Aquatic Physiotherapy Lecture Notes 2011 Aquatic Physiotherapy is the specific practice of physiotherapy in water. The aim of Aquatic Physiotherapy is to assist with the rehabilitation of neurological, musculoskeletal, cardiopulmonary and psychological function of the individual. It can involve individual treatment, groups or classes. PHYSICAL PROPERTIES OF WATER 1. Mass 2. Weight 3. Density 4. Relative Density (Specific Gravity) 5. Buoyancy (and Metacentre) 6. Hydrostatic Pressure 7. Surface Tension 8. Refraction 9. Viscosity MASS The mass of a substance is the amount of material it comprises. WEIGHT The weight of a substance is the force with which it is attracted to the centre of the earth. A body walking through water experiences resistance and viscosity. DENSITY Density = mass/volume Body type and symmetry is important to the ability to float. RELATIVE DENSITY (Specific gravity) Relative density is the ratio of the mass of a given volume of a substance to the mass of the same volume of water. • The relative density of pure water is 1. • A body with a specific gravity of less than 1 will float • A body with a specific gravity of more than 1 will sink in water. Ability to float is dependent on: • Age • Amount of body fat, muscle • Body density • Amount of air in the lungs Dissolved substances increase the density of water • Seawater (1.024), fresh water (1.0)

BUOYANCY Archimedes Principle • When a body is wholly or partially immersed in a fluid at rest, it experiences an

upthrust equal to the weight of the fluid that the body has displaced. Buoyancy is the force experienced as an upthrust that acts in the opposite direction to the force of gravity. A body in water is subjected to two opposing forces:

o Gravity acting through the centre of gravity, o Buoyancy acting through the centre of buoyancy, which is the centre

of gravity of the displaced liquid. BUOYANCY (META-CENTRE) • When the weight of the floating body equals the weight of the liquid displaced,

and the centres of buoyancy and gravity are in the same vertical line, the body is kept in stable equilibrium.

• If the centres are not in the same vertical line the two forces acting on the body will cause it to roll over until it reaches a position of stable equilibrium.

• Movement of the limbs, trunk and head that alters the body shape, will produce rotational effects, as will any alteration in shape due to disability.

BUOYANCY ASSISTED Buoyancy may be used to assist a movement when the limb is moved towards the surface of the water. • The effects of buoyancy increases as:

o The limb moves nearer to the surface of the water o The lever arm lengthens.

• When strengthening weak muscles, a longer lever and movement nearer the horizontal position gain the most assistance from buoyancy.

BUOYANCY NEUTRAL Movement is across the water where buoyancy is not assisting or resisting the movement. BUOYANCY RESISTED Buoyancy is used to resist movement when the limb is moved from the surface of the water to the vertical position. • However, when the movement is carried out against the force of buoyancy, there

will be resistance to the movement which lessens o As the limb nears the vertical position, and o With a shorter lever.

• The maximum resistance of buoyancy is thus exerted on a longer lever near to the horizontal.

EXERCISE PROGRESSION Using buoyancy assisted, neutral or resisted the following may be used: • Lever length • Speed of the movement • Turbulence • Streamlining • Floats

HYDROSTATIC PRESSURE Pascal’s Law states that fluid pressure is exerted equally on all surface areas of an immersed body at rest at a given depth. Pressure increases with:

o Density of the fluid o Depth.

• Hydrostatic pressure is most evident on the chest, where the water resists expansion.

• Increased pressure at greater depth may be used to reduce swelling. • Therefore it is more effective if the part being treated is in as deep as water as

possible. • This pressure also proves useful in smoothing out jerky, ataxic movements and

increasing co-ordination if the activity is carried out well below the surface. SURFACE TENSION The force exerted between the surface molecules of a fluid. • Surface tension acts as a resistance to movement when a limb is partially

submerged. • The effect is slight and is of value only if the muscles are small or weak. • The effect is greater the colder the water. REFRACTION The bending of a ray as it passes from a more to a less dense medium or vice versa. Due to refraction: • The pool seems to be shallower than it is. • People’s limbs appear distorted; those partially submerged seem to be bent

away from the normal at water level. • Movement of joints in water is difficult to observe from above the surface. VISCOSITY The type of friction that occurs between the molecules of a liquid that causes a resistance to the flow of the liquid. • Acts as a resistance to movement as the molecules of a liquid tend to adhere to

the surface of a body moving through it. • Air is less viscid than water; therefore there is more resistance to movement in

the pool than on land. BOUNDARY LAYER Movement of a liquid through a tube is greatest at the centre and least at the edges.

