Chapter 3 Aquatic Physiotherapy

Treatment methods

• The physical properties of water covered in the assessment chapter facilitate the application of treatment techniques that can be used to provide therapeutic benefits for patients managed in a pool. Methods of utilising these physical properties of water are as follows.

Uses of buoyancy

• To progressively strengthen concentric muscle actions (assisted – neutral – resisted)

• To resist eccentric muscle actions

• To resist isometric muscle actions

• To assist joint movement

• To assist prolonged muscle stretches

• To provide weight relief

• To assist relaxation

• To assist in the application of the metacentric effect.

Uses of turbulence

• To assist movement.

• To resist isometric muscle action.

• To resist isotonic muscle action.

• To maintain balance.

• To displace balance.

• To restore balance.

• To assist walking.

• To resist walking.

The grading of muscle actions in water

• Muscle strength is graded on land according to the Oxford or Muscle Test Rating scales. In water these scales are modified so that muscle strength can be finely graded utilising hydrodynamic principles. As on land this scale is subjective, especially when there is no ‘normal’ limb to compare against.

Muscle strength grading in water

Grade 0 No contraction

Grade 1 Assisted by buoyancy

Grade 2− Buoyancy counterbalanced

Grade 2 Buoyancy counterbalanced with speed

Grade 2+ Against buoyancy

Grade 3 Against buoyancy with small float or with speed

Grade 3+ Against buoyancy with larger float

Grade 4 Against buoyancy unstreamlined

Grade 4+ Against buoyancy with large float with speed

Grade 5 Against buoyancy unstreamlined with maximum speed or with largest float able to be moved

Muscle actions during immersion

Concentric

When considering the effect of buoyancy (alone), on movements at slow speed, the effect is as follows:

Buoyancy assisted Moving a limb or body part towards the water surface

Buoyancy counterbalanced Any movement of a limb or body parallel to the water surface

Buoyancy resisted Movement of a limb or body part downwards against the upward thrust. This resistance can be increased by the use of additional flotation aids, or by lengthening the lever arm.

Eccentric

• These contractions can only be achieved by moving a limb towards the surface at a slower rate than the upthrust effect is trying to produce. Extra flotation aids will be required for effective muscle work due to the close relative density of water and the limb.

Isometric

This type of muscle action can be achieved by:

• Buoyancy Maintaining the position of a limb or body part against the upthrust forces.

• Metacentre Holding an adopted position with altered body shape against the rotational forces caused by an imbalance between the forces of buoyancy and gravity.

• Turbulence Holding the position of a limb or body part against the drag created by an area of turbulence (low pressure water) created by the physiotherapist.

• Drag effect Holding a posture against the drag effect created when the therapist moves a patient through the water.

The latter two effects can equally be used to promote concentric dynamic muscle action.

Muscle strengthening: using buoyancy, turbulence and the metacentric effect

Buoyancy

Utilising turbulence

Therapist created

• The therapist creates an area of fast-moving water to create drag on a body part. The patient resists movement towards this area of low pressure, e.g. to create resistance for the biceps. The patients arm is supported on a float at water surface. The therapist then creates turbulence over the posterior forearm and outwards.

• These techniques are generally written as ‘turbulence resisted’.

Patient created

• The patient moves a body part through the water, thus creating an area of low pressure behind the moving part, e.g. to create a strengthening exercise for the shoulder flexors and extensors the patient moves their arm briskly backwards and forwards through the water.

• These techniques are generally written as ‘speed resisted’.

Via the ‘drag’ effect

• The patient is moved through the water while they hold a position against the drag of the water. For example, to strengthen the trunk side flexors the patient is supported supine on floats. The therapist holds the patient either at the ankles or the shoulders and swings them sideways through the water while the patient tries to prevent side flexion.

• These techniques are generally written as ‘drag resisted’.

Utilising the metacentric effect

• The patient holds a position against the turning forces created, e.g. patient in supine lying, works against the following movements to prevent the tendency for the body to rotate along its longitudinal axis:

– Turning the head

– Taking an arm or leg out to the side

– Lifting an arm out of the water.

• Patient in standing or in the ‘box position’ (squatting in the water as if sitting on a chair), supine lying, works against the following movements to prevent the tendency for the body to rotate around its transverse axis:

– Taking the head forward, backward, or to the side

– Taking the arms forward or backward

• These techniques are generally written as ‘metacentre resisted’.

Physiological considerations

• Comparing oxygen consumption and heart rate responses during exercises performed on land and in the water, both heart rate and oxygen uptake are greater during exercises in water.

• Evidence indicates that viscosity and turbulence provide a greater load during exercise than the resistance of gravity during land exercises.

• Oxygen consumption increases by about ten times over resting values in the water for male subjects performing leg exercises and about seven times for women.

• Arm exercises performed in water require less energy than leg exercises in water.

• However arm exercises require significantly more oxygen when performed in water than the same exercises performed on land (Johnson et al 1977).

