The Benefits of Water Seen Unseen Benefits of

The Benefits of Water: Seen & Unseen Benefits of Aquatic Therapy Katie St. Mars, PT, DPT

Table of Contents Fundamentals of Aquatics Properties of water Precautions Contraindications Types of Aquatic Therapy Equipment used Exercises HSP / PLS implications Research Resources

Fundamentals of Aquatics Properties of water: Buoyancy Viscosity Hydrostatic pressure Turbulence Contributing factors: Temperature Depth

Buoyancy Definition: The power of a liquid to keep something afloat Any object, wholly or partially immersed in fluid, is buoyed up by a force equal to the weight of the fluid displaced by the object (Archimedes principle). Benefits: Decreases weight which makes movement easier Reduces strain on joints due to body weight pressure

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.

Buoyancy So what? Muscle weakness Using floats will make it more difficult to run, walk or push downward with arms or legs in the water, creating more resistance for strengthening. Don’t exhale when diving underwater to increase difficulty. Muscle Spasticity Easier to work in the shallow end at 3’ depth to avoid muscle fatigue when performing standing exercises.

Viscosity Definition: The resistance of a liquid Benefits: Resistance of water (viscosity) acts as a resistance weight particularly when directed downward due to buoyancy Strengthen without straining joints. Low viscosity of water (as opposed to honey which has a high viscosity) allows for freedom of movement. Combination of the above two cannot be found in any other environment for exercise!

H 20 leg press vs. leg press on land

Hydrostatic Pressure Definition: Fluid pressure exerted equally on all surface areas Benefits: Helps return blood to the heart More efficient with less pressure on cardiovascular system Decreases swelling in extremities Improves proprioception (awareness and adjustment of body position) & coordination Through increased sensory input

Turbulence Definition: Random motion of water as it responds to a disturbance Benefits: Massaging effect reduces pain Provides varying levels of resistance Bernoulli’s principle = increased speed of flow; decreased pressure

“Gate control theory” Imagine an elevator … Elevator – travels along neural pathways from the skin to spinal cord to brain Full of Passengers – signals from water temperature and pressure Passenger attempts to board the crowded elevator… but no room! – tries to signal pain The brain interprets the temperature & pressure of the water, overriding the pain message attempting to get through.

Temperature for aerobic conditioning, water temp at 26 -29ºC to reduce spasticity & pain, water temp at 3337ºC Note: MS patients should have aquatic therapy no higher than 29ºC at most.

Depth Level of immersion: to pelvis = 60% of weight bearing in air to belly button = 50% to mid-ribs = 40% to shoulders = 20 -30% to neck = 10% full immersion = roughly zero Caution – if there is loss of respiratory function: do not immerse deeper than the belly button to avoid increased pressure on chest and respiratory muscles

Precautions for Aquatic Therapy: Bowel incontinence with firm stools Communicable diseases (cold, flu, hepatitis) Sensitivity to disinfection chemicals Sensitivity to heat/ humidity (e. g Multiple Sclerosis) Rashes, skin conditions with flaking or open areas (psoriasis) Orthostatic hypotension (decreased blood pressure) Hydrophobia (fear of water) Combative or difficult to control person or group Poor cognition Dependence in ambulation Controlled seizures, exercise-induced angina, controlled diabetes Open wounds with bio-occlusive dressing Compromised immune system (e. g. low T-cell count) On chemotherapy On dialysis for renal/kidney dysfunction

When not to do Aquatic Therapy Fever Bowel or bladder incontinence Open wounds, incisions, or skin lesions/infections that are oozing or bleeding Blistering Boils Infectious processes such as hepatitis A, strep throat, vaginal or urinary infection, staphylococcus infection or other communicable diseases Uncontrolled seizure disorder Uncontrolled cardiac problems Acute lung infections Catheters or IV lines Tracheotomies Menstruation (unless internal protection is used) Excessively high or low blood pressure Extreme fear, inappropriate or disruptive behaviors

Therapies that can be done in water: Ai Chi Feldenkrais Back. Hab Proprioceptive Neuromuscular Facilitation Water Pilates Bad Ragaz Watsu Halliwick Wassertanzen

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 Trunk extremity

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 Trunk extremity

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

Exercises you can do! Always check with your health care practitioner before beginning any exercise program. Working with a Physiotherapist is best.

Aquatic Exercises • Strengthening – Using hydrostatic pressure, buoyancy & turbulence to increase resistance & thereby increase strength • Stretching – Using hydrostatic pressure & buoyancy to improve static hold stretches with increased temperature for muscle relaxation • Cardiovascular endurance – Using hydrostatic pressure & turbulence to improve diaphragmatic breathing and cardiovascular endurance • Neuromuscular coordination – Using hydrostatic pressure to improve proprioception with dynamic movements, which improves motor planning & output coordination

Strengthening Active strengthening Upper Extremity Strengthening Begin with 10 -20 reps x 1 set; progress to 20 -30 reps x 2 -3 sets Lower Extremity Strengthening Begin with 10 -20 reps x 1 set; progress to 20 -30 reps x 2 -3 sets Trunk Strengthening Begin with 2 -3 min. duration; progress to 15 min. duration Passive strengthening e. g. Bad Ragaz therapy (buoyancy supported)

