Aquatic Exercises

BY:

Dr. Gehan Shaalan

Physical Therapy Lecturer

Aquatic Therapy (AT)

• Definition:

An active intervention that utilizes principles of hydrostatics &hydrodynamics to design interventions to target specific impairments &functional limitations

Aquatic exercise

• Aquatic exercise refers to the use of multi-depth 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.

Physical Properties of Water

• Buoyancy

• Hydrostatic Pressure

• Viscosity

• Surface Tension

• Hydromechanics

• Thermodynamics

Buoyancy

1. As the body is gradually immersed,water is displaced, creating the force of buoyancy.

2. Buoyancy: (a) reduces the gravitational

forces making it feel easier to complete movements and activities in the water.

(b)Allows patients to find positions of comfort allowing rehabilitation to occur that is not possible on land.

Buoyancy

3. Archimedes Principlea. When a body is fully or partially submerged in a

fluid at rest, it experiences an upward thrust equal to the weight of the fluid displaced.

b. Influenced by volume and density influencedby hydrostatic pressure.c. Relative Density (how well objectsfloat) = density/volume.4. Position/Size of an object influences how well it

floats.

Buoyancy• 5. Buoyancy can be used to assist, support or

resist movement.

• Depends on patients’ position – standing, supine,

• sitting, etc.

• - When immersed to pubic symphysis=60% weight bearing (WB)

• - To umbilicus = 50% WB

• - To xiphoid = 40% WB

• - To shoulders = 20-30% WB

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)

Buoyancy

Qualifiers:– Depth:

• Increased depth = Increased buoyancy

– Salt vs. Chlorinated water• Salt water is more dense than chlorinated water. This

increases the buoyancy force in salt water, thus making floating easier and swimming downwards more difficult.

– Lung capacity:• Increased lung capacity – Increased buoyancy.

Clinical benefitsBuoyancy

Help exercise when weight bearing is contraindication

(decrease stress and compression on weight bearing joints, muscles and connective tissues).

Can be used as assistive or resistive forceRaise weakened body parts against gravity. Combination of Buoyancy and Hydrostatic

pressure help in balance exercises

Hydrostatic pressure• Definition. Hydrostatic pressure is the

pressure exerted on immersed objects.

• Properties

Pascal’s 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 benefits

Immersion in water can assist in promoting circulation or alleviating peripheral edema due to venous or lymphatic insufficiency.

Facilitate cardiovascular functionSupport provided by hydrostatic pressure may

help to brace unstable joints or weak muscles.The greatest effect will occur with vertical

positioning.The effect will be less pronounced if the

patient is swimming in more horizontal position close to the water surface.

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

• Water’s viscosity creates resistance with all active movements.

Surface TensionDefinition. The surface of a fluid acts as a membrane

under tension. Surface tension is measured as force perunit length.PropertiesThe 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 SignificanceAn extremity that moves through the surface performsmore work than if kept under water.Using equipment at the surface of the water increasesthe resistance.

HydromechanicsDefinition. Hydromechanics comprise the

physical propertiesand characteristics of fluid in motion.Components of Flow MotionLaminar 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.

Hydromechanics

Clinical Significance of DragAs 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 extremitythrough water

ThermodynamicsWater temperature has an effect on the body and, therefore,

performance in an aquatic environment.Specific HeatDefinition. Specific heat is the amount of heat (calories)

required to raise the temperature of 1 gram of substance by 1C.

Properties. The rate of temperature change is dependent on the mass and the specific heat of the object.

Clinical SignificanceWater retains heat 1000 times more than air.Differences in temperature between an immersed object and

water equilibrate with minimal change in the temperature of the water.

GOALS AND INDICATIONSFOR AQUATIC EXERCISE

• 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

• Minimize risk of injury or re-injury during rehabilitation

• Enhance patient relaxation

Contraindications

• 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.

ContraindicationsIncipient 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

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

tinea pedis.Uncontrolled bowel or bladder

Equipment

• Foam dumbbells• Fins/Flippers• Float Cuffs• Floatation belt• Jug (air filled)• Kickboard• Neck collar• Resistance boots• Resistance paddles• Weights• Swim noodle

Equipment: Foam Dumbbells

• Purpose:– Strengthening

• Upper extremity

• Trunk

– Floatation support

Equipment: Fins/Flippers

• Purpose:– Strengthening

• Lower extremities

• Abdomen

• Low back

– Propulsion when swimming

Equipment: Float Cuffs

• Purpose:– Strengthening

• Upper extremity

• Lower extremity

• The further away from your body the cuff is placed, the more difficult the exercise

Equipment: Floatation belt

• Purpose:– Floatation support

– Strengthening• Resistance against

vertical in pool improves trunk & hip strength to maintain upright position for “running” or “walking” while floating.