MOVEMENT THROUGH WATER TURBULENCE When an object moves through water, a difference in water pressure develops between the front and the back of the object. • The pressure increases in the front and decreases at the rear, resulting in a flow

of water into the area of reduced pressure - known as the wake. Eddies form in the wake, partly from the water round the edges and partly from the water behind the object. • Flow in the wake is less impeded, tending to drag the object back. • The faster the movement, the greater is the drag and therefore the greater the

resistance to movement. If the movement is suddenly reversed, it is opposed by the inertia of the water and turbulence occurs. • Similarly, if the wake hits the side of the container, the rebound causes

turbulence STREAMLINED When a broad ended object moves through the water the streamlines break away from the surface of the object. Waves are formed which travel sideways away from the object, becoming gradually weaker. With a narrow object moving through water, there is little or no breakaway of the streamlines and little disturbance of the water - the object is said to be streamlined. With an unstreamlined body there is greater wave formation and so greater resistance to its movement. PRACTICAL APPLICATIONS Turbulence can be used as a form of resistance for exercises in the pool. • The quicker the movement, the greater is the turbulence. The more changes of

direction, the greater the turbulence. • Floats and bats can be made streamlined, thus altering the resistance to

movement. The wake is an area of reduced pressure in the water behind a moving object. • Thus when re-educating the patient to walk in the pool a physiotherapist should

always walk in front of the patient at first to make it easier. • Swimming in water is easier than walking because the body is more streamlined

when swimming.

PHYSIOLOGICAL EFFECTS DURING IMMERSION • Rise in body temperature • Increased cardiac function • Increased peripheral circulation • Increased heart rate • Decreased blood pressure • Increased urine output • Increased metabolic rate • Increased respiratory rate • Decreased sensitivity of sensory nerve endings • Decreased muscle tone • Skin changes RISE IN BODY TEMPERATURE • If the temp of the water is above that of skin temp 33.5°, then the body gains

heat through the areas under the water. • Temperature loss is only from the blood in the cutaneous vessels and the sweat

glands of the areas out of the water. • The body gains heat from the water and from muscular energy conversion during

exercise. INCREASED CARDIAC FUNCTION • Due to hydrostatic pressure there is a rapid increase in cardiac output and

increased central blood volume. INCREASED PERIPHERAL CIRCULATION • As the skin becomes heated the superficial blood vessels dilate and the

peripheral blood supply is increased. • The blood flowing through the vessels is heated the temp of underlying

structures rises their vessels dilate and blood supply increases. INCREASED HEART RATE • Initially decreases due to increased cardiac output • The heart rate increases with the temperature rise and as a result of exercise DECREASED BLOOD PRESSURE • As the patient enters the pool the cutaneous vessels constrict momentarily,

causing a rise in peripheral resistance and a momentary rise in blood pressure. • During immersion the arterioles dilate, producing a reduction in peripheral

resistance and therefore a fall in blood pressure. INCREASED URINE OUTPUT • Land 1ml/min, water up to 7mls/min • Inhibition of antidiuretic hormone due to increased left atrial pressure. This

suppresses water reabsorption from the kidney diuresis INCREASED METABOLIC RATE / INCREASED RESPIRATORY RATE • A rise in body temperature increases metabolism. • Therefore metabolism in the skin and muscles is increased and, as the body

temperature rises, so does the general metabolic rate. • This increases the demand for oxygen and the production of CO2,

• The respiratory rate rises proportionately with the increased metabolic rate. DECREASED SENSITIVITY OF SENSORY NERVE ENDINGS • This can be due to the mild heat, increased blood supply to the periphery or

relaxation of the muscle. DECREASED MUSCLE TONE • This can be due to the warming of the muscle and the effect of hydrostatic

pressure. • Care needs to be taken that the water is not too hot as this could cause a

rebound effect increasing the tone some time after the patient has finished the Aquatic Physiotherapy session.

