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Aquatic Therapy in Rehabilitation

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Title: Aquatic Therapy in Rehabilitation


1
Aquatic Therapy in Rehabilitation
  • Chapter 15

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

8
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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 gt 1, object will sink
  • If objects s.g. is lt 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
Viscosity
  • 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

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
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