Astri dr. tz - aquatic

AQUATIC EXERCISEPembimbing:

DR. dr. Tirza Tamin, SpKFR-K

Presentan:Setia Wati Astri Arifin

Introduction DEFINITION

The use of multidepth immersion pools or tanks that facilitate the application of various established therapeutic interventions

Schrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5 th ed. Philadelphia: F. A. Davis Company, 2007. p. 273

PURPOSEfacilitate functional recovery by providing an environment that augments a patient’s ability to perform various therapeutic interventions

Goals

Schrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5th ed. Philadelphia: F. A. Davis Company, 2007. p. 273

ROM exercise Resistance training

Weight-bearing activities

Delivery of manual

techniques

Access to the patient

Cardiovascular exercise

Functional activity

replication

Minimize risk of injury or reinjury Relaxation

Principles And Properties Of Water

Buoyancy Hydrostatic Pressure

Viscosity Flow•Laminar flow parallel•Turbulent flow not move parallelThermodynamics

Schrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5 th ed. Philadelphia: F. A. Davis Company, 2007. p. 273Becker BE, Cole AJ. Aquatic Rehabilitation. In: DeLisa JA, Frontera RW, Gans BM, Robinson L, Walsh NE, editors. Physical medicine and rehabilitation: principle and practice

Adva

ntag

es

Buoyancy weightlessness and joint unloading increase active motionHydrostatic pressure reduces or limits effusion, assists venous return, induces bradycardia, and centralizes peripheral blood flowViscosity resistance with all active movementsTurbulence destabilizer & tactile sensory stimulusReduces stress and reduces pain to a great extent

Disa

dvan

tage

sCost• Cost of building and

maintaining a rehabilitation pool

Specified personnel• Physiatrists and therapies

must be trained in aquatic safety and therapy procedures

Thermoregulation

Mobility

• Buoyant equipment may assist the movement initially• Warm temperature may increase soft tissue extensibility• Stretch techniques are used in two ways: active & passive

Trunk stabilization

• Consist of 6 steps: walking and marching; jumping in high duck position; arm circling and straight arm pulls; arm supported open chain hip, knee and ankle flexion and extension in backward position; arm supported open chain hip, knee and ankle flexion and extension in forward position; aqua jogging

Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.

Beginning Aquatic Rehabilitation

• As early as possible after the injury to minimize effect of immobilization

• Start with walking in water patient learns to move in this new therapy-medium, feels quite relaxed and pain and fear are reduced


Design Similar to land-based programsDepends on:• Type of injury/surgery • Treatment protocols• Results/muscle imbalances found in

evaluation • Goals

Hoogenboom B, Lomax N. Aquatic therapy in rehabilitation. In: Prentice WE, editor. Rehabilitation techniques for sports medicine and athletic training. 4th ed. New York: McGraw Hill, 2004. p. 326

Exercise Technique

The four variables that can be manipulated to alter resistance or assistance

1. Position or direction of movement in the water

2. Water depth 3. Lever arm length 4. Use of flotation or

weighted equipment

Brody LT. Aquatic physical therapy. In: Hall CM, Brody LT, editors. Therapeutic exercise , moving toward function. 2nd ed. Philadelphia: Lippincott Williams & Wilkins. p. 330

Temperature Regulation

• Maintain between 26⁰C and 33⁰C for mobility exerciseBecause,– Patients are unable to maintain adequate core warmth

during immersed exercise at temperatures less than 25⁰C– Hot water immersion (> 37⁰C) may increase the

cardiovascular demands at rest and with exercise

• Cardiovascular training and aerobic exercise should be performed in water temperatures between 26⁰C and 28⁰C

Schrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5th ed. Philadelphia: F. A. Davis Company, 2007. p. 273

Similar with land-based exercise, except for its mechanic-kinematic

Water will provide additional resistance to the body core Upper

extremity

Strengthening exercises can be performed completely non weight bearing in the open chainWeight bearing can be increased by reducing the depth or by using weight belts

