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Aquatic therapy refers to the use of multi-depth immersion pools or tanks that facilitate the application of various established therapeutic interventions including stretching, strengthening, joint mobilisation, balance, gait, endurance. According to the American Physical Therapy Associations Aquatic Therapy Section, aquatic therapy is defined as: The practice of physical therapy by a trained and licensed physical therapist (PT) or physical therapy assistant (PTA) within a pool environment. The bouyancy, support, and accomodating resistance of water enhance exercise and create a safe environment for progressive rehabilitation. The temperature of the water prompts muscle relaxation, facilitates stretching and generally reduces the sensation of pain


Specific Gravity and RELATIVE Density Hydrostatic Pressure Buoyancy Viscosity

Properties of Water
Relative Density 1. Definition: Property of an object that determines whether object will float. 2. Ratio of weight of an object to the weight of an equal volume of water. If the value is greater than one, the object will sink and if less than one, the object will float. 3. If a persons relative density is .96, then 4% of their body will be above water.

Physical Properties Cont.

Counteracts downward pull of gravity
Upward force that supports submerged or partially submerged object Assists motion toward waters surface

Sense of weight loss

Changes relative to level of submersion Differs in males and females due to relative CoG

Allows for ambulation and vigorous exercise

Reduces joint impact Reduces friction between articular surfaces


Physical Properties cont. BUOYANCY

Archimedes Principle a. When a body is fully or partially submerged in a fluid at rest, it experiences an upward thrust equal to the weight of the fluid displaced. b. Influenced by volume and density influenced by hydrostatic pressure. c. Relative Density (how well objects float) = density/volume. Position/Size of an object influences how well it floats.
Buoyancy is partially dependent on body weight
Weight of different body parts will vary

Determined by:
Ratio of bone weight to muscle weight Amount and distribution of fat Depth and expansion of chest

Buoyancy can be used to assist, support or resist movement. a. Depends on patients position standing, supine, sitting, etc. - When immersed to pubic symphysis=60% weight bearing (WB) - To umbilicus = 50% WB - To xiphoid = 40% WB - To shoulders = 20-30% WB

Resistive Forces Resistance to movement in water. Bernoulli's principle:

b. Depends on patient characteristics spasticity/tone increased tends to sink, decreased tends to float; innervation; body composition; fear of water; height.
A. Increased speed of flow; decreased pressure; object moves into an area of decreased pressure. B. Resistance altered by: Speed, Shape, Length

Cohesive force
Runs parallel to the direction of the water surface Due to surface tension of water molecules

Specific Gravity
Specific gravity of humans is slightly less than water
Enables the body to float Does not mean that body will float horizontally Different segments have different specific gravities Air in lungs vs. extremities

Bow force
Force generated at the front of an object during movement
Increased water pressure at the front Decreased water pressure in the rear

Creates a pressure gradient

Low pressure zones swirl = eddies (turbulence) Creates a drag force

Resistive Forces cont. Drag force

Modified by shape and speed of object
Increase streamline of object = decrease drag Increase speed of object = increase drag

Must be considered carefully when attempting to protect a limb during rehabilitation

Drag forces = increased torque at a given joint

If move in the direction of the turbulence, you will decrease the amount of work needed to move; therefore facilitating movement; if move against turbulence will provide resistance.

Hydrostatic Pressure 1. Pressure is exerted equally around an object at any given depth if pressure is exerted unequally, the object will move in that direction. 2. When you enter a pool, there is a slight increase in pressure exerted to the skin covering the body and therefore blood pressure increases slightly by momentary constriction of cutaneous blood vessels. However, body regulates quickly and blood pressure actually becomes slightly lower than when on land..


Pressure in a liquid increases with increasing depth. This is relevant to the practice of aquatic therapy because this increases blood flow from feet to thorax if standing in a pool. This helps to decrease edema in the lower extremities. Renal output is also increased during aquatic therapy which attributes to the shift in body fluids from the extremities to the thorax

Muscle weakness Loss of joint mobility Poor co-ordination or balance Pain or lack of confidence Pre-gait training
patient populations that benefit from Aquatic Therapy include: Ankylosing spondylitis Osteoarthritis Rheumatoid Arthritis Juvenile chronic polyarthritis Spondylosis Capsulitis Mechanical spinal disorders

Polymyalgia rheumatica (PMR) Fibromyalgia Syndrome (FMS) Major fractures especially of the lower limbs or spine Orthopedic surgery Neurological disorders such as hemiplegia, paraplegia, tetraplegia, polyneuropathy. Pregnancy Athletic conditioning during recovery. Children
Uncontrolled seizures, unstable angina or uncontrolled diabetes Bowel incontinence with diarrhea, and no stool program Open wounds or bleeding without bio-occulsive dressing (including menstruation without internal protection) Tracheotomies until healed Acute flare-up active joint inflammation (rheumatoid arthritis, hemophilia) Orders for NPO (nothing by mouth) Presence of DVT (deep vein thrombosis) without anticoagulation therapy or filter


Bowel incontinence with firm stools (pt should be on stool program and wear plastic pants into pool) Communicable diseases (cold flu, Hepatitis) Autonomic dysreflexia Sensitivity to disinfection chemicals Sensitivity to heat/ humidity (e.g Multiple Sclerosis) Rashes, skin conditions with flaking or open areas (psoriasis) Orthostatic hypotension Hydrophobia

