hydrotherapy Flashcards
definition of aquatic therapy
ATACP aquatic therapy association of chartered physiotherapist 2014
“at is a therapy program utilising the properties of water, designed by a suitably qualified physio specifically for an individual to maximise function which can be phy, psych or physiological. Treatments should be carried out by appropriately trained personnel, ideally in a purpose built and suitably heated aquatic therapy pool”
at versus hydrotherapy definition
terms used interchangably but aquatic therapy is ually active and involves exercises prescribed by a physio.
ht literally means water healing
definition of hydrotherapy pool
atacp 2014
a warm water pool designed for aquatic physiotherapy treatment and rehab. they are used to treat people post injury, surgery, or med condition”
heated to 35 degrees and hoist available
what properties of water exist that alter exersising?
buoyancy hydrostatic pressure dynamic forces eg drag viscosity refraction density
what is buoyancy
Archimedes principle states that buoyancy is an…
- upward thrust of water on immersed object in opposite direction of gravity
- the buoyant force is equal to the weight of displaced water that the object displaces
- amount of water displaced depends on the density of the object
what are the implications of buoyancy
-body weight feels less in water than on land
less loading on injured structures
(reduction in weight depends on immersion depth)
-buoyancy and weight are often not aligned and also tissue proportion or mass may not be equally distributed causes rotational effect
-need equilibrium between centre of buoyancy and center of mass
-joint unloaded
-flotation devices increases resistance
what is hydrostatic pressure
pascal’s law= fluid pressure is exerted equally on all surfaces of an immersed body
pressure is directly proportional to immersion depth and fluid density ie more pressure with depth
implications of hydrostatic pressure
- improves balance in water
- no risk of falling
- reduction in swelling and oedema especially in feet so beneficial for swollen joints
- increases blood flow
- decrease in pain perception
but can affect lung vol CI
what is density
relationship between mass and volume of an object
d=m/v
density increases with increased amount of dissolved substance eg sea water >dense
what is relative density and relationship to fat and bone
-is the mass of an object compared to that of an equal volume.
-determines how much of an object will sink or float
aka a cork 0.2 20% will sink
- water =1 therefore fat= 0.8 to water so floats but bone= 1.5-2 so sinks
hence body builder would sink as low fat
implications of density
-when remaining motionless people with low body fat will find it harder to float
-also air in lungs if lungs full then will float but if empty lungs sink
BREATHING TECHNIQUES
-ie use breathing to control float
what are dynamic fluid forces AND EQUATION
drag ( indirection of flow)
lift (at right angles to drag)
F=1/2 P V^2 C S
p=density, v= velocity, c coefficient of smootheness and orientation to flow, and s =cross sectional area exposed to flow
what are the types of drags
- form drag= frontal surface area and shape of body, larger the area the more the drag
- surface drag= (friction between surface of the body and molecule of water)
- wave drag= (waves at surface) deeper you go more drag, closer than .4m reduces the drag
implications of drag
- used for muscle strengthening and cardio training ie by creating resistance in the water, can create progression by manipulating speed
- high speed more resistance
- poor technique causes turbulence making exercises harder
viscosity what is it
- fluid’s resistance to flow and deformation
- depends on cohesion and adhesion of molecules in fluid
- reduces as temp increases
implications of viscosity
- supporting and stabilising effect
- weak patients may not seem as weak in water
- psychological benefits: allows patients to complete exercises that might not be able to on land
- weightlessness feeling can move more and control better
what is surface tension
-caused by attractive forces between molecules and atoms on a fluid surface
implications of surface tension
makes exercise at water surface more difficult
what is refraction and implications of it at
-when light enters the water it changes speed and if light enters an angle the change in speed causes the light beam to bend away from the original path
-angles alignment or joint motion look different
Implications: therapist may think patient performs better/ worse than they actually are
techniques used in aquatic therapy
- buoyancy to assist or resist
- floats used to suspend the patient or increase resistance
- creating turbulence to increase resistance ( wave drag)
- aerobic exercise incl. aqua jogging with belt.