Upper Extremity Strengthening Arm Circles Shoulder depressions Shoulder retractions Pool side push-ups

Lower Extremity Strengthening Leg circles Kicking Seated outside of pool Seated on pool step On kickboard Side-stepping Jumping forward (1 leg or both) Stepping up/down pool steps Jumping jacks

Trunk Strengthening Diving underwater for rings Balancing on kickboard Straddle sit on swim noodle Plank + kick on pool step Abdominal twists

Stretching Active stretching Begin with 10 -30” hold x 1 -3 x Progress to 30” hold x 3 Upper extremity Lower extremity Passive stretching Partner performs passive range of motion (PROM) or proprioceptive neuromuscular facilitation (PNF) Best performed by a Physiotherapist

Upper extremity Stretching Chest / biceps stretch Clasp hands behind back or grab handrails / pool side if unable to reach behind back Triceps / shoulder stretch Use swim noodle

Lower Extremity Stretching Calf stretch Hamstring stretch Place heel on pool step

Cardiovascular endurance Treading water Begin with 10 -30” trials x 3 Progress to 1 -2 min. trials x 2 -3 Walking in chest-waist deep water Begin with 2 -3 min. trials x 3 Progress to 5 -10 min. trials x 2 -3 Progress to 20 -30 min. x 1 Aqua jogging (use Flotation Belt)

Neuromuscular coordination Exercises that improve the brain-body connection with coordinated movement! Shooting basketball Stepping up/down pool step Side-stepping Walking backwards Dribbling weighted soccer ball To improve balance Karate kicks on one leg Making “waves” Creating turbulence while maintaining sitting or standing

Case Examples: Primary Lateral Sclerosis Hereditary Spastic Paraplegia

for PLS (Primary lateral Sclerosis)… Stiffness, weakness and spasticity in legs Leg exercises, PROM, water temp more than 35ºC Decreased balance & increased clumsiness Picking up swim rings with feet to improve coordination Trunk weakness Balancing on swim noodle or kickboard Hoarseness, reduced rate of speaking, slurred speech and drooling Blowing bubbles in water to maintain strength Difficulties with swallowing and breathing If you have breathing difficulties, do not immerse deeper than the belly button to avoid increased difficulty.

for HSP symptoms… Difficulty walking Negotiating obstacles Balance on one leg Progressive spasticity Water temp more than 35ºC Muscle weakness Strengthening exercises

Word of caution… Avoiding overuse Overuse can often exacerbate weakness & spasticity Strengthening can only occur once muscles have achieved muscle fatigue This can be difficult to feel in the water Use caution with muscles < 3+/5 per MMT (manual muscle test) Difficult pool! to move against gravity? Don’t isolate muscle in Signs of overuse: cramps or spasm, pain, extreme fatigue

Research Aquatic exercise provides increased ease of movement with less pain than land-based programs. (Broach & Dattilo, 2001; Cooper, 1976; Mobily, Lessard & Berkenpas, 2000; Mobily & Verburg, 2001). Participants can typically participate with lower body temperatures, less muscle stress, less energy expenditure and less guarded actions associated with fear of failing and improved performance. (Broach & Dattilo, 2001).

Research cont’d The sheer weight of the water provides natural compression on joints and promotes reduction in swelling. (Mobily, Lessard, & Berkenpas, 2000). Water provides a source of graded resistance conducive to improvement in muscular strength and endurance when the limbs are moved repeatedly through a range of motion over the course of an extended period of time. (Mobily & Verburg, 2001).

Research cont’d The physical benefits of activity performed in the water may include: relief of pain, decreased spasticity and increased relaxation, improved bone density, improved pulmonary function, strengthened muscles, improved endurance and improved range of motion and increased circulation. (Broach & Dattilo, 1996) Participants stated they felt that the most important outcome of AT included increased freedom of movement, relaxation, energy and social interactions Broach and Dattilo (2001),

Research cont’d Psychological benefits of participation in aquatic therapy have been identified to include improved mood, enhanced self-esteem and body image and decreased anxiety and depression. (Broach & Dattilo, 1996). Scuba diving program significantly reduces spasticity per Modified Ashworth scale for paraplegics. (Haydn et al. 2007)

Resources Spine Health Water Therapy Exercise Program http: //www. spinehealth. com/topics/conserv/water 01. html Aquatic Therapy and Rehab Institute www. atri. org Aquatic Exercise Association (AEA) http: //www. aeawave. com/ Aquaticnet. com http: //www. aquaticnet. com/index. htm

Resources cont’d Books / Videos Free at your local library or on youtube. com http: //www. youtube. com/watch? v=A 80 fpk. GHBp. U&fea ture=related http: //www. youtube. com/watch? v=FHph. Tme. ZV-g

About the author: Graduated from Virginia Commonwealth University’s Medical College in 2008 Doctor of Physical Therapy (physiotherapy) Practice experience with: progressive neurological disorders, sports medicine, post-op orthopaedics, paediatrics to include autism. Paediatric Physical Therapist (physiotherapist) with Himmel Home Health- New Braunfels - San Antonio area, Texas, USA.