Case directed therapeutic aquatic exercise in

musculoskeletal diseasesUrs N. Gamper, PT, CH-ValensInternational Congress 2016Comprehensive Aquatic Therapy put into PracticeSantiago de Querétaro, October 31, 2016

Topics

� Characteristics of musculoskeletal diseases� Assessments and measurements� Attendant treatment in msk diseases� Delayed and protective muscle activity� Why water � Actual evidence for aquatic exercises in msk

diseases� Characteristics of fascia's and how we can treat it’s

with Bad Ragaz Ring Method®

Musculoskeletaldiseases

specific undifferentiated non specific

specific intervention

like: SurgeryDMARD

Antibiotics

Diagnosticchallenge:Teamwork Doctors

Therapists

non specificintervention

like:Multidimen-

sionalapproach

Chronic musculoskeletal diseases in aquatic therapy

� Low back pain� Osteoarthritis� Osteoporosis� Rheumatoid Arthritis� Spondylitis ankylosans� Fibromyalgia� Myofascial pain syndrome

Pain and pain related limitations of daily

activities and participation

Maintaning functional capacity over life course

Health problem

Rehabilitatio n

Integrated behavioural on neuromuscular explanation of activity limitations in musculoskeletal diseases

Neuromuscular model

Behavioural model

Pain during activity Psychological distress

Avoidance of activity

Muscle and soft tissue weakness

Pain during activity

Poor proprioception

Laxity/Stiffness

Accessory movement

Activity limitationsAdapted from Dekker J: Springer 2014

International classification of functioning, disability and health (ICF) and aims of interventions in muskuloskeletal-diseases

Reduction of symptomsReduce painImprove mobility

- Joint / Nerves- Soft tissue

Improve enduranceImprove muscle forceImprove postural control

Reduction of ADL limitationsImprove mobility

- Changing and maintaining body positions- Walking and moving

Improve self careImprove domestic life

- Household tasksImprove major life areas

Source: WHO http://apps.who.int/classifications/icfbrowser/

Rehab Cycle and outcome measurements

Identify problems and needs

Relate problems to modifiable and limiting factors

Define target problems and target mediators, select appropriate measuresPlan, implement and

coordinate the interventions

Measure the effect

Measurements has to measure on:� Body function

� Activity and Participation

Measurements must be:� metric

� sensitive

� reliable

Stucky G, Sangha O, Principles of Rehabilitation. In: Klippel JH, Dieppe PA, eds. Rheumatology, 2nd ed. Mosby:1998

Pain neuroscience education (PNE)

13 RCT, PEDro Scala 7-10

Content of PNE:� Neurophysiology of pain� Nociception and nociceptive pathways� Synapses and action potentials� Spinal inhibition and facilitation� Peripheral and central sensitization� Plasticity of the nervous system� Psychosocial factors and beliefs contributing to pain

� No reference of anatomic or patho-anatomic models� No discussion of the emotional or behavioural aspects of pain

The efficacy of pain neuroscience education on musculoskeletal pain: A systematic reviewLouw A et al. Physiotherapy Theory Practice, 2016; 32: (5), 332-55

The efficacy of pain neuroscience education on musculoskeletal pain: A systematic reviewLouw A et al. Physiotherapy Theory Practice. 2016;32(5),332-55

A key element of “teaching people about pain” appears to be the combination of education with active/movement strategies. A conceptual framework of kinesthetic education must be consistent with and reinforces pain neuroscience education. They also provide some specific guidance for integrating pain neuroscience education with exercise and movement in a more congruent manner, enhancing the effectiveness of specific movement approaches such as graded exposure techniques. What is often overlooked, however, is the consistency between the messages of pain neuroscience education and those of other therapeutic interventions, including movement therapies. The addition of guided purposeful movement performed in a manner consistent with pain neuroscience education may be vital to the desired behavioral changes, and when inconsistent messages are delivered between education and movement interventions, outcomes may be adversely impacted.