prevalence of musculoskeletal disorders
Labour force survey 2015
7.5 million working days are lost anually from work related MSD’s
>200, 000 people report LBP at work annually
Waller et al 2009
80% of pop exerience LBP during their lifetime
Backcare 2016
healthcare cost to the UK= 2.8 billion direct
causes of lbp
nhs 2018
- cant always identify
- certain med conditions
- occupational accident
Exercise to treat clbp
NICE 2016
recommends group exercise programmes within NHS for people with a specific episode or flare up of LBP with/ without sciatica
or combined programme
evidence for exercise to treat msd’s
intervsen et al 2012/ van middelkloop 2011
exercise shown to reduce pain, disability and increase muscle function and strength for RA & clbp
evidence for how the properties of water help with exercising with clbp 6points
Waller et al 2009
- water immersion decreases axial loading of the spine through buoyancy allows for movements hard on land
- utilise properties of water eg resistance to create a graded exercise programme
- hydrostatic pressure and water temp may assist with balance, mobility and pain control for patients eg pregnant women support spine
- suitable for patients restricted on land gives psychological benefit
- better than land based?
Mooventhan 2014
6. warm water and buoyancy reduce swelling and pain on joints and promotes muscle relaxation as block nociceptors
what is missing from existing research on hydrotherapy
- exercise details in many aquatic studies are not well reported or completely absent,
- little info on muscle activation of trunk supporting muscles in water
- no info on muscle activation for people with clbp suggest may be different to on land but unsure
references for hydrotherapy and lbp
-granath et al 2006
- waller et al 2009
-the water study
-colado et al 2013
bressel et al 2011
Baena beato et al 2014
Torres Ronda et al 2014
Mooventhan et al 2014
granath et al 2006
390 participants
land versus water
19 weeks gestational
intervention: 45 min activity x1 week, strength, flexibility and fitness
Results:
-water aerobics diminished pregnancy related LBP and sick leave due to pregnancy related LBP more than land based
ie 6 women land based versus 0 in water group with sick leave LBP
BUT NO EVIDENCE ON SPECIFIC EXERCISES
WALLER ET AL 2009
37 trials on at for lbp
methodological quality was poor
aquatic exercises not well reported
RESULTS:
1.pregnancy related lbp and pelvic pain studies showed sig benefits in reducing number of sick days to lbp (34%) and pain score
2. 6 studies showed therapeutic at exercise sig increase benefit on LBP but no evidence control more or less effective
3. both aquatic and land improved function on the owestry disability index and reduction in pain scores suggests water possibly as effective for lbp
4.three times a week produced largest imporvement
5. adherence to aquatic high
6. no studies reported a negative effect on lbp due to aquatic therapy
Bressel et al 2011
example of exercises
1. trunk rotations sitting on a board
2. kickboard oblique ie use board and twist side to side
found compared to land
The aquatic exercises that maximize trunk muscle activity in the healthy males studied are abdominal bracing and Swiss ball exercises. Some muscles were selectively activated during abdominal hollowing (LA) and hip abduction (MT) exercises when compared to most other exercises.
Colado et al 2013
24 fit healthy male uni studies
completed 3 reps of shoulder extension using 4 devices a drag weshap, drag glove, floating dumbell and floating wristband
2 depths clavicle and xiphoid depth
found no difference between 4 devices on neuromuscular response on shoulder extension at xiphoid depth
Regarding depth found xiphoid process depth to show increase muscle activation for latissimus dorsi (17.4%) compared to clavicle depth significant.
