Aquatic Therapy - Compressed

AQUATIC
THERAPY
Pembimbing : Dr. dr. Tirza Z. Tamin, Sp. K.F.R., M.S.(K)
Cita Nuansa Imane Putri Istanto

Martina Sartika FS
CONTENT
1. Introduction 5. Stretching
exercise
Water Strengthening
2. properties 6. exercise
Biologic aspects of
aquatic rehabilitation Aerobic conditioning
3. 7. exercise
Pools and equipment

4. for aquatic exercise
AQUATIC THERAPY
• Aquatic therapy: the use of water
for rehabilitation purposes.
• Treatment options that may

otherwise be difficult or impossible
to implement on land.
Joint
Stretching Strengthening
mobilization
Endurance Balance and gait

training training
GOALS OF AQUATIC
EXERCISE
Facilitate ROM Initiate resistance Facilitate weight- Enhance delivery of
exercise training bearing activities manual techniques
Facilitate Minimize risk of injury

Initiate functional Enhance patient
cardiovascular or re-injury during
activity replication relaxation
exercise rehabilitation
Kisner C, Colby L. Therapeutic Exercise Foundations and Techniques. 7th ed. Philadephia: F. A. Davis Company; 2018.
PHYSICAL PROPERTIES OF
WATER
Buoyancy Viscosity Hydrostatic pressure
Hydromechanics Thermodynamics
BOUYANCY
Buoyancy: upward
force that works
opposite to gravity.
Archimedes’ principle
law: “an immersed
body experiences
upward thrust equal
to the volume of
liquid displaced”.
Houglum PA. Therapeutic Exercise for Musculoskeletal Injuries. 4th ed. Leeds: Human Kinetics; 2016. Kisner C, Colby L.
Therapeutic Exercise Foundations and Techniques. 7th ed. Philadephia: F. A. Davis Company; 2018.
Clinical significance:
Relative weightlessness, joint
unloading, reducing force of gravity
effect to body
Provide resistance to movement

when moved against the force of
gravity (to strengthen muscles)
Allow practitioner 3-dimensional

access to patient
Kisner C, Colby L. Therapeutic Exercise Foundations and

Techniques. 7th ed. Philadephia: F. A. Davis Company; 2018.
Center of buoyancy:
reference point of an
immersed object on which
bouyant (vertical) forces
of fluid perdictably act
Clinical Tip
Rotator cuff pathology.
A patient recovering from rotator cuff repair can use the buoyancy
force to increase range of motion
in shoulder abduction and/or flexion while performing the
motion in neck-deep water. When performing shoulder
extension from a 90° flexed position, the force of buoyancy
becomes a resistance as the patient pulls the arm downward
through the water.
HYDROSTATIC
PRESSURE
Pascal’s law: “the pressure
exerted by fluid on an immersed
object is equal on all surfaces of
the object.’ As density of water
and depth of immersion increase,
so does hydrostatic pressure.
↑
– pressure 🡪 reduces or limits
effusion, assists venous return,
induces bradycardia, and
centralizes peripheral blood flow.
VISCOCITY
Viscosity: friction occurring between molecules of liquid
resulting in resistance to flow.
Resistance from viscosity is proportional to velocity of
movement through liquid.
Increasing the velocity of movement 🡪 increases the
resistance
Increasing the surface area moving through water 🡪
increases resistance
STRENGTHENING EXERCISE
SURFACE TENSION
Surface of a fluid acts as a membrane under
tension.
Resistive force of surface tension changes
proportionally to the size of object moving
through the fluid surface.
Extremity that moves through the surface
performs more work than if kept under
water.
Using equipment at surface of the water
increases the resistance.
HYDROMECHANICS
Laminar movement in which all molecules
flow move parallel to each other (slow
movement)
movement in which molecules do

Turbulent not move parallel to each other
flow (faster movement)
cumulative effects of turbulence

Drag and fluid viscosity acting on an
object in motion
Houglum PA. Therapeutic Exercise for Musculoskeletal Injuries. 4th ed. Leeds: Human Kinetics; 2016. Kisner C, Colby L.
Therapeutic Exercise Foundations and Techniques. 7th ed. Philadephia: F. A. Davis Company; 2018
THERMODYNAMICS
Water temperature has an effect on the body 🡪 on
performance in an aquatic environment
Temperature Transfer
Water conducts temperature 25 times faster than air.

