By Greg King, FNP, and Cheryl Ogran, MSPT, CLT-LANA
Healthy individuals spend very little time worrying about motion mechanics and proprioception. Most people have a natural, reflexive ability to move within space. However, once someone becomes affected by an injury or undergoes a surgical procedure to a joint, his or her strength, range of motion, and proprioceptive abilities can be seriously impaired. At this point, physical therapy is typically introduced to improve strength and mobility, decrease pain, facilitate proper motion mechanics, and improve proprioception.
One of the keys to helping patients heal is to get them into a rehabilitation program as soon as possible. Unfortunately, land-based physical therapy regimens can be too painful and difficult for those who are ready to move, but not against the forces of gravity. For this reason, referring physicians and surgeons are prescribing aquatic therapy for patients of all ages who require an efficient, effective treatment to promote joint and soft tissue mobility.
[sidebar float=”right” width=”250″]Product Resources
Pools, spas, and accessories for water-based rehabilitation are available from these manufacturers:
Aquatic Access Inc
Hudson Aquatic Systems LLC
Nespa Tiled Spas
Sure Hands Lift and Care Systems
Moving Aquatic Rehab Patients Through Proprioceptive-Promoting Protocols
It is not unusual for first-time aquatic rehabilitation patients to be surprised at how engaged they need to be when exercising in the water. They are trying to maintain their balance, which can be challenging for those recovering from a loss of proprioception. When an individual is weak, they have lost flexibility and strength. Just staying in a standing position in the water or doing a repetitive exercise can translate to a difficult workout. At the same time, the warm water is massaging the soft tissues, providing pain relief and actually stimulating nerves that may have been damaged. The end result is a heightened awareness of every square inch of the body, as well as how it moves.
Patients who participate in aquatic therapy programs may be able to watch themselves walk, twist, move, jump, and run through the use of underwater video cameras which send real-time images to a large screen. This provides individuals with visual input of a “correct” movement, thereby retraining the brain and body for land-based efforts. Having an immediate visual of what is happening in a therapy pool minimizes the risks associated with inappropriate gait-training that can lead to further pain, overuse injuries and related improper body mechanics.
Clinicians looking to use video technologies for therapy pools will find a range of configurations available. HydroWorx, headquartered in Middletown, Pa, offers video systems that are integrated with the company’s therapy pools, and provide front view and side view of the person in the pool. The pool’s underwater cameras project video onto flat-screen monitors which enable the person using the pool to observe themselves in real time. Some facilities have found that using the underwater video systems are helpful in monitoring a user’s form, improve function for rehab patients, or enhance sport performance training.
For physical therapists working in an aquatic therapy environment, the opportunities are as expansive as those in a land-based setting. One example of an opportunity is the ability to coordinate concentric and eccentric workouts for aquatic patients, both of which help with strength, joint function, and proprioception. As the concentric contractions cause the muscles to shorten and generate force, the eccentric contractions cause the muscles to elongate in response to greater opposing forces.
Another benefit of aquatic therapy for physical therapists and their patients is the ability to actively work upper and lower extremities in a safe environment that minimizes falls while working on overall stability. For instance, running on an underwater treadmill is a much different sensation than running on a track or traditional treadmill. The drag forces of the water systematically push back against the upper and lower areas of the body, making it essential for the runner to remain vigilant about moving against the resistance. This works the arms and chest, improving caloric burn and cardiovascular responses to the physical therapy session. It also necessitates cognizance of every movement and thereby fosters proprioception and increased strength for basic motion mechanics.
Underwater treadmills designed for the physical therapy market are available from several sources. For clinics looking for a smaller footprint, the HydroWorx 300 Sport is built to be compact enough to be installed in the existing gym area of some practices and fit through a 36-inch doorway. Made to be construction-free, the 300 Sport has an integrated variable speed underwater treadmill with speeds that increase in .1 mph increments from 0.1 to 10 mph. The Sport 300 also has an optional underwater camera monitoring system. HydroWorx’s 2000 series are larger in-ground therapy pools that also are equipped with camera systems, a moveable floor, and an underwater treadmill.
Hudson Aquatic Systems LLC, Angola, Ind, also offers several models of underwater treadmill systems. The company’s AquaCiser III is a fiberglass modular system with an underwater treadmill designed to serve PT clinics, nursing homes, or hospitals. The AquaCiser III has an exercise chamber with a clear door and windows, 12 whirlpool jets, two resistance jets, and can adjust water depth from 12 inches to 48 inches. The treadmill speed is adjustable, and a programmable touchscreen control console can provide hundreds of exercise options. Hudson Aquatic also offers its AquaFit underwater treadmill system designed with a larger tank and doorway to accommodate bariatric patients and athletes.
Treatment of Athletes Affected by Proprioception Problems
Aquatic therapy has useful benefits for patients of all ages and with a multitude of conditions, but there is one population that has found a special use for water-based rehab: athletes.