SKIN CHANGES • Initially there is blanching due to the vasoconstriction and this is followed by

pinkness and then redness due to the dilatation. • There is increased activity of sweat and sebaceous glands as the skin

temperature rises. • Long contact with water macerates keratin, which, by absorption of water

becomes soft, thick, white and wrinkled. AFTER IMMERSION Body temperature returns to normal Heart, respiratory and metabolic rates return to normal Blood pressure returns to normal • Body temperature returns to normal due to the considerable activity of the sweat

glands and results in considerable fluid loss from the body. • Patients and staff should have a rest period and a drink of water after their

Aquatic Physiotherapy session. • Blood pressure returns to normal more slowly than the heart, respiratory and

metabolic rates. THERAPEUTIC EFFECTS • Relief of pain and muscle spasm • Relaxation • Increasing range of joint movement • Re-educating weak muscles • Improving functional activities • Improving balance and coordination • Provides for therapeutic recreational activities • It is easier to move patients RELIEF OF PAIN AND MUSCLE SPASM • The warmth of the water plus the effects of buoyancy and hydrostatic pressure

produce a relief of weight from painful structures and a feeling of weightlessness. Often a patient’s treatment will start in the pool rather than dry land.

RELAXATION • Often it is very difficult for the patient to move on land and once in the water they

feel they are at last able to move as their body is supported by the buoyancy of the water.

INCREASING RANGE OF JOINT MOVEMENT • With the neutral warmth provided by the water the pain and muscle spasm can

be decreased, allowing for a greater ROM • The hydrostatic pressure exerted on swollen joints has a tendency to reduce the

swelling in an area, which assists in gaining increases in ROM • Due to the buoyancy and support offered by the water. RE-EDUCATING WEAK MUSCLES • A finely graded progression of exercise can be obtained by using buoyancy to

assist movement, then as a support and finally as a resistance. • Each variation of the exercise can be modified by:

o Altering the length of the lever arm of the body part being moved o Changing the speed of the movement o Creating turbulence o Streamlining o Use of floats

• As a result of this a finely graded exercise program can be designed especially for very weak muscles.

MODIFIED OXFORD SCALE 1 = Contraction with buoyancy assisting 2 = Contraction with buoyancy neutral 2+= Contraction against buoyancy 3 = Contraction against buoyancy with speed 4 = Contraction against buoyancy + small float 5 = Contraction against buoyancy + large float IMPROVING FUNCTIONAL ACTIVITIES - WALKING • Because of the weight relief afforded by the water it is an ideal medium for the

re-education of gait and progressing from partial weight bearing to full weight bearing.

• If the head and neck are out of the water, approximately 90% of the body weight is relieved.

IMPROVED BALANCE AND COORDINATION • Due to support of the body there is a longer reaction time to loss of balance. • Due to slower movements in water compared to land the patient has a better

opportunity to achieve coordinated movements PROVIDES FOR THERAPEUTIC RECREATIONAL ACTIVITIES • Many patients who are severely handicapped out of water are surprisingly mobile

in the water. • Ability for patients to be free of walking aids and supports • This is of great psychological value. EASIER TO MOVE PATIENTS • This is of particular advantage to the therapist when treating heavy or severely

disabled patients. • It is possible to perform movements in the water that would not be possible on

land due to the restrictions of gravity.

CONTRAINDICATIONS Refer to “Guidelines for Physiotherapists working in and/or managing Hydrotherapy Pools”. ABSOLUTE • Infectious Conditions

o Active tuberculosis o Herpes simplex o Bladder infections o Infected skin rashes o Diarrhoea – symptom free for 7 days

• Acute/febrile conditions • Unreliable faecal incontinence • Menstruating patients with HIV, Hepatitis B • Open wounds in patients with AIDS, Hep B, VRE, MRSA, • Heat sensitive conditions - >34.50C MS, Chronic Fatigue Syndrome, Pregnancy PRECAUTIONS • Tinea and plantar warts • Vital capacity <35% of that expected • Uncontrolled hypertension or hypotension

These are the patients who if they get into trouble in the water will just quietly sink to the bottom of the pool

• Epileptics • Open Wounds – occlusive dressings • External fixateurs – occlusive dressings • Dermal sensitivity to sanitizing chemicals • Angina

ASSESSMENT • Aquatic Physiotherapy patients should be assessed on land and in the water. • It is necessary to take into account the nature of the medium and the effects that

occur when a body enters the water and is acted upon by two forces simultaneously.