Is there a role for transversus abdominis in lumbo-pelvic stabilityHodges PW. Manual Therapy. 1999;4(2):74-86

Adapted from: Cresswell AG et al. Exp Brain Res. 1994;98:336-41

unexpectedexpected

Leg muscles movement

Back muscle dysfunction during remission from recurrent back painMacDonald D et al: Pain. 2009, 142(3):183-88

Healthy

LBP

Shoulder Flexion Shoulder Extension

○ □ healthy people● ■ recurrent episodes unilateral low back pain

SF

SF

LF

LF

Gait parameters and muscle activation patterns afte r 3, 6, 12 month after total hip arthroplastyAgostini V et al. J Arthroplasty. 2013;29(6):1265-72

arthroplasty sound

Why Aquatic Therapy

Physical properties

Water is a newenvironment (Tasks)

Rules of exercise physiology

Patient needs

Patho-physiology

� Buoyancy� Hydrostatic pressure� Viscosity� Waves� Turbulences� Temperature

Physical properties

Harrison RA et al. Physiotherapy Practice. 1987,3:60-63 and Physiotherapy.1992;78(3):164-66

0

10

20

30

40

50

60

70

80

90

100

ASIS Proc. Styl. C-7

stand

s. walk

f. walk

Percentage of weight-bearing during partial immersion in the hydrotherapy pool

How we can influence muscular activity in the pool?

� Turbulences

� Waves

� Flotation aid

� Depth

� Surface

� Body shape

� Radius

� Speed

� Problem solving strategy- Change in neuro-motor behaviour- Different compensation strategy (land/water)- Balance reactions (strategy and time)

� Increase of sensory input� No risk to fall

Water as a new Environment (new tasks)

Aquatic Therapy is recommended in several clinical Guidelines

� EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritisFernandes L et al. Ann Rheum Dis. 2013;72:1125-1135 doi:10.1136/annrheumdis-2012-202745

� EULAR revised recommendations for the management of fibromyalgiaMacfarlane GJ et al. Ann Rheum Dis. 2016; doi:10.1136/annrheumdis-2016-209724

� 2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitisJ Braun, et al. Ann Rheum Dis. 2011;70:896-904 doi:10.1136/ard.2011.151027

� An updated overview of clinical guidelines for the management of non-specific low back pain in primary careKoes BW et al. Eur Spine. 2010;19(12):2075–2094 doi:10.1007/s00586-010- 1502-y

Systematic Review

Aquatic exercise for the treatment of knee and hip osteoarthritisBartels EM et al. Cochrane. 2016;3: doi:10.1002/1465858.CD005523.pub3

13 RCs 1190 participants, mean duration OA 6.7 y, mean duration aquatic exercise 12 weeks (6-20)

Paracetamol SMD 0.18 (0.11-0.25), NSAR SMD 0.37 (0.26-0.49)McAlindon TE et al. Osteoarthritis and Cartilage. 2014:22(3):363-88

doi:10.1016/j.joca.2014.01.003.

Total 538 537 -0.31 (-0.47, -0.15)

Outcome: Pain

Aquatic exercise for the treatment of knee and hip osteoarthritisBartels EM et al. Cochrane. 2016;3: doi:10.1002/1465858.CD005523.pub3Disability

QoL

Total 529 530 -0.32 (-0.47, -0.17)

Total 493 478 -0.25 (-0.49, -0.01)

Effectiveness of aquatic exercises for musculoskeletal conditionsBarker AL et al. Arch Phys Med Rehabil 2014;95:1776-86

OA

RA

FM

LBP

-0.31 (-0.5,-0.13)

0.00 (-0.47,0.47)

-1.02 (-1.65,-0.38)

-0.74 (-1.68, 0.20)

Total (95%CI) 586 603 - 0.37 (-0.56,-0.18)

Pai

n: A

quat

ic e

xerc

ise

vs. n

o ex

erci

ses

Aquatic exercise no exercise

Effectiveness of aquatic exercises for musculoskeletal conditionsBarker AL et al. Arch Phys Med Rehabil. 2014;95:1776-86

Out

com

e P

hysi

cal F

unct

ion:

aqu

atic

vs.

no

xerc

ises OA

RA

FM

Osteoporosis

0.32 (0.10,0.54)

0.22 (-0.25,0.699)

0.63 (0.20,1.00)

0.36 (-0.88,0.16)

Total (95% CI) 581 573 0.32 (0.13,0.51)

No exercises Aquatic exercises

The benefits of a high-intensity aquatic exercise program (HydrOS) for bone metabolism and bone mass of postmenopausal womenMoreira LD et al. J Bone Miner Metab, 2014;32(4): 411-19

Femoral trochanter BMD P1NP (Bone formation marker)

N=108, EG 64, CG 44, CG normal physical statusEG High intense AE 24 weeks 3/w 50-60 min. Intensity mod. Borg Scale 5-9

Early aquatic physical therapy improves function an d does not increase risk of wound-related adverse events for adults after orthopaedic surgeryVillalta EM et al. Arch Phys Med Rehabil. 2013;94:138-48

