AQUATIC PHYSICAL THERAPY The Therapeutic Effects of Water Paula Godes, PT, DPT
Overview • History of Aquatic Exercise • What is Aquatic Physical Therapy? • Goals of Aquatic Physical Therapy • Who Participates • Hydrodynamics: Application of Newton’s Laws • Law of Inertia • Law of Acceleration • Law of Action/Reaction • Water’s Viscosity and Frontal Resistance • Center of Gravity • Center of Buoyancy • Hydrostatic Pressure • Surface Tension • Drag and Turbulence • What is Your Goal? - Return to Running • Our Program: Present and Future
History of Aquatic Exercise • Early writings in the Old Testament: Ascleius, Greek God of Medicine • FDR: Therapeutic spa made by Native Americans • Early running rehab: track athletes – 1970’s • Research: 1990’s and increasing • Boomer’s: Leading the way for alternative exercises- over 10 million participated in aquatic exercise (Aquatic Exercise Assoc., 2000)
What is Aquatic Physical Therapy? • Aquatic Physical Therapy is the evidence-based and skilled practice of physical therapy in an aquatic environment by a physical therapist or by a physical therapist assistant who is under the direction and supervision of a physical therapist. Aquatic Physical Therapy includes but is not limited to treatment, rehabilitation, prevention, health, wellness and fitness of patient/client populations in an aquatic environment with or without the use of assistive, adaptive, orthotic, protective, or supportive devices and equipment. • The buoyancy, support, accommodating resistance and other unique properties of the aquatic environment enhance interventions for patients/clients across the age span with musculoskeletal, neuromuscular, cardiovascular/pulmonary, and integumentary diseases, disorders, or conditions.
What is the Difference? • Aquatic physical therapy requires the “skilled service” of a PT and/or PTA which may include: a) the clinical reasoning and decision making skills of a PT/PTA; b) the patient has impairments and/or disabilities which can be minimized or eliminated with aquatic physical therapy; and c) the patient has potential for reaching new functional goals/outcomes to improve quality of life and ease burden of care.
Specialized Training • Is there a certification program for aquatic physical therapy? • No; however, the APTA Aquatic Physical Therapy Section is in the process of conducting a practice analysis to see if there is a need for a certification process. • What education requirements are needed to specialize in Aquatic PT? • Water safety, risk management, and an understanding of hydrodynamic principles and various techniques. • Continuation Courses • Aquatic Therapy & Rehab Institute (ATRI): certification and membership
Who Participates • The Elderly: those with painful, arthritic joints • Obese or sedentary individuals • Decreased function/weakness – poor tolerance and endurance for land exercises • Chronic illnesses/pain syndromes – fibromyalgia, back pain • Those recovering from illness or surgery • Well-conditioned individuals or athletes: Advance training using increased resistance of water/equipment
Goals of Aquatic Physical Therapy • Aquatic Physical Therapy interventions are designed to improve or maintain: ► function► aerobic capacity/endurance conditioning► balance, coordination and agility► body mechanics and postural stabilization► flexibility► gait and locomotion► muscle strength, power, and endurance
HYDRODYNAMICS:Law of Inertia • An object will remain at rest or in motion with constant velocity unless acted on by a net external force • Total Body Inertia: requires more muscular effort to start, stop or change movement. • Water’s Inertia: increases resistance • Add travel through the water – more effort
Law of Acceleration • The reaction of a body as measured by its acceleration is proportional to the force applied, and inversely proportional to its mass. • In other words, if you use more muscular effort, you accelerate (increase) the force. • Note: Going faster will increase intensity, but is normally not recommended in a therapeutic environment – lose ROM- use force instead of speed to increase intensity • The greater the body mass, the more force it takes to move that mass
Law of Action/Reaction • For every action, there is an equal and opposite reaction • Viscosity of the water with arms and legs can be used to “assist” or “impede” movement • Actions of the arms and legs working with each other (assisting) or in opposition (impeding) • Example: jogging forward with front crawl arms (assisting), less intense than jogging forward pushing arms forward (impeding)
Water’s Viscosity • Friction between molecules of a liquid cause them to adhere to each other (cohesion) or to a submerged body (adhesion) • Resistance surrounds the body and affects every movement in every direction • Larger surface area = MORE resistance • Smaller surface area = LESS resistance