• The land and water assessment should follow the soapier guidelines. The water assessment should also include:

SOAPIER FORMAT S The patients attitude to water, their perceived ability in water and details of

previous aquatic physiotherapy treatment.

O Examination of the patient’s shape and density and consideration of the precautions /contraindications for aquatic physiotherapy

A Analysis of shape and density. This may form part of the problem list.

P Strategies used to overcome the problems associated with working in water.

I May include mental adjustment, balance restoration and rotational control.

E Evaluation of the intervention given

R Proposed treatment changes and when the next treatment will occur.

ASSESSMENT CRITERIA • Shape and density • Goniometry • Oxford scale of muscle power modified for water • Percentage weight bearing • Muscle tone • Breathing control RECORDING • Length of treatment • Depths used • Exercises, patterns included • Progressions of exercises • Any improvements • Any untoward effects • Individual/ Group treatment

TYPES OF AQUATIC PHYSIOTHERAPY CONVENTIONAL TECHNIQUES These include all buoyancy assisted, neutral and resisted exercises with the variations of speed, lever length, turbulence, floats and streamlining to gain a fine progression of exercise. HYDRODYNAMIC EXERCISES These are based on three hydrodynamic principles of relative density, turbulence and metacentre. Each exercise requires: • Static maintenance of posture and position against the effect of altered shape • Static maintenance of posture or position due to a change of shape • Reaction to the changes of shape and /or to the effects of turbulence The process by which Hydrodynamic Exercise is achieved: • Adoption of a stable shape • Change of shape which requires movement + the creation of turbulence • Balance against the turbulent effects caused by the movement • Balance in the new shape The relevance of these exercises is: • Balance and movement • Functional for daily life and work • Recreation DYNAMIC STABILISATIONS Any activity or exercise that challenges proper spinal alignment or strengthens the muscles that promotes this alignment. Used to improve: • Posture • Strengthening • Flexibility • Endurance • Function Positions: • Standing • Vertical Hanging • Sitting • Supine lying Exercise progression can be achieved by altering lever length, speed of the movement, turbulence, streamlining and floats. METACENTRIC EXERCISES Movement of the limbs, trunk and head that alters the body shape, will produce rotational effects, as will any alteration in shape due to disability. Metacentric exercises require the movement of a body part to change the metacentric point. The patient is required to counteract the rotational effect with appropriate muscle work.

PASSIVE MOBILISATIONS The success of passive mobilisation depends on: • A water confident patient • Suitable depth for the physiotherapist • Patient comfort in flotation equipment • Non-slip pool floor • Pool design features for fixation Specific aims of passive mobilisations • Reduce local muscle spasm • Reduce muscle tone • Relieve pain and effusion of a joint by reducing joint pressure • Increase range of movement of the joint • Gain weight reduction on the spine in buoyancy supported flotation • Gain general relaxation • Use the water for post-mobilisation activity Types of mobilisations: • Passive manual mobilisation • Passive mobilisation using turbulent drag BAD RAGAZ RING METHOD Developed at Bad Ragaz in Switzerland in the 1930’s but has been revised several times since. Applies the principles of Proprioceptive Neuromuscular Facilitation. Most patterns are worked with the patient in supine lying supported by floats. The therapist provides the stability for the patient and therefore must be in water no deeper than T11. All techniques are on a one to one basis. Resistance can be varied by altering: • The speed of the movement • The shape of the moving part • The degree of flotation Therapist’s action in relation to the client: • Isokinetic – The therapist provides fixation while the client moves through the

water • Isotonic – The therapist acts as a “movable fixation point. • Isometric – The client holds a fixed position while being pushed through the

water by the therapist. Types of patterns: • Isometric/ Isotonic • Repeated contractions • Slow reversals • Rhythmic stabilisations