Heat transfer increases with velocity 🡪 patient moving
through the water loses body temperature faster than
an immersed patient at rest.
AQUATIC TEMPERATURE
Patient’s impairments and intervention goals determine the
water temperature selection:
cooler temperatures →
higher-intensity exercise
→
warmer temperatures mobility and flexibility exercise
and for muscle relaxation
temperatures < 25°C →
patients are unable to maintain
adequate core warmth during immersed exercise
temperatures > 37°C →
harmful if prolonged or
maintained at high intensities
increase cardiovascular demands at rest and with
exercise
cardiac output increases significantly at rest
Temperature regulating system demand is
increasing when exercising in a pool:
Generally use a maximum immersion time of 20

minutes for patients with non-compromised
cardiopulmonary systems. Begin with 10-minute
sessions and increase the time as tolerated.
Always monitor vital signs to ensure patient
safety.
Water temperature 36°C high. ≥ →
Water temperature between 26°C and 35°C →
low.
Cardiovascular training
Rheumatoid Arthritis and aerobic exercise
Higher temperatures are Water temperatures between 26°C
recommended (except in acute and 28°C → maximizes exercise
efficiency, increases stroke volume,
stage)
and decreases heart rate
General flexibility, strengthening, gait

training, and relaxation
Temperature range may be between 26°C and
35°C
Temperature at 33°C→ beneficial for patients
with acute painful musculoskeletal injuries
BIOLOGIC ASPECTS OF
AQUATIC
REHABILITATION
CIRCULATORY SYSTEM
Immersion to the neck→ Mean stroke volume
increases 35% on average (from a resting
baseline of about 71 mL/beat to about 100
mL/beat) Cardiac output increase but heart
rate response ranges remain relatively fixed
or decreased
Frontera WR, editor. DeLisa’s Physical Medicine and Rehabilitation. 5th ed. Philadephia: Lippincott Williams & Wilkins; 2010.
Submersion to the neck increases cardiac output by more than 30%. Output
increases by about 1,500 mL/minute, of which 50% isdirected to increased muscle
blood flow.
Normal resting cardiac output is approximately 5 L/minute. Maximum output in a

conditioned athlete is about 40 L/minute, which is equivalent to 205 mL/beat times
195 beats/minute.
Maximum output at exercise for a sedentary individual on land is approximately 20

L/minute, equivalent to 105 mL/beat times 195 beats/minute.
Because immersion to the neck produces a cardiac stroke volume of about 100
mL/beat, a resting pulse of 86 beats/minute produces a cardiac output of 8.6
L/minute and is already producing increased cardiac work.
PULMONARY SYSTEM
MUSCULOSKELETAL
During immersion→ increased cardiac output is
redistributed to skin and muscle→ increase
muscle performance.
Hydrostatic forces add an additional circulatory
drive to remove edema, muscle lactate, and
other metabolic end products
RENAL AND ENDOCRINE
Flow of blood to kidneys
increases immediately on
immersion
Sodium excretion increases
🡪 accompanied
by free water, creating the
diuretic effect of immersion
Potassium excretion also
increases with immersion
PRECAUTIONS
CONTRAINDICATIONS
Incipient cardiac failure and unstable angina

Respiratory dysfunction with vital capacity <1
liter
Severe kidney disease
Open wounds without occlusive dressings,
colostomy, and skin infections
Uncontrolled bowel or bladder
Menstruation without internal protection
Water and airborne infections or diseases
Uncontrolled seizures during the last year
TRADITIONAL
THERAPEUTIC POOL
Length: 100 feet
Width: 25 feet
Depth: begins at 3 to 4 feet with a
sloping bottom, progressing to 9 or 10
feet.
Used for groups of patients
Built-in chlorination and filtra-tion
system.
INDIVIDUAL PATIENT
POOLS
Used for individual patient