Lower extremity


Special Equipment

Pools in-ground swimming pool minimum range 4–5 m depth 1.2 - 1.4 m


Inflatable Cervical Collar maintain head

Floatation Ring positioning and relaxation

Buoyancy Belt supine, prone, or vertically for shallow and deep water position

Special Equipment

Special Equipment

Swim Bars/ Buoyant

dumbbells maintain head

Gloves generates resistance

Hand Paddles generates resistance

Special Equipment

Hydro-tone® Bells and Boots

generates resistance

Kickboards generates resistance

Ergocycle generates resistance

PrecautionsFear of Water

• need an orientation period

Neurological Disorders

Seizures

• patients with controlled epilepsy require close monitoring

Cardiac Dysfunction

• angina and abnormal blood pressure need close monitoring

Small Open Wounds and Lines• Small, open wounds and tracheotomies may be covered by waterproof dressings• Patients with intravenous lines, Hickman lines, and other open lines require proper

clamping and fixationSchrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5 th ed. Philadelphia: F. A. Davis Company, 2007. p. 273

Contraindication

Schrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5 th ed. Philadelphia: F. A. Davis Company, 2007. p. 273

seizures

Incipient cardiac failure and unstable angina.

Respiratory dysfunction; vital capacity of less than 1liter.

Severe peripheral vascular disease.

Danger of bleeding or hemorrhage.

Severe kidney disease

Open wounds, colostomy, and skin infections such as tinea-pedis and ringworm.

METHODS

Bad Ragaz Ring Method• Technique– The therapist provide stability for the client– 3 action ways: isometrically, isokinetically, isotonically

aquaticsintl.com

Garret G. Bad Ragaz Ring method. In: Ruoti RG, Morris DM, Cole AJ, editors. Aquatic rehabilitation. Philadelphia: Lippincott; 1997. p. 289

• The client wears neck ring float, body ring at the L5-S2 level and extremity rings•The water level should not exceed axillary (T8-T10) level of therapist• Minimal pool area 15,8 m2

• Water depth usually 0,9-1,2 m• Temperature 33,3⁰C – 36,6⁰C

Bad Ragaz Ring Method

• Aim:– Tone reduction– Relaxation– Increasing ROM– Muscle re-education– Strengthening– Spinal

traction/elongation– Improving alignment and

trunk stability

– Preparation of the LE for weight-bearing

– Restoration of normal pattern of LE&UE movement

– Improve general endurance

– Training the body functional capacity


Indication

• Orthopedic & rheumatologic conditions

• Neurologic disorders• Pain syndrome• Sensory

desensitization• Developmental delay

symptoms

Contraindication

• Precaution to excessive fatique

• Vestibular problems• Acute conditions



• Trunk Pattern– Stabilization– Rotation– Rotation with flexion– Rotation with

extension• Arm Pattern• Leg Pattern

• Isokinetic/Isotonic/Isometric• Bilateral/Unilateral• Starting Position• Therapist hold• Verbal Commands• Finishing Position• Progression


Halliwick Method

BALANCE AND

POSTURE

Can be used for patients with neurologically or developmental impaired

Focusing on patients ability in water and NOT disability on land

Mental AdaptationMaintaining posture and balance with buoyant force influenceOvercome breathing difficultyAdjustment to therapist dis-engagement Balance

RestorationUse primitive reflex activities to control vertical, lateral, and combined rotation movement

InhibitionTeaches clients to hold a posture when challenges are applied on body

FacilitationControlling movement through the waterMaintain balanced posture while being moved passivelySwim stroke

Halliwick Method

AQUATIC REHABILITATION FOR OSTEOARTHRITIS

Aquatic Therapy With Knee Osteoarthritis

• Purpose Prevent atrophy and motion loss and abnormal movement pattern development

Aquatic rehabilitation richaed g.ruoti, david m.morris, andrew j.cole. LIPPINCOT Philadhelpia New york 1997

Limitations of Weight bearing with Buoyancy effect

Aquatic Therapy With Knee Osteoarthritis

Condition associated with weight bearing limitations

Can use exercise according to early phase , intermediate phase and late phase

Limited weight bearing using buoyancy can be initiated early to prevent athropy and motion loss and abnormal movement pattern development

Primary goal : Restore normal gait mechanics• Proper heelstrike• Proper weight

transfer• Proper knee and

hip flexion• Proper knee

ekstensionAquatic rehabilitation richaed g.ruoti, david m.morris, andrew j.cole. LIPPINCOT Philadhelpia New york 1997. pg 79-81

Primary goal:• Increased endurance in

gait• Restoration of full motion• Return of muscle

function.