HALLIWICK METHOD This is a method of teaching water confidence/swimming through a ten-point programme with four phases. Phase 1 – Mental Adjustment 1. Mental Adjustment Learning with the help of an Instructor to move in the water, first in the vertical position and later in the horizontal position, changing from land habits to being creatures of water. 2. Disengagement Developing independence from the Instructor and allowing the buoyancy of water to support the body. No artificial flotation aids are used to complicate the balance of the disabled swimmer. Phase 2 – Balance Restoration 3. Vertical Rotation The position of the head controls the feet. Forward or vertical rotation occurs around the pelvis and is caused by flexing the head and the body. By doing this, the swimmer can achieve an upright balanced position in the water. 4. Lateral Rotation The initiating and /or controlling of movements around the longitudinal axis of the body (around the spine). 5. Combined Rotation This is the use of vertical and lateral rotations to control any rotations around the diagonal axis. If the swimmer falls forward using a vertical rotation and perform a lateral rotation, the swimmer will achieve a horizontal back float position in the water without concern about breathing. Phase 3 – Movement Inhibition 6. Upthrust This is a phase of mental inversion. The swimmer is required to carry out activities on the floor of the pool against the feeling of upthrust or buoyancy. The swimmer uses rotational control to recover to a safe breathing position. 7. Balance is Stillness Controlling the body in a vertical or horizontal position against movements of the water or asymmetry of the body shape. The swimmer achieves this by use of contra- rotational actions to maintain balance. 8. Turbulent Gliding The floating body is moved through the water by an Instructor creating turbulence around the swimmer’s body. Phase 4 – Movement Facilitation 9. Elementary Propulsion The swimmer makes small controlled movements with the hands near the body at the level of the hips (sculling)

10. Basic Stroke The swimmer uses the hands and arms as oars. The hands are lifted low out of the water to the level of the shoulder and followed by a pull through the water towards the hips. Reasons why no flotation aids are used: • Keeps the face clear of the water – poor breath control • False body position – poor stroke technique • Inhibits performance of some skills e.g.: rolling, submerging • Aids do not compensate for asymmetry • False sense of security and over dependence • Aids may be unsafe. They can support people face down in the water • Do not help integration • With progressive conditions support can be gradually increased • Freedom in water from appliances • Aids are not as adaptable as a helper Halliwick technique requires development of breath control, balance in water and muscle relaxation. AQUATIC PHYSIOTHERAPY CLASS WORK GROUPS • Arthritis • Ante and post natal • Low back pain • Seniors • Paediatrics • Neurological • Ankylosing Spondylitis • Frailed Aged • Chronic Pain ADVANTAGES OF WATER OVER LAND • Less force through wt bearing joints • Graded exercises (buoyancy, equipment) • Warm water pain relief • Adaptable to individual needs • Less wt bearing (PWB) • Easier to move people with disabilities • Recreational DISADVANTAGES OF WATER OVER LAND • Requires special equipment • Requires dressing, showering & redressing • Requires extra staff • Clients need to be water confident • Physiological changes occur • Difficult to see under water • Noise levels

PROPERTIES OF WATER TO CONSIDER • Buoyancy • Turbulence • Hydrostatic pressure CONSIDERATIONS FOR CLASS WORK IN WATER • Spacing (lines, circles. random. along side of pool). • Exercising in groups or pairs • Vary depth • Vary speed • Music - needs to be slower than land based • Allow for social interaction ASSESSMENT • May require full SOAPIER • Priority problem list • Other medical conditions (e.g. unstable BP) • Decide on a measurable objective outcome • Have they exercised in water before? • Have they exercised recently? • Swimming ability/water confidence INFORMATION FOR FIRST SESSION • May feel tired • May have increased appetite • Need to pace themselves • Need to replace fluids • An increase in pain lasting more than 2 hours means they have overworked

during the class STRUCTURE OF CLASS • Warm up exercises / activity • Stretches • Aerobic exercise • Muscle work • Stretches • Cool down exercises / activity • Relaxation CLASS ORGANISATION • Everybody does the same thing • Concurrent groups • “Core” exercises, then individual programs • Individual programs ARTHRITIS • Include extension exercises • Consider buoyancy (weightlessness) & hydrostatic pressure for swelling • Offer alternatives • Ensure class participants pace themselves • Emphasis on balance work