In addition to built-in filtration
systems→ include treadmills
SPECIAL EQUIPMENT
FOR AQUATIC
EXERCISE
Special Equipment for Aquatic Exercise
Aquatic equipment is used to:
provide buoyant support to the body or extremity
challenge or assist balance
generate resistance to movement
By adding or removing equipment => progress exercise
intensity
Type of equipment used is determined by current
functional level of patient and specific goals for therapy
session
COLLARS, RINGS, AND BELTS
Inflatable cervical collars: Flotation rings: Belts:

for supine patient to support neck and support extremities (wrists and ankles) fto position supine, prone, or
maintain the head out of the water during manual techniques to assist vertically for shallow or deep activities
with patient positioning and relaxation
SWIM BAR (BUOYANT DUMBBELLS)
Useful for:
supporting upper body or trunk
in upright positions.
Supporting supine or prone
positions.
Patients can balance (seated or
standing) on long swim bars in deep
water to challenge balance,
proprioception, and trunk strength.
GLOVES, HAND PADDLES, AND
HYDRO-TONE® BELLS
Gloves and hand paddles: Used to
achieving resistance to upper extremity
movements.
Hydro-tone bells:
Large, slotted plastic devices
that increase drag during upper
extremity motions.
The bells generate substantially
more resistance than gloves or
hand paddles
FINS AND HYDRO-TONE® BOOTS
Used to the feet during lower

extremity motions generates
resistance by increasing the
surface area moving through the
water
Fins => useful for challenging
hip, knee, and ankle strength.
Hydro-tone® boots => effective
during deep water walking and
running.
KICKBOARDS
to provide buoyancy in prone or
supine positions.
shallow water: create resistance
to walking patterns when held
vertically
deep water: used to challenge
seated, kneeling, or standing
balance.
POOL CARE AND SAFETY
Therapeutic pools require regular care and cleaning to avoid Pseudomonas
aeruginosa.
Frequent use increases total organic carbon as well as ammonia and organic
nitrogen found in the pool.
Cleaning at least twice weekly

chlorine and pH level tests twice daily
All walking surfaces near and around the pool should be slip-resistant and free of
barriers
Water splashses should be dried immediately to prevent slips and falls
Safety rules and regulations are a must, as are emergency procedures
Life preservers should be readily available and at least one staff member who is
CPR certified should be present at all times
TERMS ARE USED FOR EQUIPMENT-
ASSISTED EXERCISE
Buoyancy-assisted (BA)
Vertical movement directed parallel to vertical forces of buoyancy that assist
Buoyancy-supported (BS)
Horizontal movement with vertical forces of buoyancy eliminating or minimizing the need
to support an extremity against gravity
Buoyancy-resisted (BR)
Movement directed against or perpendicular to vertical forces of buoyancy, creating drag
Buoyancy-superresisted (BSR)
Use of equipment generates resistance by increasing the total surface area moving
through water by creating greater drag. Increasing the speed of motion through water
generates further drag
The four main variables that
can be manipulated to alter
resistance or assistance are
1. Position or direction of movement in

the water
2. Water depth
3. Lever arm length
4. Flotation or weighted equipment use
Brody L, Hall C. Therapeutic Exercise Moving Toward Function. 3rd ed. Vol.
53, Journal of Chemical Information and Modeling. Philadephia: Lippincott
Williams & Wilkins; 2011.
STRETCHING EXERCISE
STRETCHING EXERCISE
Patients may tolerate immersed stretching exercises better
than land stretching => because of the effects of relaxation,
soft tissue warming, and ease of positioning.
Manual stretching: patient supine in waist depth water
with buoyancy devices at neck, waist, and feet.
Alternative => patient may be seated on steps.
CERVICAL SPINE STRETCHING
Flexion Lateral Flexion
Practitioner Stand at the patient’s
Stand at the side facing the patient
Position head facing caudalward
Patient BS supine without cervical
BS supine without cervical collar
Position collar
Cup the patient’s head Reach fixed hand dorsally under
with the patient and grasp contralateral
Hand Place-
your hands, forearms arm; support the head with
ment
supinated and thumbs placed movement
laterally hand
As you flex the cervical spine,