Combative or difficult to control population Poor cognition Dependence in ambulation Controlled seizures, exercise-induced angina, controlled diabetes Exercise induced asthma Open wounds with bio-occulsive dressing Compromised immune system (e.g. low T-cell count) On chemotherapy for cancer On dialysis for renal/kidney dysfunction


EQUIPMENTS Equipment Flotation vest

Pool noodles Flotation rings Dumbbells Paddles Gloves Fins Ankle weights/cuffs Resistive boots Kickboards Steps Resistive bands

Therapeutic Pool Environment

1. Need to decide what type of program you are implementing to decide on the design and temperature of the water. a. Pediatrics requires shallow depth and specific entry requirements lifts, zero entry. 2. Bad Ragaz and Halliwick require chest height water for the therapists. 3. Aerobic conditioning and sports med programs require cooler temperatures and varying depths (80 to 85 degrees).

Type: Pools can be below ground, below ground deck level, semi-raised, or raised. But below ground with or without deck construction is recommended Shape: more room than square Rectangular, square, or kidney shaped pools are available. But rectangular is best because it has less turbulence than square shaped and kidney shaped pools. The larger the pool, the more you can do. Minimum space per person is 2.5 x 2.25 meters Floor: A sloped floor is recommended because it offers less risk of patients slipping. Material on Level throughout, stepped, or sloping. the floor needs to be non-abrasive and non-slippery.


Depth: A maximum depth of 5 feet is recommended. Entry: Steps, ramps, and hoists are available and which is used depends on the status of the patient. Ventilation: Maintain humidity at 50% and have dehumidifying air conditioning to control condensation and allow body heat to evaporate. Temperature: The range in an exercise pool should be between 79 and 97 degrees F. Air temperatures depend on the population between 68 and 72 degrees for aerobic and 80 to 100 degrees for therapeutic



Whirlpools Extremities Whirlpools Ferno Jr. Whirlpools Full Body (Hubbard Tank) Whirlpools Mobile Whirlpools Podiatry Whirlpools Sports Whirlpools Stationary


Holdrelax Breathing exercises Joint mobilisation exercises Strengthening exercises Stretching exercises PNF techniques Aerobic exercises NDTs Stability exercises Gait training Under water massage


Group therapy



Aquatic Techniques
Must consider
Type of injury/surgery Treatment protocols if appropriate Results/muscle imbalances found in evaluation Goals/expected return to activity

Upper Body
Shoulder Horizontal Abduction / Adduction, Elbows Straight Shoulder Lateral Abduction / Adduction, Elbows Straight Shoulder Internal / External Rotation, Elbows Straight Shoulder Internal / External Rotation: Combined Motion Shoulder Forward Flexion to 90 Shoulder Forward Flexion to 180 Shoulder Extension from 0 Shoulder Extension from 90 Shoulder / Elbow Forward Press Shoulder / Elbow Pull-Back Shoulder Horizontal Fly, Elbows Bent Shoulder (Scapula) Retraction Shoulder External / Internal Rotation,

Program design
Warm-up Strengthening/mobility activities Endurance/cardiovascular Cool down/stretch

Elbows Bent Shoulder / Elbow Vertical Press Shoulder: Pendulum (Clockwise / Counterclockwise) Shoulder: Pendulum (Side-toSide) Straight Arm Circles Elbow Flexion / Extension Elbow / Wrist Supination / Pronation Wrist Flexion / Extension Wrist Circles Wrist / Hand Radial / Ulnar Deviation Finger Flexion / Extension Thumb to Fingertips Finger Abduction / Adduction Thumb Circles Shoulder Stabilization Pushaway

Lower Body
General Tips Hip Flexion, Knee Bent Hip Extension, Knee Bent Hip Flexion, Knee Straight Hip Extension, Knee Straight Hip Horizontal Abduction / Adduction, Knee Bent Hip Horizontal Abduction / Adduction, Knee Straight Hip Lateral Abduction / Adduction To Midline Hip Lateral Abduction / Adduction Past Midline Hip Flexion / Abduction, Knee Straight Combined Motion Hip Internal / External Rotation, Hip / Knee Bent Hip Internal / External Rotation, Hip / Knee Straight Hip / Knee Extension, Resisted Using Buoyant Object Hip Flexion / Extension High Kick Knee Flexion / Extension Knee Extension / Flexion, Hip Flexed Squat Leg Circle

Ankle Circle Ankle Dorsiflexion / Plantar Flexion Ankle / Toe Writing Ankle Inversion Ankle Eversion Toe / Heel Raise Trunk Pelvic Posterior Tilt Pelvic Anterior / Posterior Tilt / Pelvic Rock Neutral Pelvis Sequence, Standing Spine Stabilization, Standing in Place Spine Stabilization, Dynamic Standing Neutral Pelvis Sequence, Sitting Spine Stabilization, Sitting, Feet on Pool Floor Spine Stabilization, Sitting Suspended


Physiological effects
Psychological impact
Increased confidence due to increased function allowed by water

Free movement with less risk of injury Decreases weight bearing on joints Buoyancy may assist weak muscles to allow increased performance of active exercise Has the ability to affect all major body systems. Slippery environment with increased risk of falls outside pool Risk of infection Difficulty stabilizing or isolating body parts during exercise Risk of drowning

Strengthening and muscle re-education

Dependent on effort put forth by athlete

Energy expenditure
Aerobic workout possible to maintain CV fitness