ANTE AND POST NATAL • Water temperature • Fatigue • Dehydration • Back pain • Pelvic floor muscles LOW BACK PAIN • Ability to control a transverse abdominal contraction • Need to be taught transverse abdominal contractions prior to commencing class • Posture in water • Water temperature • Activities related to function SENIORS • Health problems • Mode of demonstration • Facilities especially floor surfaces and exit/entry • Emphasis of balance and postural exercises • Monitor progress by 6/12 min walk/run/swim test PAEDIATRICS • Halliwick Swimming • Acquire skills of balance restoration, head and breathing control NEUROLOGICAL • Mental adjustment • Temperature of water • Length of class • Over stimulation ANKYLOSING SPONDYLITIS • Extension exercises • Stretches to end of range • Strengthening of postural muscles • Mobilise stiff joints • Aerobic component FRAILED AGED • Health problems • Minimal turbulence in pool • Emphasis on standing and supine float position • Small groups • Good support / helpers in and out of the pool CHRONIC PAIN • May have done aquatic physiotherapy in the past and have preconceived ideas • Teach transverse abdominal contractions prior to commencing classes • Emphasise correct posture • Emphasise pacing • Complement land based exercise programme • May be part of multi-disciplinary approach •

AQUATIC PHYSIOTHERAPY PRACTICAL NOTES 2003 CONVENTIONAL TECHNIQUES These include all buoyancy assisted, neutral and resisted exercises with the variations of speed, lever length, turbulence, floats and streamlining to gain a fine progression of exercises. To design a graduated program you can take any muscle or joint movement and apply the physical principles of water immersion especially the effect of buoyancy to progress the movement from buoyancy assisted to buoyancy neutral to buoyancy resisted. If one of these positions is non-functional (eg the patient needs to have their head under the water) then exercise progression variations (as listed above) are used to progress the difficulty of the exercise. BUOYANCY ASSISTED • Most easily performed. • The part moves from a position at right angles to the surface of the water to the

horizontal position. This effect of buoyancy increases as the part approaches the horizontal position and beginning further from the horizontal can increase difficulty.

• Progression is made from a long weight arm to a short weight arm. BUOYANCY NEUTRAL • Buoyancy neither assists nor resists the movement. BUOYANCY RESISTED • The part is moved against the upthrust of the water from the horizontal position to

one at right angles to the surface. The effect is greatest as the part moves from the horizontal.

• Progression is made: o From a short lever arm toward a long lever arm. o Use of floats from proximal to distal and increasing the size of the floats.

Example: Knee Flexion Buoyancy assisted: • Standing with the thighs together flex the affected leg bringing the heel towards

the buttock. Buoyancy neutral: • Side lying in floats with the thighs together flex the affected leg bringing the heel

towards the buttock. Buoyancy resisted: • Supine lying in floats with the thighs together flex the affected leg bringing the

heel towards the buttock.

BAD RAGAZ RING METHOD Ref: Ruoti, (1997), Chapter 15

ISOMETRIC SHOULDER ABDUCTION Starting Position

Supine floating (fully supported with floats) with the arms abducted to 90°.

Movement Therapist holds the feet and pushes the patient through the water head first.

Command “As I push you through the water, don’t let your arms move” Note Bats held in the vertical position will increase the resistance

through the water as the streamlining of the body is reduced and there is a longer lever arm.

ISOMETRIC SHOULDER ADDUCTION

Starting Position

Supine floating (fully supported with floats) with the arms abducted to 45°

Movement The therapist stands at the patient’s head, hands on the patient’s shoulders. The patient is moved through the water feet first

Command Keep your arms in the same position as I push you through the water

Note Using the bats in the vertical position will make the movement more difficult to perform

TRUNK FLEXION and TRUNK FLEXION WITH ROTATION

Starting Position

Supine floating with a neck collar on. The therapist stride stands between the patient’s knees holding onto the lateral aspect of the thighs.

Movement 1) The patient reaches forward and touches the therapist’s shoulders, as the therapist “sits down”. 2) Alternatively the patient reaches both hands to one shoulder only, achieving trunk flexion with rotation.

Command 1) “Sit up towards me and put your hands over my shoulders”. 2. “Sit up towards me bringing both hands over my right shoulder”

Note If it is not possible to stand between the patient’s knees then stand to the side of the body and work the patient from this position. The position of the therapists arms are such that the patient is close to the therapist at all times.

TRUNK SIDE FLEXION

Starting Position

Supine floating with a neck collar. The therapist stands between the patient's legs at the knees. The therapist’s forearms are along the lateral side of the patient’s thighs.

Movement

The therapist moves the patient's body to one side and when the turbulence has built up on the opposite side of the body, the patient is instructed to "bend". Side flexion can be performed against turbulence or into turbulence depending on the capability of the patient.

Command "Bend to your right (or left) and then relax.” “Bend and relax, bend and relax.”