Increasing Intensity • It’s NOT about speed! • Use inertia, acceleration, action/reaction, frontal surface area, hand positions, levers, to increase intensity – much more effective • Use training techniques that maintain ROM against the water’s resistance • Most movements done in the water involve only concentric muscular contractions - muscle soreness is minimal
Center of Gravity • Center of a body’s mass • Position of body parts determine position of center of gravity • Widen base of support – stabilizes the center of gravity • Men – torso near the chest • Women – torso nearer to pelvic girdle
Center of Buoyancy • Center of the volume of the body displacing the water • Affects movement when submerged • Located in the chest area (lungs, air pockets) • Impacted by volume of air (inhaling or exhaling), and by the density of the body • Muscle vs. fat – “Buoyant” bodies have more fat • Buoyancy decreases effects of gravity-reduces weight bearing/compression of joints • In water up to neck: 90% reduction • In water to waist: 50% reduction • Joint capsules OPEN when submerged – greater flexibility
Buoyancy • Force of buoyancy vertically upward-movement toward the surface of the pool - buoyancy “assisted” • Movement of a buoyant object toward the pool bottom – buoyancy “resisted” • Floating movement on the surface of the water – buoyancy “supported” • Biceps curls with foam dumbbells: concentric triceps (buoyancy resisted) eccentric triceps (buoyancy assisted)
Hydrostatic Pressure • Pressure increases with depth • Affects on body: • Increased blood flow from 1.8 to 4.1 mL/min/100g of tissue = increased oxygen delivery and circulatory force • Improvement with dependent edema – reduced swelling • Renal blood flow increased by 10% - increased urinary output/waste excretion
Surface Tension • Force exerted between the surface molecules of a liquid • Caution with arm patterns that move above and below the water’s surface • No “snapping” out of the water- especially careful w/ buoyant equipment
Drag &Turbulence • Drag is the force that you feel that opposes your movements in the water • Drag affected by frontal surface area, velocity and shape of object • Submerged movement – resisted in all planes of movement and in all directions of movement by the water’s viscosity and drag properties
Why Deep Water Running? • The most biomechanically specific form of cross training for the runner • Alternative training during an injury – excellent for stress fractures or foot, ankle, or knee injuries for whom running on land is contraindicated – no impact • Provides a strengthening component land running doesn’t • 800 times denser than air and provides up to 12 times the resistance • Regular runners burn about eight calories a minute, aqua-runners burn 11.5 in the same time (with the same intensity) • Scientific evidence has demonstrated that deep water running results in a sufficient training response in order to affect fitness improvement. This has been further documented by studies that have shown maintenance of exercise and performance in even competitive distance runners while training strictly with deep water running for periods up to six weeks long. (Dr. Robert Wilder, Director of Sports Rehab- UVA) • For Soldiers, a quicker return to running – (TBD)
Aquatic Running Form • Running in deep water is performed with the body in a 5 degree forward tilt. This bend should occur at the hips, nor from the spine. The biomechanical movement patter of water running resembles that used on land. • The head is held comfortably out of the water, facing forward; avoid the forward head/shoulder posturing. • Maintain a neutral spine. Always use a buoyancy belt to maintain form. • The arm action is the same as for land running, with the primary movement occurring at the shoulder and with the hands relaxed - slight scapula depression and retraction • Hip flexion should reach approximately 60-80 degrees at the same time the knees flex or extend. • Ankle movements should include both dorsi and plantar flexion.
Deep Water Alignment Mistakes • Leaning forward • “Snapping” the knee when kicking • Exaggerated lumbar hyperextension • Cervical hyperextension (looking up) • Hyperextending elbows and knees • Movements without precision • Overflexing the knee joint • Neglecting hand positioning • Emphasize ADIM for pelvic alignment
Instruction Pearls • Find out who doesn’t swim • Ensure proper amount of buoyant equipment is used to suspend with head above water • Emphasize working at own pace – use time, not group counts • Check pain level before activity. Emphasize aquatic therapy should not increase pain. • Stretching session afterwards – great time to increase ROM!
Our Program:Goals and Future Direction • Our Capacity: • Tuesday/Thursday 0700-0800 • 10 scheduled slots + Acute walk-ins (10-12 avg.) • Must be evaluated by DeWitt Physical Therapist and recommended for aquatic therapy: Max 8 sessions • MWR Benyaurd Indoor Pool • MWR lifeguards – one therapist • Future: SPRING 2011? • Separate therapy pool: 1st floor • Daily therapy sessions: group and individual • Increased staff: 1-2 Therapists; 2-3 PTAs • Leader in Aquatic Research
AQUATIC ARMY STRONG Who says it’s easy?