Primary goal:• Progression to full weight

bearing on ground• Impact loading, plyometric

exercise and functional activities in the pool (optional)

Early Phase

Intermediate Phase

Late Phase

Special Requirement• Water temperature 27-30°C• Depth– Subacute phase: xyphoid level– Chronic phase: SIAS level

• Modify:– Patient’s position– Lever arm length – Direction of movement– Use of flotation or weighted

equipment


Sample Training Program for Knee Problem

Trunk stabilization Flexion/extension in

floating supine and prone position

Balance training Single leg standing on

heels (up to toes - down to heels - repeat)

Upper extremity training Straight arm pull

Lower extremity training

Walking (forward, backward, sideways)

Endurance training Jogging in deep water Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli

LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.

Activities to improve posture

Activities to increase ROM and flexibility

Activities to increase muscular strength and endurance

Cardiovascular training

Musculosceletal Conditions Of The SpineGOAL :


Activities To Improve Posture

• Spinal stabilization exercise • Forward walking with a

resistance board• Trunk strengthening

with paddles• Advance spinal

stabilization exercise • Balancing (sitting) on a

kickboard

Activities To Increase ROM And Flexibility

• Hamstring strech with use of floatation bouyance• Forward walking exercise

Passive Trunk Flexion And ExtensionFlexion

Extension Wall slide /squats

Supine lap work, holding kickboard at chest

Hanging in corner, lower extremity flexed, back to wall

Posterior pelvic tilt with back to wall, vertical stabilization with lower

extremities flexion

Activities To Increase Muscular Strength And Endurance

Increase the strength and endurance of the paraspinal and abdominal musculature (important)

Cardiovascular Training

Important in completing the rehabilitation process and facilitating the transtition to a regular fitness regime

1. Walking2. Jogging 3. Swimming strokes4. Immersed cycling 5. Immersed treadmill

Impairment Oriented Rehabilitation

• Mechanical back pain• Soft tissue injuries• Postural dysfunction• Other imparment

oriented considerations

Phase :• Early• Intermediate• Late

Mechanical Back Pain • Include : – discogenic pain, – facet syndrome ,– degenerative joint

disease,– obesity

• Goal : reduction of pain– Unloading the spine by

means of immersion into the shallow/deep end of the pool

– Sensory input from flow along the body

– Water’s warmth

Early PhaseGOALS:1. Reduction of pain2. Correction of any

postural faults (lateral shift, lumbar spine flexion)

3. The establishment of normal movement patterns.

• Variety of positions:– Bad Ragaz techniques for

passive lateral trunk flexion– Passive trunk flexion and

extension– Gentle traction for

lumbar/cervical spine (supine by stabilizing distally or proximally at the trunk then traction force at the head or hips)

– Vertical traction in deeper water by using ankle weight and flotation vest

Intermediate Phase

GOAL :• Increasing the pain-free ROM• Improving ability to generate torque in the trunk

musculature for extended periods of time • Increasing the number of activities performed

without pain.

Technique

Exercise by resistive trunk rotation : • Stabilizing the feet on the bottom of the pool and

rotating the trunk • Stabilizing the trunk by holding on to a stationary

object with the arms and rotating the legs.

Exercise in the pool allows the person to

increase the exercise time and repetition

without increasing joint compression

Patient usually can demonstrate proper

posture when cued, but has difficulty

maintaining the posture for any length of time

Late phase

• Pain free ROM• Dynamic control of posture• Muscular endurance

Functional Needs

NEUROLOGIC DISORDER

Aquatic Rehabilitation Of Clients With Neurologic Disorder

Neurorehabilitation modelMotor learningEnchancing motor skill throught

task analysis

Balance dysfunction • Biomechanical aspect• Motor coordination

• Sensory integration and aquatic solution for balance dysfuntion

Voluntary movement deficit • Central mechanism dysfunction• Periferal mechanism dysfunction

• Aquatic solution for voluntary movement deficit

Gait dysfunction • stance and swing phase

• aquatic solution to gait dysfunction

STROKE

Stroke Aquatic Program

GOAL :

Produce a positive influence on participants over all endurance, strength and flexibility

Provide a convenient, regularly scheduled opportunity for participant to exercise and socialize in a positive, fulfilling manner.