Note This technique can be progressed by changing the therapist’s hand hold to an axillary hand hold and then eventually to a bilateral elbow hold

ISOMETRIC TRUNK SIDE FLEXION Starting Position

As for the previous exercise

Movement As for the previous exercise Command "Keep your body straight as I move you through the water". Note This can be a useful exercise for trunk stabilisation

UNILATERAL HIP AND KNEE FLEXION Starting Position

Supine floating (fully supported by floats). An ankle float is on the non-exercising leg. The therapist stands slightly to the side of the foot of the exercising leg. The therapist’s proximal hand is placed on the posterior aspect of the leg to be exercised just inferior to the knee. The distal hand cups the patient’s heel.

Movement The patient moves toward the therapist as the hip and knee are flexed. As the therapist extends the knee passively, she takes a step backwards.

Command “Pull your knee up and relax” Note The opposite pattern of movement can be performed (extension)

and they can also be used bilaterally and as reversals, either unilaterally or bilaterally. (useful for muscle balance work)

HALLIWICK METHOD Ref: Campion M, (1991) Hydrotherapy in Paediatrics, (2nd ed), Oxford, Butterworth Heinemann WATER RUNNING Points to remember: • Water running technique should resemble as close to (land) sprinting action as

possible. • No trunk flexion. 20 degrees forward lean angle of whole body in water. • Must get knee extension just before heel strike • Must get hip extension on swing through • Must use arms as if running (no dog paddle with arms). • Must do opposite arm/leg pattern METACENTRIC EXERCISES All the exercises are done slowly with no movement of the body under the water. • Squat position – back upright, hip and knees as close to 90o as possible, arms at

90o shoulder flexion. o Lift 1 arm out of the water o Lift the other arm out of the water o Lift both arms out of the water

• Squat position – back upright, hip and knees as close to 90o as possible, arms at 90o shoulder abduction.

o Lift 1 arm out of the water o Lift the other arm out of the water

o Lift both arms out of the water • Squat position – back upright, 1 leg in 90o hip and knee flexion, the other leg with

hip flexion, knee extension and heel on the bottom of the pool. The leg is positioned at a 45o angle.

o Apply the same arm combinations as in the first two exercises. HYDRODYNAMIC EXERCISES After each alteration of shape it is important for the person to stop and hold the new position before moving onto the next position • Stand to squat position. Once the patient is able to do this independently ↑ speed

of the movement but remembering to hold stillness at each new position. • Standing. Move right leg into hip flexion and hold, take a step forward with the

right leg and hold the left leg in hip extension. Hold the position. Bring the left leg into hip flexion and hold. Repeat the sequence.

• Standing. Use the same sequence as previous exercise but add a 180o turn after the hip flexion step. This increases the need for truncal control.

• Sitting. In the squat position jump and land on the feet. Hold. Jump staying in the squat position and hold.

o Arms held in front o Arms held down by the side

• Sitting. In the squat position jump and land on the feet. Hold. Jump and turn 90o. Hold. Jump and turn 90o. Hold. Jump and turn 90o. Hold. Try this exercise in a clockwise and anti clockwise direction.

• Standing. One arm is resting on top of a floatation devise (ring, board, noodle) o Reach forward as far as possible and lifting the back leg if possible. Hold.

To return to the upright position uses the back extensors. o Reach out to the side as far as possible, lifting the opposing leg. To return

to the upright position uses the trunk side flexors.

DYNAMIC STABILISATION EXERCISES Throughout these exercises you are trying to maintain the position of the trunk in good static posture.

• Standing. Hold the trunk position whilst

o Arms: bilateral shoulder flexion or extension o Arms: reciprocal shoulder flexion/extension o Arms: unilateral shoulder abduction o Arms: bilateral shoulder abduction o Arms: horizontal flexion/extension o Arms: crossovers in front of the body o Arms: reciprocal hand behind back and hand in front

• Standing. Hold the trunk position whilst o Legs: Unilateral hip flexion/extension o Legs: Unilateral hip abduction/adduction o Legs: circles on the bottom of the pool o Legs: hip at 90o flexion and int/ext rotation

• Standing. Holding onto a kick board o Board is held vertical whilst moving it towards and away from the body o Board is angled away from the body whilst moving it towards and

away from the body o Board is angled towards the body whilst moving it towards and away

from the body. o Push the board down towards the bottom of the pool.

o Push the board down towards the bottom of the pool and return it to the surface as slowly as possible.

o Draw a letter X in front of the body o Do a paddle action with the board (as if paddling a canoe) but hold the

pelvis still. • Sitting on a noodle

o Hold stationary position o Hold good posture and flex/ext one leg o Hold good posture and flex/ext both legs

• Vertical hanging with a buoyancy belt or noodle o Maintain one leg in extension and flex the other towards the chest.