Equipment: Jug (air filled)

• Purpose:– Strengthening

• Upper extremity

• Trunk

Equipment: Kickboard

• Purpose– Floatation

support

– Balance • Attempting to

maintain prone

Equipment: Neck collar

• Purpose– Floatation support

– To prevent strain to cervical spine

Equipment: Resistance boots

• Purpose– Strengthening

• Lower extremity

• Abdomen

• Low back

Equipment: Resistance paddles

• Purpose– Strengthening

• Upper extremity

• Trunk

Equipment: Weights

• Purpose– Assistance to maintain vertical

positioning

– Strengthening• Will be easier than performing

weighted exercise on land

– Coordination • Using medicine ball to dribble

like soccer ball

Equipment: Swim noodle

• Purpose– Floatation assistance

– Strengthening• Upper extremity

• Lower extremity

Exercise Guidelines• Start exercising gently and increase persistently within

pain tolerance.

• It is crucial to individualize programs based upon fitness levels, nature of symptoms, level of progress, and symptoms on a given day: give lots of personal attention; provide lots of options.

• The best time to exercise is when feeling energetic. For many, this is late morning /mid-day.

• Teach, and constantly reinforce “Power Posture”. Constantly draw attention to functional posture and alignment and always emphasize postural musculature training in and outside of the class.

Exercise Guidelines• Frequent rest breaks between intervals of gentle

activity are important, especially when starting a program.

• Many clients will experience a longer recovery period and more post-exercise discomfort than ‘normals’. Be careful not to overdo it. Start by having clients do

less than they feel they can do.

• Keep reminding clients to self-monitor (BORG’s RPE scale) and respect their limitations.

Exercise Guidelines

• Reinforce the benefits in quality of life that are to be gained by being active.

• Some people get light headed, dizzy, or lose balance easily. Highly coordinated movements will not be appropriate, nor will moves requiring lots of strength (eg: propulsion or rapid direction changes).

• Highlight mental focus: teach participants to use deep breathing and relaxation techniques (especially effective while stretching); emphasize the difference in

sensation between a stretching versus a strengthening exercise…

Examination for aquatic rehab

• Full land based exam

• Consideration of Contraindications:– Excessive fear of water.

– Open wounds, Rashes

– Active infections

– Incontinence

– Tracheostomy

Precautions in Aquatics

• CV changes

• Pulmonary impairments

• Over exercise- reduced gravity environment, support of buoyancy, m relaxation with immersion, HP and water temperature

Treating Impairments with Aquatics

• Mobility impairments: Progress activities to enhance function and reduce disability ASAP.

• Considerations:– Force of buoyancy– Position and available ROM at the jt.– Direction of desired movement– Need for floatation or weighted equipment

Mobility impairments Con’t

• Buoyancy will facilitate ROM. Change the lever length and equipment as pt. improves

• Static stretches can be done using steps, pool sides and bars

• Observe the exercise on land first. Observe closely once in the water secondary to refraction

Balance impairment

• Supportive medium with destabilizing forces make this approach ideal

• Falls are dramatically slowed, inc. pt.s time for response

• Single Leg Support activities• Single Leg Support with arm mvt.• Single toe raises• Step ups

Aquatic Rehab to treat Functional Limitations

• Functional limitations are restrictions in performance affecting the whole person.

• Good situation for working on posture or position.

• Chairs can be submerged, buoyancy sitting equipment. As sitting tolerance improves, water depth is decreased.

• Forward reach

Coordinating Land and Water

• Land based activity should begin as soon as tolerated

• It is difficult to produce eccentric m contractions in the pool

• With pain, aquatics may be most of the program

• Sometimes alternating the pool with land based interventions works best

Patient education

• Before entering the pool, explain the fundamental properties of H2O to the pt.

• Make sure the pt. is aware of the entrances and exits from the pool, drop offs, gutters, and bars.

• Show the pt. the exercises on land first.