Provide effective, worthwhile educational program

b) Streching (10’- held @15 “) with active streches preferred :1. Hip flexor2. Hip adduction 3. Heel cord4. Back extension5. Shoulder flexion6. Shoulder horizontal

abduction

activities

a) warm up (5 ‘ )for perform increasing blood circulation :

1. Slow walking2. Slow marching at wall3. Slow cycling

c) Movement control (10‘) Aimed : improving control of muscular contractions to enchance smooth, effective joint movement

d) Aerobic activities (15’)to increase heart rate to 50 % to 70 % of maximum heart rate :1. Water walking2. Water running3. Marching at the

side of the pool4. Cycling in the

innertube5. Cycling while held

by a partner

e) Cool down (15’)to return the heart rate gently to a resting level :1. Slow walking2. Slow marching

at the wall3. Slow cycling

PEDIATRIC

Aquatic Rehabilitation In Pediatric

General Safety Consideration :• Oral Motor Control• Ear Chronic Infection• Hiponatremi• Flotation device for

safety

Behavioral considerationsAge guidelines

Cognitive status

Behavioral concerns related to diagnosis.


Using Water To Address Problem Area

Alteration in stiffness:

• Hypotonia • Hypertonia • Weakness

ROM

Respiratory problems

Arousal problems

Sensory perseptual difficulties


Parent/ Guardian/Caregiver Instruction

• Children require more intense supervision• The assisting enter the water with the child

and therapist to learn the necessary skills• A demonstration by the therapist followed by

a return demonstration by the learner.

Adapted Bad Ragaz

• Requires : the patient respond to a verbal command by the therapist.

• Modified the therapist’s hands become the

vehicle of communication and slight pressure or traction to move.

The therapist’s may be able to hold the child without using flotation if she is small enough or buoyancy enough.

Example • To activate the lateral trunk and legs by

beginning in supported supine, holding at the shoulders, elbows or rib cage to provide stability.• By quickly moving the upper trunk and

shoulders side to side, the child can be helped to move her lower trunk and legs to the side.

Adapted WATSUVery useful :

The severely or profoundly mentally retarded child

Child with increased stiffnessNot indication :

Children who are significantly hypotonic

• Can be used early in the session to “loosen up” the child in preparation for more active work.

Cerebral Palsy, Spastic Diplegia With Minimal Severity Sesion Plan

1. Enter via jumping off deck from a sitting position near therapist

2. Turn around to place hands and feet on the wall, push off the wall with feet and continue with supine flutter kick

3. Supine recovery to do prone flutter kick back to the wall

4. Repeat steps 2 and 3 several times for trunk and lower extremity strengthening.

5. Race across the pool using kickboards for upper extremity stability and flutter kick in either prone or supine.6. Perform an obstacle course with object to retrive from the pool floor using a surface dive7. Trunk and lower extremity exercise in suspended vertical with arms in two kickboards8. Practice with simple hand stands9. Handstands with controlled lower extremity movements into flexion / extension and abduction / adduction10. Exit pool via staircase using two rails and assist as needed

ATHLETE

Aquatic Rehabilitation Of The Athlete

Benefit of aquatic programming for the athlete The Principle of Unloading

The aquatic medium provide the athlete with the opportunities for injury prevention and for immediate onset of safe and functional rehabilitation


Purpose


To negate or lessen any force that would interfere with a

final goal

unloaded articular cartilage and the cortical and cancellanous bone

Protection of the ligaments and muscle-tendon from

excessive torque or damaging vibrational forces

Exercise prescription

The general principle1. Work in the most shallow water tolerated2. Functional activities should be practice as a whole3. Sytematically remove external stabilization provided for

clients4. Encourage stabilizing contractions in upright positions with

movement of selected body segment5. Encourage quick, reciprocal movement6. Encourage active movement problem solving7. Gradually increase the difficulty of the task.

Type training to improve gait dysfunction

• Standing weight shift• One leg up• Marcing• Kick back• Side kick

• Straight leg kick• Walking with front

support• Walking with side

support

Hoogenboom B, Lomax N. Aquatic therapy in rehabilitation. In: Prentice WE, editor. Rehabilitation techniques for sports medicine and athletic training. 4th ed. New York: McGraw Hill, 2004. p. 326

Application

Application

Noodle Water

Astri dr. tz - aquatic

Health & Medicine

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