PT 113: INTRO TO THERAPEUTIC EXERCISE

Chapter 9: Aquatic Exercise

Ms. Trisha Sandico, PT, PTRP, DPT – Faculty of Physical Therapy
1st Semester | Finals | A.Y 2022 – 2023

Aquatic Therapy – use of water for rehabilitation purposes 3. Respiratory Disorders – affect the breathing
o Lung expansion = inhibited d/t hydrostatic
➢ Provide treatment that impossible or difficult on
pressure against the chest wall
land
4. Cardiac Dysfunction – Pts with angina, abnormal bp,
DEFINITION OF AQUATIC EXERCISE heart disease or compromised pump mechanism
Aquatic Exercise – use of water for therapeutic interventions
require close monitoring
including:
5. Small, Open Wounds and Lines

➢ Stretching ➢ Small, open wounds and tracheotomy = waterproof

➢ Strengthening dressing

➢ Joint mobilization ➢ Intravenous lines, Hickman lines, and other open

➢ Balance and gait training lines = proper clamping and fixation

➢ Endurance training ➢ G tube and suprapubic appliances

GOALS AND INDICATIONS FOR AQUATIC EXERCISE Contraindications

➢ Any situation creating potential effects to either pt

➢ Purpose: facilitate functional recovery by providing
or water environment
an environment that helps pt’s and/or PT’s ability to
➢ Such factors include:
perform interventions
o Incipient cardiac failure and unstable
➢ Specific goals:
angina
o Facilitate range of motion (ROM) exercise
o Respiratory dysfunction, vital capacity of
o Initiate resistance training
less than 1 liter
o Facilitate weight-bearing activities
o Severe peripheral vascular disease
o Enhance delivery of manual techniques
o Danger of bleeding or hemorrhage
o Provide three-dimensional access to the
o Severe kidney disease (patients are unable
patient
to adjust to fluid loss during immersion)
o Facilitate cardiovascular exercise
o Open wounds without occlusive dressings,
o initiate functional activity replication
colostomy, and skin infections, such as
o Minimize risk of injury or re-injury during
tinea pedis and ringworm
rehabilitation
o Uncontrolled bowel or bladder (bowel
o Enhance patient relaxation
accidents require pool evacuation, chemical
PRECAUTIONS AND CONTRAINDICATIONS treatment, and possibly drainage)
Precautions
o Menstruation without internal protection
1. Fear of Water – limit effectiveness o Water and airborne infections or diseases
o Increased symptoms during and after (examples include influenza,
immersion because of muscle guarding, gastrointestinal infections, typhoid, cholera,
stress response, and improper form with and poliomyelitis)
exercise o Uncontrolled seizures during the last year
2. Neurological Disorders – increased difficulty (they create a safety issue for both clinician
controlling movements and patient if immediate removal from the
o Pt’s w/ heat-intolerant multiple sclerosis – pool is necessary)
fatigue w/ immersion in temp > 33 C
o Pt w/ controlled epilepsy – close monitoring
& drink meds before treatment

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 PROPERTIES OF WATER o The proportionality of depth and pressure
allows patients to perform exercise more
➢ Have physiological implications
easily when closer to the surface

