(c) 2004 the mcgraw-hill companies, inc. all rights reserved chapter 16: aquatic therapy in...

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved

Chapter 16: Aquatic Chapter 16: Aquatic Therapy in Rehabilitation Therapy in Rehabilitation

Jenna Doherty-Restrepo, MS, ATC, LATJenna Doherty-Restrepo, MS, ATC, LAT

Entry-Level ATEPEntry-Level ATEP

Rehabilitation Techniques in Athletic Rehabilitation Techniques in Athletic TrainingTraining


Aquatic TherapyAquatic Therapy

• Rapidly becoming popularRapidly becoming popular– Not a new form of therapy Not a new form of therapy revisited revisited

• Effects:Effects:– Decreases joint compressionDecreases joint compression– Reduces muscle guardingReduces muscle guarding– Improves movement and fitnessImproves movement and fitness


Physical PropertiesPhysical Properties• BuoyancyBuoyancy

– Counteracts downward pull of gravityCounteracts downward pull of gravity• Upward force that supports submerged or partially Upward force that supports submerged or partially

submerged object submerged object

• Assists motion toward water’s surfaceAssists motion toward water’s surface

– Sense of weight loss Sense of weight loss • Changes relative to level of submersionChanges relative to level of submersion

• Differs in males and females due to relative CoGDiffers in males and females due to relative CoG

– Allows for ambulation and vigorous exercise Allows for ambulation and vigorous exercise • Reduces joint impactReduces joint impact

• Reduces friction between articular surfacesReduces friction between articular surfaces


• Specific GravitySpecific Gravity– Buoyancy is partially dependent on body weightBuoyancy is partially dependent on body weight

• Weight of different body parts will varyWeight of different body parts will vary

– Determined by: Determined by: • Ratio of bone weight to muscle weight Ratio of bone weight to muscle weight

• Amount and distribution of fat Amount and distribution of fat

• Depth and expansion of chestDepth and expansion of chest

– Specific gravity of humans is slightly less than water Specific gravity of humans is slightly less than water • Enables the body to floatEnables the body to float

• Does not mean that body will float horizontallyDoes not mean that body will float horizontally

• Different segments have different specific gravitiesDifferent segments have different specific gravities

• Air in lungs vs. extremitiesAir in lungs vs. extremities

Physical Properties cont.Physical Properties cont.


• Cohesive forceCohesive force– Runs parallel to the direction of the water surfaceRuns parallel to the direction of the water surface– Due to surface tension of water moleculesDue to surface tension of water molecules

• Bow forceBow force– Force generated at the front of an object during Force generated at the front of an object during

movementmovement• Increased water pressure at the front Increased water pressure at the front

• Decreased water pressure in the rearDecreased water pressure in the rear

– Creates a pressure gradientCreates a pressure gradient• Low pressure zones swirl = eddies (turbulence) Low pressure zones swirl = eddies (turbulence)

• Creates a drag forceCreates a drag force

Resistive ForcesResistive Forces


• Drag forceDrag force– Modified by shape and speed of objectModified by shape and speed of object

• Increase streamline of object = decrease dragIncrease streamline of object = decrease drag• Increase speed of object = increase drag Increase speed of object = increase drag

– Must be considered carefully when attempting Must be considered carefully when attempting to protect a limb during rehabilitationto protect a limb during rehabilitation• Drag forces = increased torque at a given joint Drag forces = increased torque at a given joint

Resistive Forces cont.Resistive Forces cont.


Archimedes's PrincipleArchimedes's Principle

• A gradual increase in weight bearing A gradual increase in weight bearing can be achieved with aquatic therapycan be achieved with aquatic therapy

• Progression: deep to shallowProgression: deep to shallow– Take advantage of buoyancy propertyTake advantage of buoyancy property

• Closed kinetic chain exercisesClosed kinetic chain exercises– Proprioceptive benefitsProprioceptive benefits– Reduces joint compression/friction Reduces joint compression/friction

forcesforces


Aquatic Rehabilitation: Aquatic Rehabilitation: Advantages Advantages • AROM exercises supported through buoyancy AROM exercises supported through buoyancy

– Minimizes discomfort Minimizes discomfort – Sense of security Sense of security

• Useful in early stages of rehabilitationUseful in early stages of rehabilitation– Supportive environment Supportive environment

