motion within pain-free range

23. Lower Extremity Injuries • Intermediate Level • Goal: Develop strength and eccentric control throughout ROM • Use weights and flotation devices to increase difficulty • Proximal resistance may be necessary due to the injury • Utilize straight and diagonal plane activities • Balance training • Stand on cuff, noodle, uneven surfaces

24. Lower Extremity Injuries • Integrate eccentric activity • Double and single leg reverse squats • Deep water running/sprinting • Continue to integrate supine and prone exercises as athlete’s strength and ability increase • Jumping progression • Integration of sports-specific activity

25. Lower Extremity Injuries • Final Level • Goal: Functional strengthening and conditioning • Program should compliment land-based program • Decrease use of floatation devices • Aquatic endurance training • May be useful in preventing recurrence of injury

26. Conclusions • Should be utilized in conjunction with land-based rehabilitation exercises • Many physical and psychological benefits during early stages of rehabilitation • Sport-specific training • Utilize land and water based training to achieve goals • Must be sure to engage in activity at “normal” speeds and force levels prior to return to play