Move the patient into lateral flexion
Direction of patient has a tendency to drift
and apply stretch force at desired
Movement away from you if not perform
intensity
the motion slowly
THORACIC AND LUMBAR SPINE
STRETCHING
Lateral Flexion/Side Bending
Stand on the side opposite that to be
Practitioner
stretched, facing cephalad with ipsilateral
Position
hips in contact
BS supine, if tolerated.
The patient’s stretch side arm is
Patient Position
abducted to end-range to facilitate
stretch
Grasp patient’s abducted arm with the fix-
ed hand. Movement hand is at lateral
Hand Placement
aspect of lower extremity of the side to be
stretched
Direction of With the patient stabilized by your hip, pull
Movement the patient into lateral flexion
SHOULDER STRETCHING
Flexion
Stand on the side to be stretched facing
Practitioner Position
cephal
BS supine with affected shoulder
Patient Position
positioned in slight abduction
Grasp buoyancy belt with fixed hand;
Hand Placement movement hand is at elbow of the
affected extremity
After positioning the arm in desired
Direction of degree of abduction, direct the arm into
Movement flexion and apply stretch force with the
movement hand
HIP STRETCHING
Extension External Rotation Internal Rotation
Face the lateral aspect of the
Kneel on one knee at patient’s Face lateral aspect of patient’s thigh
involved thigh with ipsilateral arm
Practitioner Position af- with your ipsilateral arm under the
under the
fected side patient’s flexed knee.
flexed knee
BS supine with the hip extended BS supine; hip flexed 70° and knee BS supine, hip flexed 70° and knee
Patient Position
and the knee slightly flexed flexed 90° flexed 90°
Stabilize patient’s affected
extremi-ty by hooking the top of Grasp buoyancy belt with Stabilize buoyancy belt with
the foot with your ipsilateral thigh. contrala- contrala-
Hand Placement Grasp teral (fixed) hand while ipsilateral teral (fixed) hand while grasping the
buoyancy belt with the movement (movement) hand grasps the thigh with ipsilateral (movement)
hand and guide the motion with thigh hand
fixed hand on the knee
Direct patient caudally with the
movement hand. To increase Externally rotate hip with the
Internally rotate the hip as
stretch on rectus femoris, lower movement hand as patient’s body
Direction of patient’s
the patient’s knee in the water. lags
Movement body lags through water to create the
Motion is performed slowly to through water to create stretch
stretch force.
limit spinal force
and pelvic substitution
KNEE STRETCHING
Flexion with Patient Supine
Half-kneel lateral to the affected knee with dorsal
Practitioner Position as-pect of patient’s foot hooked under the
ipsilateral thi-gh
Patient Position BS supine, affected knee flexed
Place ipsilateral (fixed) hand on distal tibia and

Hand Placement contralateral (movement) hand on buoyancy belt
to pull the body over the fixed foot
Pull patient’s body over the fixed foot, creating

Direction of stretch to increase knee flexion.
Movement Lower the patient’s knee into water to extend
the hip and increase stretch on rectus femoris
SPINE STRETCHING
Shallow water
Neck stretch
Sine extension-flexion
pelvic roll
standing crunch
trunk rotation
wall push-off
pull down
Deep water
double leg lift
trunk rotation
lateral flexion
Houglum PA. Therapeutic Exercise for Musculoskeletal Injuries. 4th ed. Leeds: Human Kinetics; 2016.
Lateral Stretch Pelvic Roll
STRENGTHENING
EXERCISE
STRENGTHENING EXERCISE
AEROBIC CONDITIONING
Deep-water Eliminates the effects of impact on lower
walking/running extremities and spine
Mid-water Lessens the effects of impact on spine and
jogging/running lower extremities
Immersed Immersed cycle, treadmill, or upper body

equipment ergomaeter
To train and improve cardiovascular fitness
Swimming
strokes Added benefit of hip and trunk strengthening for some
patients with spinal conditions
THANK YOU

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AQUATIC

Cita Nuansa Imane Putri Istanto

Pools and equipment

• Treatment options that may

Endurance Balance and gait

Facilitate Minimize risk of injury

Buoyancy Viscosity Hydrostatic pressure

Provide resistance to movement

Allow practitioner 3-dimensional

Kisner C, Colby L. Therapeutic Exercise Foundations and

movement in which molecules do

cumulative effects of turbulence

Water conducts temperature 25 times faster than air.

Generally use a maximum immersion time of 20

General flexibility, strengthening, gait

Normal resting cardiac output is approximately 5 L/minute. Maximum output in a

Maximum output at exercise for a sedentary individual on land is approximately 20

Incipient cardiac failure and unstable angina

Used for individual patient

Inflatable cervical collars: Flotation rings: Belts:

Used to the feet during lower

Cleaning at least twice weekly

1. Position or direction of movement in

As you flex the cervical spine,

Patient Position BS supine, affected knee flexed

Place ipsilateral (fixed) hand on distal tibia and

Pull patient’s body over the fixed foot, creating

Immersed Immersed cycle, treadmill, or upper body

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