Aquatic Physical Therapy

18 Aquatic Physical Therapy



Thomas Cesarz, David Speach




KEY POINTS



• Swimming skill is not required for patients to safely engage in water-based therapies.

• Aquatic exercises are generally as safe as land-based exercises but health contraindications exist that may prohibit water-based therapy.

• Aquatic physical therapy is indicated when an individual cannot tolerate land-based therapies.

• Pain relief and improved function are the most common reasons for prescribing aquatic-based physical therapy.

• Scientific literature supporting purported benefits of aquatic therapy is limited. Extrapolated research in patients with knee arthritis and ankylosing spondylitis do demonstrate modest benefits in pain reduction and well-being following aqua therapy.

For millennia people have used water for healing and for rituals, traditions continuing through the present. Today, water is applied in a variety of therapies, with proponents of each often making broad and unsubstantiated claims of health benefits. Commonly used terms for water-based therapies include hydrotherapy, aquatic therapy, balneotherapy, and spa therapy.


Hydrotherapy and aquatic therapy are often used interchangeably to refer to physical therapy performed in water. Spa therapy refers to physical modalities applied in a relaxing atmosphere that may be purely commercial, devoid of oversight from a licensed practitioner at point of delivery. Spa therapies can include land-based modalities such as massage and electrotherapy, as well as water-based forms such as balneotherapy and whirlpool. Spa treatments, even when water-based, are typically passive.1 Studies of spa interventions prove difficult. Balneotherapy refers to the immersion of patient or limb in a natural thermal mineral water, defined as at least 20° C, and containing a concentration of specific salts in excess of 1 g/L.1


This chapter focuses on aquatic therapy exercises that are analogous to land-based physical therapy. It will cover the theoretical underpinning of aquatic exercise with appropriate indications and contraindications.



Clinical Case Examples


A 78-year-old woman with advanced bilateral knee osteoarthritis and leg and back pain occurring only when walking and standing has been unable to tolerate land-based aerobic exercise due to pain.


A 68-year-old obese male smoker with chronic axial low back pain and poor endurance presents to a chronic pain center with markedly reduced daily function and pain with any movement or prolonged positioning.



Basic Science


For such a widely used and presumably safe activity, immersion in water has far-reaching physiological effects that help explain the patient’s relief of symptoms but also raise the flag of specific contraindications. Water differs from air in density, buoyancy, and viscosity, rendering it of different therapeutic value.


Water is nearly 800 times as dense as air.2 The bottom of a mass of material exerts a pressure based on the density of the material. For example, at sea level, effectively at the “bottom” of the earth’s atmosphere, patients are exposed to the pressure of air. When a patient enters a body of water, be it a hot tub, swimming pool, or ocean, the water exerts pressure that increases with increasing depth. Water affects the cardiovascular and renal systems. Water’s hydrostatic pressure compresses veins, increasing venous return and pushing blood centrally, leading to a rise in central blood volume, cardiac blood volume, and cardiac output.3 Compression of veins can reduce edema. Healthy individuals seated for 2 hours in water from the renowned spa at Bath, England, showed a doubling of diuresis and 50% increase in cardiac index. The increase in diuresis is not due to an increase in creatinine clearance, though alteration of renally active hormones may play a role.4 It is unclear if hydrostatic pressure is the primary mechanism underlying all of these systemic effects.


Water is a viscous substance that resists movement. The resistance offered by the water increases as speed of movement increases, so when the patient first starts exercising in water, a slower velocity is naturally used. As strength and endurance improve, faster movement is possible with greater challenge. Because of the mechanics of fluid, resistance is maximized if the patient performs exercises in a continuous movement in which the limb is kept below the water surface. Resistance can be strategically lessened to accommodate the patient’s strength level with partial submersion and pausing during the movement. For the stronger patient, water mitts and hand paddles can be added to increase drag of the limb.5 Training in water has several advantages compared to land. Movements against water are inherently more difficult than identical movements against air because of water’s viscosity, making virtually any movement against water a resistance training exercise. Performing resistance training movements in water puts less stress on joints because they are unloaded of gravitational forces compared to land.


Pain decreases in water through several mechanisms. The natural buoyancy of water unloads joints and supports the body so less muscle activation and coordination is required to maintain balance. Standing upright with water up to the neck, the upward buoyant force counteracts gravity so that about 10% of the normal gravitational force is exerted on the body. Discs, facets, and peripheral joint structures are unloaded allowing for functional movements such as walking with less stress.6 Reduction of muscle activity to maintain balance allows for easier control of proper pelvic tilt and lumbar curvature. Body support from buoyancy in positions of spinal flexion and extension means the patient can actively range through normally painful spinal load movements with less compression on the spine. Normal range of motion may be achieved in a pain-free manner in the aquatic environment before trying similar exercises on land.5 A negative effect of buoyancy is a decrease in body stability with water levels above the T8 spinal level. Shallower water may be indicated if the patient has difficulty keeping his or her feet planted on the pool floor.5 An additional factor in aquatic therapy pain relief is that water acts as a diffuse sensory stimulus that can alter or suppress the typical pain experience.5



Case Studies



Treatment, Clinical Challenges, and Future Treatments


A 78-year-old woman with bilateral knee osteoarthritis and leg and back pain occurring only when walking and standing has been unable to tolerate land-based aerobic exercise. For this individual, her knee arthritis interferes with her ability to bear weight and train her spine on land. Evidence exists showing that aquatic exercises decrease pain from peripheral joint arthritis. The unloading effect that occurs in water allows for strength training and aerobic conditioning while in a supportive environment that protects from falls. Her history is suggestive of neurogenic claudication from lumbar spinal stenosis, a condition where the patient often obtains relief while in positions of flexion. In water a flexion posture is achieved with less compressive force on the vertebral bodies, limiting the risk of an exercise-induced osteoporotic compression fracture or aggravation of mechanical low back pain. Eventually, this patient can try transitioning to a land-based program with the goal of improving her walking tolerance.


A 47-year-old obese male smoker with chronic axial low back pain and poor endurance presents to a chronic pain center with markedly reduced daily function and pain with any movement or prolonged stationary position. Chronic low back pain is very challenging to treat. Once an individual becomes deconditioned, land-based exercises can be too challenging, particularly in patients with limited pulmonary capabilities as in obstructive pulmonary disease. Water is an ideal environment to begin recovery of strength, endurance, and flexibility. The prescribing physician must pay attention to any contraindications for aquatic therapy that are present in this patient, such as comorbid severe heart disease or open wounds. The primary goal for this patient will be to decrease the pain associated with movement. The buoyant aquatic environment reduces axial load on his spine. Limb exercises performed quickly under water will be more difficult than on land. An aquatic-based conditioning program must be titrated to his endurance, which will increase over the course of therapy.

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The Role of Spinal Injections in Treating the Aging Spine Default ThumbnailEconomics of Spine Care Land Based Rehabilitation and the Aging Spine Radiofrequency Kyphoplasty: A Novel Approach to Minimally Invasive Treatment of Vertebral Compression Fractures Dorsal Endoscopic Rhizotomy for Chronic Nondiscogenic Axial Low Back Pain Interspinous Spacers for Minimally Invasive Treatment of Dynamic Spinal Stenosis and Low Back Pain

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Aug 6, 2016 | Posted by in NEUROSURGERY | Comments Off on Aquatic Physical Therapy

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