Effect of ADL

Adverse effect

Total (95% CI) 146 144 0.01 (-0.05,0.079

Start with Aquatic Therapy4 days after surgery

Total (95% CI) 115 119 0.33 (0.07,0.58)

Postoperative Rehabilitation of Patients with Shoul der Arthroplasty ? A Review on the Standard of CareKraus M et al. Intern J Phys Med Rehabil. 2014;S5:001. doi: 10.4172/2329-9096.S5-001

Ideal for individualized Aquatic Therapy

Muscle Test 30°°°°/S 60°°°°/S 90°°°°/S

Supraspinatus LandWater

16.683.93

p=.015

17.465.71

p=0.15

22.7927.32

p=0.73

Infraspinatus LandWater

11.102.28

p=.0325

10.762.89

p=.0524

15.0321.06

p=.5566

Subscapularis Land Water

5.961.49

p=.0072

6.832.26

p=.0346

7.4510.73

p=.2421

Anterior deltoideus

Land Water

15.883.61

p=.0047

18.824.49

p=.0273

22.0932.83

p=.3273

Percentage of maximal voluntary contraction

Shoulder muscle activation during aquatic and dry land exercises in no impaired subjectsKelly B et al. J Orthop Sports Phys Ther. 2000;30(4):204-10

Effects of aquatic resistance training on mobility limitation and lower-limb impairments after knee replacementValtonen A et al. Arch Phys Med Rehabil. 2010;91(6):833-39

N=50, E 26 C 24 unilateral knee replacement, time since surgery: 9 month,2/w 45 progressive aquatic exercises RPE 12-16, HydroBoots, 12 weeks, CG no inervention

Fascial treatment in the

pool?

Sensory findings after stimulation of the thoracolu mbar fascia with hypertonic saline suggest its contribut ion to low back painSchilder A et al. Pain. 2014;155:222-31 doi:10.1242/jeb.112268

12 healthy subjects

Hypertonic saline 5.8%

Fascial adaptation to lifestyle

Schleip R Ed. 2015 Fascia in sport and movement. HandspringMod. after Reeves ND et al. Exp Physiol. 2006;91:483-98

Plyometric training effects on Achilles tendon stif fness and dissipative propertiesFouré A et al. J Appl Physiol, 2010;109:894-54 doi:10.1152/japplphysiol.01150.2009.

n=19, (EG 9, CG 10) 14 w/ 2/w 60 minutes EG diff. jumping exercises CG normal daly activity

EGpretestposttest

CGpretestposttest

Muscle-tendon-unit activity during counter-movement and no counter-movementSchleip R et al. J Bodyw Mov Ther. 2013;17(1):103-15

Kawakami Y et al. J Physiol, 2012; 540.2:635-46 DOI:10.1113/jphysiol.2001.013459

Oscillatory movement with recoil properties

conventional muscle training

Human Achilles tendon plasticity in response to cyc lic strain: effect of rate and durationBohm S et al. J Exp Biol. 2014; 217: 4010-17 doi:10.1242/jeb.112268

Referenc 4x

high strain rate72 jumps

long strain duration1x

14 weeks, 4/w, leg press 90% 1RM)

Reference protocol Long strain duration

*p=0.009ǂp=0.081

*p<0.008

P=0,002

P<0.05

Loading of different facial componentsSchleip R et al. J Bodyw Mov Ther. 2013;17(1):103-15

Effect of fascia training on collagen turnover

Schleip R Ed. in Fascia in sport and movement, Handspring 2015Magnusson SP et al. Nat Rev Rheumatol. 2010;6:262–68 doi:10.1038/nrrheum.2010.43

The pathogenesis of tendinopathy: balancing the response to loadingMagnusson SP et al. Nat Rev Rheumatol, 2010;6:262–68 doi:10.1038/nrrheum.2010.43

a) 36 km runningb) 1 h max. knee kickingc) 10 times 10 repetition

(70% 1 RM)

Fascial training

� Soft tissue stretching� Rebound elasticity

• Tendon: high load, 70% 1 RM oscillatory recoil like slow jumping

• Intramuscular Fascia: low load, 30% 1 RM slow, dynamic, fluidly

� Fascial release• Manual techniques

� Fluid refinement• Free movements in al directions

Schleip R et al. J Bodyw Move Ther. 2013;17(1):103-15 doi:10.1016/j.jbmt.2012.06.007

Fascial training use BRRM ®: soft tissue stretching

Fascial training use BRRM ®: soft tissue stretching

Fascial training use BRRM ®: rebounding elasticity

Fascial training use BRRM ®: soft tissue stretching

Questionsand try it’s in the

pool