• Proprioception enhancementProprioception enhancement– Turbulence provides perturbations and tactile sensory Turbulence provides perturbations and tactile sensory

stimulusstimulus

• Extremely useful with lower-extremity injuriesExtremely useful with lower-extremity injuries– Provides gradual transition from non to full weight-bearingProvides gradual transition from non to full weight-bearing– May allow earlier locomotion due to decreased May allow earlier locomotion due to decreased

compressive forcescompressive forces


• Psychological impactPsychological impact– Increased confidence due to increased function Increased confidence due to increased function

allowed by waterallowed by water

• Strengthening and muscle re-educationStrengthening and muscle re-education– Dependent on effort put forth by athleteDependent on effort put forth by athlete

• Energy expenditureEnergy expenditure– Aerobic workout possible to maintain CV Aerobic workout possible to maintain CV

fitnessfitness

Aquatic Rehabilitation: Aquatic Rehabilitation: AdvantagesAdvantages


Aquatic Rehabilitation: Aquatic Rehabilitation: DisadvantagesDisadvantages• Building and maintaining a rehabilitation Building and maintaining a rehabilitation

poolpool– Space and personnel Space and personnel

• Aquatic training may be too challenging if Aquatic training may be too challenging if athlete unable to stabilize bodyathlete unable to stabilize body

• ThermoregulationThermoregulation– May impact tolerance for participation in heatMay impact tolerance for participation in heat

• Contraindications: Contraindications: – Open wounds, fear of water, fever, urinary Open wounds, fear of water, fever, urinary

tract infection, allergies to pool chemicals, tract infection, allergies to pool chemicals, cardiac dysfunction or uncontrolled seizurescardiac dysfunction or uncontrolled seizures


Facilities and EquipmentFacilities and Equipment

• Facility must have certain characteristicsFacility must have certain characteristics– Should be at least 10 x 12Should be at least 10 x 12– Adequate accessAdequate access– Shallow and deep areasShallow and deep areas– Flat pool floor with marked gradientsFlat pool floor with marked gradients– Adequate temperature (79-82 degrees)Adequate temperature (79-82 degrees)

• AncillariesAncillaries– Prefabricated pools with treadmill or current Prefabricated pools with treadmill or current

producing deviceproducing device– Pool toys – limited by imaginationPool toys – limited by imagination


Aquatic TechniquesAquatic Techniques• Must considerMust consider

– Type of injury/surgeryType of injury/surgery– Treatment protocols if appropriateTreatment protocols if appropriate– Results/muscle imbalances found in evaluationResults/muscle imbalances found in evaluation– Goals/expected return to activityGoals/expected return to activity

• Program designProgram design– Warm-upWarm-up– Strengthening/mobility activitiesStrengthening/mobility activities– Endurance/cardiovascularEndurance/cardiovascular– Cool down/stretchCool down/stretch


Upper Extremity Injuries Upper Extremity Injuries • Initial LevelInitial Level

– Start at chest depth Start at chest depth – Warm-up: Walking with natural arm swing in an Warm-up: Walking with natural arm swing in an

effort to restore normal scapulothoracic motionseffort to restore normal scapulothoracic motions– Goal: Shoulder movement without compensationGoal: Shoulder movement without compensation– Supine positioningSupine positioning

• Stretching, mobilization and range of motionStretching, mobilization and range of motion

– Prone positioning (w/ snorkel)Prone positioning (w/ snorkel)• Pendulum and PNF diagonal plane activityPendulum and PNF diagonal plane activity


• Intermediate LevelIntermediate Level– Goal: Develop strength and eccentric control Goal: Develop strength and eccentric control

throughout ROMthroughout ROM– Strengthening progressionStrengthening progression

• Use equipment to resist motion, increase surface area, Use equipment to resist motion, increase surface area, or increase lever armor increase lever arm

– Maintain good postural mechanicsMaintain good postural mechanics• Work on scapular mechanics in prone and supine Work on scapular mechanics in prone and supine

positionspositions

– Land-based program and aquatic program should Land-based program and aquatic program should be coordinated to assure continued improvement be coordinated to assure continued improvement of strength, endurance, and functionof strength, endurance, and function

Upper Extremity InjuriesUpper Extremity Injuries


• Final LevelFinal Level– Goal: Functional Goal: Functional

strengthening and strengthening and trainingtraining

– Transition from Transition from aquatic to land-based aquatic to land-based treatmenttreatment

– Increase the use of Increase the use of equipment to equipment to maintain motivation maintain motivation levels of athletelevels of athlete

Upper Extremity InjuriesUpper Extremity Injuries


Spine DysfunctionSpine Dysfunction

• Initial LevelInitial Level– Goal: Proper biomechanics (gait pattern), ROM, Goal: Proper biomechanics (gait pattern), ROM,

proprioception, pain modulationproprioception, pain modulation– Wall squats used to find pelvic neutral positionWall squats used to find pelvic neutral position

• Wall provides sensory feedback to maintain positionWall provides sensory feedback to maintain position