Maintain vertical position o Both legs towards the chest with the knees flexed. o Scissor kick. Maintain trunk position o Bilateral hip abduction whilst maintaining trunk position o Bilateral forward pedalling with the legs o Bilateral backward pedalling with the legs. Maintain the upright

posture. PASSIVE MOBILISATIONS Ref: Campion M, (1997), Hydrotherapy Principles and Practice, Oxford, Butterworth Heinemann, Chapter 11 STRETCHES Utilise the buoyancy of water and the use of floats to gain muscle stretches. Remember that doing land based stretches in water may not be the most effective method of stretch due to the effects of buoyancy and the metacentre. RELAXATION During the prac sessions the following will be covered: • Seaweeding • Mitchell’s Relaxation • Supine noodle support relaxation CASE STUDIES FOR PRACTICAL CLASSES Devise an aquatic physiotherapy program for a client who has undergone a right total hip replacement at these stages. 4 days post right total hip replacement Aims:

• Encourage partial weight bearing gait pattern. • Increase strength of the quadriceps, hip extensors and gluteus medius. • Increase range of movement of hip abduction and hip extension. • Increase aerobic capacity.

6 weeks post right total hip replacement Aims:

• Encourage full weight bearing. • Increase eccentric muscle strength of the quadriceps. • Advance strength of the hip extensors and gluteus medius. • Provide and teach swimming and water exercise activities to do

unsupervised for the above aims. • Maintain aerobic capacity.

Devise an aquatic physiotherapy program for a client who has undergone a right total knee replacement at the following stages: 4 days post right total knee replacement Aims:

• Decrease swelling of the knee and calf. • Increase range of knee flexion. • Strengthen the quadriceps particularly the last 20 degrees of knee extension

(the patient has full passive knee extension, but has a quads lag). • Encourage partial weight bearing walking.

8 weeks post right total knee replacement Aims:

• Progress strengthening of the quadriceps and hamstrings. • Commence training for functional activities of stairs (up and down) and

getting in & out of a chair. • Provide and teach swimming and water exercise activities to do

unsupervised for above aims. • Maintain aerobic capacity.

Devise an aquatic physiotherapy program for a client who has undergone a discectomy at L4/L5 level. Aims:

• Increase strength of the abdominal and quadriceps muscles. • Increase isometric strength of the back extensors. • Increase the general muscle strength of the muscles around the hips and

pelvis. • Advise and teach swimming and water exercises to do unsupervised to

increase and maintain aerobic fitness. Devise an aquatic physiotherapy program for a client who injured their right shoulder 6 weeks ago. The shoulder is not painful. They have full passive range of movement, 100° of active shoulder abduction and 120° of active shoulder flexion. Aims:

• Increase the range of active shoulder abduction and flexion. • Increase the strength of the right shoulder generally (flex/ext, abd/add, ext/int

rotation) • Increase aerobic capacity (the client wants to return to playing hockey).

REFERENCES Campion M. (1991) Hydrotherapy in Paediatrics (2nd ed), Oxford: Butterworth-Heineman Campion M. (1997) Hydrotherapy: Principles and Practice, Oxford: Butterworth-Heineman Davis B.C, Harrison R.A, (1988) Hydrotherapy in Practice, Edinburgh: Churchill Livingstone Geytenbeck, J (2002). “Evidence for effective hydrotherapy”. Physiotherapy, 88(9) 514-529 Larsen J, Pryce M, Harrison J et al (2002) Guidelines for physiotherapists working in and /or managing hydrotherapy pools. Published by the Australian Physiotherapy Association. Princess Margaret Hospital for Children. Hydrotherapy in Paediatrics (video) Ruoti R, Morris D, and Cole A, (1997) Aquatic Rehabilitation, Philadelphia: Lippincott Skinner A.T. & Thomson A.M, eds (1983) Duffield’s Exercise in Water, 3rd edn, London: Bailliere Tindall