PHYSICAL PROPERTIES OF WATER

Viscosity – friction occurring between molecules of liquid
Buoyancy – upward force that works opposite to gravity
resulting in resistance to flow
• Properties – Archimedes’ Principle: an immersed
• Properties – resistance from viscosity is proportional
body experiences upward thrust equal to the
to the velocity of movement through liquid
volume of liquid displaced
• Clinical Significance – creates resistance with all
• Clinical Significance – effects include:
active movements
o provides the patient with relative
o Increasing the velocity of movement
weightlessness and joint unloading by
increases the resistance.
reducing the force of gravity on the body.
o Increasing the surface area moving
In turn, this allows the patient to perform
through water increases resistance
active motion with increased ease.
o provides resistance to movement when an Surface Tension – surface of a fluid acts as a membrane
extremity is moved against the force of under tension; measure as force per unit length
buoyancy.
• Properties – attraction of surface molecules is
▪ This technique can be used to
parallel to the surface
strengthen muscles.
o The resistive force of surface tension
o The amount of air in the lungs will affect
changes proportionally to the size of the
buoyancy of the body.
object moving through the fluid surface
▪ Buoyancy will be increased with
• Clinical significance - an extremity that moves
fully inflated lungs and decreased
through the surface performs more work than if
with deflated lungs.
kept under water
o Body composition will also affect buoyancy.
o Using equipment at the surface of the water
Obese patients will have increase buoyancy
increases the resistance
due to fat tissue having a lower specific
gravity. Hydromechanics - physical properties and characteristics of
▪ Patients with increased bone fluid in motion
density will have less buoyancy
• Components of flow motion - three factors affect
than those with decreased bone
flow
density.
o Laminar flow - Movement in which all
o allows the practitioner three-dimensional
molecules move parallel to each other,
access to the patient
typically slow movement
Hydrostatic Pressure – pressure exerted by the water on o Turbulent flow - Movement in which
immersed objects molecules do not move parallel to each
other, typically faster movements
• Properties – Pascal’s law: pressure exerted by fluid
o Drag -the cumulative effects of turbulence
on an immersed object is equal on all surfaces of
and fluid viscosity acting on an object in
the object
motion
o Density & depth of immersion increase =
▪ Clinical significance of drag
hydrostatic pressure increase
• As the speed of movement
• Clinical Significance
through water increases,
o Increased pressure reduces or limits
resistance to motion
effusion, assists venous return, induces
increases
bradycardia, and centralizes peripheral
• Moving water past the
blood flow
patient requires the patient
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 to work harder to maintain
his or her position in pool.
▪ Application of equipment
(glove/paddle/boot) increases
drag and resistance as the patient
moves the extremity through water
Thermodynamics – water temp has an effect on the body
1. Specific Heat – amount of heat (calories) required
to raise the temp of 1 gram of substance by 1 C
Temperature Regulation
o Properties – rate of temp change depends
on the mass and specific heat
o Clinical Significance - Water retains heat
1,000 times more than air
▪ Differences in temperature
between an immerse object and
water equilibrate with minimal
change in the temperature of the
water
Center of Buoyancy – center of gravity; reference point
where buoyant forces of fluid act
• Properties - Vertical forces that do not intersect the
center of buoyancy create rotational motion
• Clinical Significance
o Vertical position – sternum
▪ posteriorly placed buoyancy
devices cause the patient to lean
forward
▪ anterior buoyancy - causes the
patient to lean back.
o Unilateral manual resistance exercises - the
patient revolves around the practitioner in a
circular motion.
o Pt w/ unilateral lower extremity amputation
- leans toward the residual limb side when
in a vertical position
o Patients bearing weight on the floor of the
pool (i.e., sitting, kneeling, or standing)
experience aspects of both the center of
buoyancy and center of gravity
AQUATIC TEMP AND THERAPEUTIC EXERCISE
➢ Pt impairment & intervention goals = water temp
selection
o Cooler – high intensity exercise
o Warmer – mobility, flexibility and muscle
relaxation
➢ Ambient air temp 3 C > water temp
➢ Temperature regulation during immersed exercise
differs from that during land exercise because of
alterations in temperature conduction and the
body’s ability to dissipate
o With immersion there is less skin exposed to
air, resulting in less opportunity to dissipate
heat through normal sweating mechanisms.
➢ Water conducts temperature 25 times faster than
air more if the patient is moving through the water
and molecules are forced past the patient.
➢ Patients perceive small changes in water
temperature more profoundly than small changes in
air temperature.
➢ Over time, water temperature may penetrate to
deeper tissues.
o Internal temperature changes are known to
be inversely proportional to subcutaneous
fat thickness
➢ Patients are unable to maintain adequate core
warmth during immersed exercise at temperatures
less than 25°C
➢ Conversely, exercise at temperatures greater than
37°C may be harmful if prolonged or maintained at
high intensities.
o Hot water immersion may increase the
cardiovascular demands at rest and with
exercise
➢ In waist-deep water exercise at 37°C, the thermal
stimulus to increase the heart rate overcomes the
centralization of peripheral blood flow due to
hydrostatic pressure.
➢ At temperatures greater than or equal to 37°C,
cardiac output increases significantly at rest alone
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Mobility and Functional Control Exercise
➢ Flexibility, strengthening, gait training, and
relaxation - 26°C and 35°C
➢ Beneficial for pt’s with acute painful
musculoskeletal injuries (effects of relaxation,
elevated pain threshold, decreased muscle spasm)
Aerobic Conditioning
➢ CV training aerobic exercise – temps between 26°C
and 28°C (bc it maximizes efficiency, increase
stroke volume)
POOLS FOR AQUATIC EXERCISE
➢ Adequately ventilated – to avoid accumulation of
condensation on walls, windows, floors
Traditional Therapeutic Pools
➢ Measure at least 100 ft (L) 25 ft (W) 3-4 ft (depth,
w/a sloping bottom, progressing to 9-10 ft)
o This larger type pool may be used for
groups of patients and the therapists
conducting the session while in the pool
o Entrance to larger therapeutic pools
includes ramps, stairs, ladders, or
mechanical overhead lifts.
o These pools have built-in chlorination and
filtration systems
Individual Patient Pools
➢ These self-contained pools are entered via a door or
one to two steps on the side of the unit.
➢ The therapist provides instructions or cueing from
outside the unit
➢ In addition to built-in filtration systems, these units
may include treadmills, adjustable currents, and
varying water depths
SPECIAL EQUIPMENT FOR AQUATIC EXERCISE
Collars, Rings, Belts, and Vests
➢ assist with patient positioning by providing
buoyancy assistance can be applied to the neck,
extremities, or trunk
Swim Bars
➢ supporting the upper body or trunk in upright
positions
o the LE in the supine or prone positions
Gloves, Hand Paddles, and Hydro-tone Bells
➢ Resistance to upper extremity movements
➢ are not buoyant = only resist motion in the direction
of movement
Fins and Hydro-tone Boots
➢ generates resistance by increasing the surface area
moving through the water
Kickboards
➢ to provide buoyancy in the prone or supine
positions
➢ to create resistance to walking patterns in shallow
water when held vertically
➢ to challenge seated, kneeling, or standing balance
in the deep water
POOL CARE AND SAFETY
➢ Require regular care and cleaning to avoid
Pseudomonas aeruginosa (infection causing
folliculitis)
➢ Cleaning should occur at least twice weekly, and
chlorine and pH level tests should be done twice
daily
➢ All walking surfaces near and around the pool
should be slip-resistant and free of barriers. Water
splashes should be dried immediately to prevent
slips and falls.
➢ Safety rules and regulations are a must, as are
emergency procedures, and should be posted and
observed by all involved in therapeutic pool use
➢ Life preservers should be readily available, and at
least one staff member who is CPR certified should
be present at all times
Stretching Exercises
Manual Stretching Techniques
Spine Stretching Techniques
a. Cervical Spine: Flexion
b. Cervical Spine: Lateral Flexion
c. Thoracic and Lumbar Spine: Lateral Flexion/Side
Bending
Shoulder Stretching Techniques
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 a. Shoulder Flexion c. Hip Flexion With Knee Flexion
b. Shoulder Abduction d. Hip Internal/External Rotation
c. Shoulder External Rotation e. Knee Extension
d. Shoulder Internal Rotation f. Ankle Motions
g. Ankle Dorsiflexion and Plantarflexion
Hip Stretching Techniques
h. Ankle Inversion and Eversion
a. Hip Extension
Dynamic Trunk Stabilization
b. Hip External Rotation
c. Hip Internal Rotation a. Dynamic Trunk Stabilization: Frontal Plane
b. Dynamic Trunk Stabilization: Multidirectional
Knee Stretching Techniques
Independent Strengthening Exercises
a. Knee Extension With Patient on Steps
b. Knee Flexion With Patient on Steps Extremity Strengthening Exercises
c. Knee Flexion With Patient Supine
Lumbar Spine Strengthening
d. Hamstrings Stretch
Trunk-Strengthening Exercises: Standing
Self-Stretching With Aquatic Equipment
Trunk-Strengthening Exercises: Semi-Reclined
• Patient position. Includes BA (seated/upright), BS
(supine), or vertical. Trunk-Strengthening Exercises: Supine
o Buoyancy-assisted - Using the natural
Trunk-Strengthening Exercises: Prone
buoyancy of water to “float” the extremity
toward the surface. Trunk-Strengthening Exercises in Deep Water