– Progression Progression • Upper/lower extremity activity can be incorporated with Upper/lower extremity activity can be incorporated with

stabilization exercisesstabilization exercises

• Increase ability to bear weight by progressing from deep end Increase ability to bear weight by progressing from deep end to shallow endto shallow end

– Traction provided by deep waterTraction provided by deep water– Increase pelvic mobility through stretchingIncrease pelvic mobility through stretching


Spine DysfunctionSpine Dysfunction• Intermediate LevelIntermediate Level

– Goal: Core strengtheningGoal: Core strengthening– Move away from wallMove away from wall– Incorporate Incorporate

pulling/pushing motionspulling/pushing motions– Incorporate single leg Incorporate single leg

stance and lunges to stance and lunges to challenge dynamic challenge dynamic stabilization of corestabilization of core

– Supine and prone Supine and prone activity can also be activity can also be utilized to train coreutilized to train core


• Final LevelFinal Level– Goal: Functional strengthening and trainingGoal: Functional strengthening and training– Incorporate sport-specific activities to Incorporate sport-specific activities to

challenge core stabilizationchallenge core stabilization– Train bilateral activity Train bilateral activity

• Integrate opposite movement patternsIntegrate opposite movement patterns

– Incorporate land-based training Incorporate land-based training • Water does not allow for normal speeds and forces Water does not allow for normal speeds and forces

during sports-specific activitiesduring sports-specific activities

Spine DysfunctionSpine Dysfunction


Lower Extremity Injuries Lower Extremity Injuries

• Initial LevelInitial Level– Goal: Proper biomechanics, ROM, Goal: Proper biomechanics, ROM,

proprioception, and strengtheningproprioception, and strengthening– Work to restore normal gait patternsWork to restore normal gait patterns– Initiate AROM exercises (hip, knee, ankle)Initiate AROM exercises (hip, knee, ankle)

• Progression: utilize cuffs, noodles, or kickboards Progression: utilize cuffs, noodles, or kickboards under foot under foot

– Balance activitiesBalance activities• Enforce proper postural mechanics while challenging Enforce proper postural mechanics while challenging

balance/neuromuscular controlbalance/neuromuscular control


– NWB conditioning and cross-training in deep NWB conditioning and cross-training in deep waterwater• RunningRunning

• BicyclingBicycling

• Cross country skiingCross country skiing

• Incorporation of sports specific skillsIncorporation of sports specific skills

– Incorporation of supine activitiesIncorporation of supine activities• Work on active hip and knee motion within pain-free Work on active hip and knee motion within pain-free

rangerange

Lower Extremity InjuriesLower Extremity Injuries


• Intermediate LevelIntermediate Level– Goal: Develop strength and eccentric Goal: Develop strength and eccentric

control throughout ROMcontrol throughout ROM– Use weights and flotation devices to Use weights and flotation devices to

increase difficultyincrease difficulty•Proximal resistance may be necessary due to Proximal resistance may be necessary due to

the injurythe injury

– Utilize straight and diagonal plane Utilize straight and diagonal plane activitiesactivities

– Balance trainingBalance training•Stand on cuff, noodle, uneven surfacesStand on cuff, noodle, uneven surfaces



– Integrate eccentric activityIntegrate eccentric activity•Double and single leg reverse squatsDouble and single leg reverse squats

– Deep water running/sprintingDeep water running/sprinting– Continue to integrate supine and prone Continue to integrate supine and prone

exercises as athlete’s strength and exercises as athlete’s strength and ability increaseability increase

– Jumping progressionJumping progression– Integration of sports-specific activityIntegration of sports-specific activity



• Final LevelFinal Level– Goal: Functional strengthening and Goal: Functional strengthening and

conditioningconditioning– Program should compliment land-based Program should compliment land-based

programprogram– Decrease use of floatation devicesDecrease use of floatation devices– Aquatic endurance training Aquatic endurance training

•May be useful in preventing recurrence of May be useful in preventing recurrence of injuryinjury



ConclusionsConclusions

• Should be utilized in conjunction with land-Should be utilized in conjunction with land-based rehabilitation exercisesbased rehabilitation exercises

• Many physical and psychological benefits Many physical and psychological benefits during early stages of rehabilitationduring early stages of rehabilitation

• Sport-specific training Sport-specific training – Utilize land and water based training to Utilize land and water based training to

achieve goalsachieve goals– Must be sure to engage in activity at “normal” Must be sure to engage in activity at “normal”

speeds and force levels prior to return to playspeeds and force levels prior to return to play

(c) 2004 the mcgraw-hill companies, inc. all rights reserved chapter 16: aquatic therapy in...

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