Athletes, especially professional or elite-level athletes, are typically looking for accelerated rehabilitation programs. This is where aquatics can provide them with the initial proprioceptive-promoting skills they will require when they return to play. Treating injured athletes in a pool allows them to run and jump before they could safely perform these activities on land because of too much pressure on their joints. In the water, athletes are unloaded enough to safely engage in explosive and plyometric exercises as part of their intensive rehabilitation regimens.
While keeping their bodies in shape, they are likewise able to take advantage of the buoyancy, hydrostatic pressure, and other benefits of water therapy. This helps reduce the chances of re-learning a gait pattern that is awkward, abnormal, and/or unsafe.
Aquatic Case Study Sample: Knee Injuries
Anterior cruciate ligament (ACL) injuries and total knee replacements are on the rise across the country, so it is fitting for physical therapists to learn how to treat ACL patients early in an aquatic environment to reinstitute proprioceptive abilities of their clients.
Whether geriatric patients or collegiate athletes, orthopedic patients all struggle with the challenge of recovering their normal gait patterns. Many among those populations may be fearful, but water relieves pressure from the joints and allows for a comfortable freedom of movement. Additionally, thanks to a reduction in pain and the decreased compression on the healing joints, those individuals tend to be less timid about using standard gait movements while underwater, rather than tentatively putting pressure only on the toes.
Once submerged, the patient can begin walking at a very slow speed, such as 0.2 MPH, on an underwater treadmill. The water will naturally accentuate the gait pattern, and the patient will be able to see himself or herself clearly using video feedback. This allows for instant normalization of gait and improved responses to the physical therapist’s suggestions.
In many cases, aquatic therapy leads to patient progressions that are approximately twice as fast as when land-based rehab is the only method utilized.
Waking the Nerves to Improve Proprioception
For patients with spatial relationship and proprioception issues, their ultimate progress depends heavily on nerve stimulation and its resulting benefits. “Waking” the nervous system through the power of the massage hose with resistance jets encourages full participation of the brain and body. Plus, it promotes a psychological feeling of wellness and improvement, which rewards the patient for remaining compliant. From all perspectives, this makes aquatic therapy a sensible choice for patients who have impaired motion mechanics and are eager for returned strength, range of motion, and proprioception. PTP
Greg King, FNP, received his training from Pittsburgh State University as an orthopedic nurse practitioner, specializing in orthopedic surgery. King provides on-site athletic coverage for multiple high schools and colleges.
Cheryl Ogran, MSPT, CLT-LANA, earned a Bachelor of Science degree from Murray State University, received her MSPT from the University of Kansas, and is a LANA-certified Lymphedema specialist. For more information, contact [email protected].
Pool Lifts Complete the Picture
By Frank Long, Editorial Director
While fitness clientele may have no trouble entering a therapy pool, individuals affected by balance issues, neurological conditions, or who have mobility issues that restrict them from safely entering a water environment must be provided the means of access. A pool lift approved for use under the Americans with Disabilities Act (ADA) can be a solution to these challenges. Several manufacturers offer devices to the PT market for above-ground or in-ground pools built to offer convenience and a high level of safety.
Water-Powered Lift Provides Clean, Green Access
The IGT-180 series of lifts available from Aquatic Access Inc, Louisville, Ky, are built to operate on water pressure, providing a green source of power that can help reduce energy costs. Devices in this series can lift up to 400 pounds but be modified for heavier users. A seat belt is provided with each lift as well as a flip-up footrest. The company’s IGAT-180/135 pool lift can accommodate side-to-side transfers and is engineered to provide 135-degree seat rotation for use with pools or spas that have seats or benches built in. Aquatic Access also offers the Pool Lift Model AG72 for facilities equipped with above-ground high-wall therapy pools. This lift has a vertical seat travel of 51 inches and a manual 360-degree seat turn. For other above-ground installations or for use with freestanding nursing home tubs, the Pool Lift AG-60 provides 42 inches of vertical seat travel as well as a manual 360-degree seat turn.
Pine Island NY-based SureHands Lift & Care Systems offers the Wheelchair-to Water Pool Lift built to move the user directly from the wheelchair into the water. This lift has a mobile design and is powered by rechargeable batteries. The unit is built to engage and disengage easily from the floor socket and can be rolled away from the pool when not in use. An emergency stop button is built in to halt all motion of the device’s lifting arm. This lift has four castors and is designed to be compact and fold up easily.
ADA-compliant lifts can also be found through Spectrum Aquatics, Missoula, Mont. The company’s electric-powered lifts include the Freedom ADA-Compliant Pool Lift and Aspen ADA-Compliant Pool Lift, both of which offer a 350-pound lifting capacity and 90 lifts per battery charge. The company’s water-powered lifts include the ADA/ABA-compliant Gallatin Water Power Assisted Access Lift for in-ground pools and spas without customization, and the Glacier Pool Lift, a vertical lift platform designed to accommodate a wheelchair for individuals who require stabilized support for entry.