o Equipment-assisted - Includes use of

AEROBIC CONDITIONING
buoyancy devices attached or held distally Treatment Interventions
on an extremity.
Deep-water walking/running
Shoulder Flexion and Abduction
Mid-water jogging/running (immersed treadmill running)
Hip Flexion
Immersed equipment
Knee Extension
Swimming strokes
Knee Flexion
Physiological Response to Deep-Water Walking/Running
Strengthening Exercises
Manual Resistance Exercises Cardiovascular response

Upper Extremity Manual Resistance Techniques Training effect

a. Shoulder Flexion/Extension Proper Form for Deep-Water Running

b. Shoulder Abduction
Instruction for beginners
c. Shoulder Internal/External Rotation
d. Unilateral Diagonal Pattern: D1Flexion/Extension of Accommodating specific patient populations

the Upper Extremity Exercise Monitoring

e. Unilateral Diagonal Pattern: D2Flexion/Extension of
the Upper Extremity Monitoring intensity of exercise

f. Bilateral Diagonal Pattern: D2Flexion/Extension a. Rate of perceived exertion

g. of the Upper Extremities b. Heart rate

Lower Extremity Manual Resistance Techniques Monitoring beginners

a. Hip Adduction Equipment Selection

b. Hip Abduction
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Deep water equipment

Midwater equipment

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