Regarding core muscles though no effect on depth or device used.
what were the aims of the water study 5
which aquatic exercises work best? Psycharakis 2015-2017
- how are trunk supporting muscles activated in aquatic exercises
- which exercises are more effective for each muscle
- what is the exercise pain, perceived exertion and intensity
- any differences in activation between CLBP participants and healthy controls
- what are the patterns for similar land exercises? compared exercises in water to land
what was the protocol of the water study
20 non specific clbp and 20 healthy water 26 and land 28 exercises selected 54 exercises in total -exercise pace controlled as same resistance to speed (metronome) -at at shallow depth familiarisation muscles: 7 trunk supporting equipment: electromyography with 2d video analysis
7 muscles used in the water study
elector spinae multifidus ra eo io gluteus maximus gluteus medius
main outcome measures of the water study
EMG
exercise intensity
percieved exertion
percieved pain or discomfort for CLBP group
main findings of the water study
- no difference between water or land
(clbp being generally active, mild to mod level of disability) - pain was level and occurrence was relatibely low in both environments
- pain level had a non sig trend lower values in water (2/10 then 2.3/10)
- pain occurrence was nearly 3x lower on water
- for 15 land “equivalent” exercises; intensity higher on land, ma and pe in water equal to land in 2/3 cases, higher ma in water in 5% of comparisons (sig diff found in some muscles in 4 out of 15 exercises) , higher ma in land in 28% of comparison (for at least 1 muscle in 14/15 exercises)
- asymmetries in activation in 4% of water and 12% on land ie 3x more on land as no buoyancy and pressure support
- hr higher on land as water immersion reduces hr
- percieved exertion was
-higher in water for 3 exercises
-higher in land for 6 exercises
-no different in remaining 6 exercises
conclusions of the water study
Aquatic exercises…
- often produce sufficient ma, intensity and pe
- should not be assumed less strenuous or less effective in activating muscles
- may be more approriate than land for early stages of rehab, higher disability levels, people with kinesiophobia or pain limiting factor
summary of benefits of hydro therapy
-warmth of water reduces pain acts on nocicpetors/ improves blood flow and facilitates muscle relaxation
-improved joint range of motion
-improved muscle length, strength and control,
improved balance and co-ord
- increased energy expenditure yet decreased mechanical loads on joints
-psychological benefit when unable to exercise on land
-general health improvement with exercise ie prevent co-morbidities
contraindications
infection pulmonary disease open wounds infectious skin disease inflammation uncontrolled hd or hypertension vascular condition kidney problem cancer incontinence fever
baena-beato eta l 2014
RCT 49 sedentary patients with clbp 24 versus 25 cg no randomisation 2month 40 sessions x5 per week, 55-60 minutes aerobic + resistance exercises cg=no exercise concluded aquatic programme in sb adults and clbp well tolerated
-increased hrqol
-decreased back pain
-increased body comp and fitness using flexilbity sit and reach, handgrip strength, curl up and rockport 1mile test
NO SPECIFIC EXERCISES
control group no sig changes
Torres-ronda properties of water
2014
- Water as a counterbalance to gravity
a. Density and buoyancy
b. Reduce impact on joint
c. Found when exercise is involves a horizontal movement at submaximal speeds eg aqaua jogging at a depth shallow immersion, vo2 and muscle activity are greater when performing the same exercise at the same speed on land.
d. Conversely when exercise is static or vertical the cvd and neurom activity are reduced in comparison to land due to buoyancy
e. Use flotation aids - Water as resistance
a. Density, viscosity and drag and buoyancy
b. Various studies support at can improve aerobic and muscle strength
c. Equipment - Water as a compressor
a. Hydrostatic pressure
b. Increased blood flow and increased cardiac output
c. Chest wall compressed altering pulmonary function - Water as a thermal conductor
a. Heat muscle relaxation, blocks nociceptor pain and increased blood flow
references for properties of water
Waller et al 2009
Mooventhan et al 2014
Torres Ronda et al 2014
Reference for effectiveness of aquatic therapy
Granath et al 2006 Waller et al 2009 Colado et al 2013 Bressel et al 2011 Psycharakis 2015-17 Baena-Beato et al 2014