Improving range of movement (ROM)

Utilising buoyancy

Buoyancy assisted

• The body part is moved towards the water surface, assisted by a float. This can be done as a contract/relax technique or as a prolonged stretch (Figures 3.1–3.17).

• These techniques are generally written as ‘buoyancy assisted’.

• Therapist created turbulence can be added to assist the effect.

Figure 3.1 Stretch for hip abductors (right illustrated).

Figure 3.2 Stretch for hamstrings (left illustrated).

Figure 3.3 Stretch for hip flexors (left illustrated).

Figure 3.4 Stretch for hip extensors (left illustrated).

Figure 3.5 Stretch for hip rotators (right lateral rotators illustrated).

Figure 3.6 Stretch for hip rotators (right medial rotators illustrated).

Figure 3.7 Stretch for knee extensors (left illustrated).

Figure 3.8 Stretch for hip extensors and spinal rotators.

Figure 3.9 Stretch for knee flexors (right illustrated).

Figure 3.10 Stretch for hip flexors and quadriceps (right illustrated).

Figure 3.11 Stretch for shoulder adductors (right illustrated).

Figure 3.12 Stretch for shoulder to increase flexion (left illustrated).

Figure 3.13 Stretch for abdominals.

Figure 3.14 Trunk side flexors (left illustrated).

Figure 3.15 Pectorals and abdominals.

Figure 3.16 Trunk rotators (left illustrated).

Figure 3.17 Combined hip and trunk rotators.

The lower limb stretches

• Keep trunk upright allow float to take leg up towards surface of pool (Figure 3.1).

• Trunk braced against poolside, patient instructed to hold a lordosis, allow float to take leg up towards surface of the pool (Figure 3.2).

• Patient holding onto side of pool (elbows flexed to help keep body upright). Patient flexes left knee and hip to eliminate lumbar hyperextension (Figure 3.3). Allow float to take leg towards surface of pool, patient instructed to keep knee in extension.

• Patient holding side of pool with elbows extended. With left hip and knee flexed, allow float to bring the flexed leg towards pool surface (Figure 3.4).

• Patient with trunk braced against pool side, right hip flexed to 90°, right hand to fix knee to enable rotation around axis of femur to occur. Allow float to bring the foot up (Figure 3.5).

• As per stretch for lateral rotators, but with opposite rotation of femur (Figure 3.6).

• Patient holds side of pool to keep trunk upright and thigh in neutral position. Allow float to bring foot up towards pool surface (Figure 3.7).

• Patient facing pool side with both forearms on rail. Tread on inside of inner surface of ring. Twist knees to R and flex both up the wall to the R so that L thigh is against wall. Both feet and float remain under the knees (Figure 3.8).

• Patient in standing or sitting on stool, flex hip to 90°. Patient to fix thigh position and allow float to bring foot up to surface of pool (Figure 3.9).

• Patient with trunk horizontal to water surface, left hip in 90° flexion, allow float to take foot up to surface of pool (Figure 3.10).

The upper limb stretches

• Patient supported by floats in right side lying, facing side of pool. Keeping elbow extended allow wrist float to bring the arm through abduction to surface of pool (Figure 3.11).

• Patient with trunk parallel to pool surface with waist float. Keep elbow in extension allow float to bring hand to surface of pool (Figure 3.12).

Trunk stretches

• Patient prone, keeping knees extended allow float to bring legs to surface of pool, producing spine extension (Figure 3.13).

• Patient to grasp side of pool, keeping shoulders level and thighs against pool side, allow float to bring the legs up towards pool surface (Figure 3.14).

• Patient holding pool side with feet fixed on pool floor. Allow float under scapulae to bring trunk up to pool surface (Figure 3.15).

• Patient grasps pool side with right arm in extension. Patient reaches under the trunk with left arm and allows float to take the hand up to pool surface (Figure 3.16).

• Patient with float under hips and float around ankles allowing feet to float to surface of pool, keeping thighs in the water (Figure 3.17).

• The stretches can also be carried out as slow prolonged stretches, using flotation and the same starting position as described in Figures 3.1–3.17. With this type of stretch the end position with buoyancy providing the stretch should be maintained for 30–60 seconds.

Buoyancy counterbalanced: mobilising work

• The body part is moved parallel to the water surface, this is done slowly in order to avoid the build up of turbulent (low pressure) water behind the moving part.

• These techniques are generally written as ‘buoyancy counterbalanced’.

Stretches using drag

• Some muscle groups can also be stretched using the principles of drag. In most instances the patient needs to be supported on floats and the body moved through the water in a direction which provides drag on the muscle group to be stretched, e.g. the patient lies supine supported by floats, while the therapist grasps either the shoulders or lower legs and moves the patient in an arc to the right, which will stretch the right side flexors.

• Stretch can be increased by increasing the speed of movement and/or by increasing the length of the moving lever.

• For these stretches to be effective the patient must be able to relax whilst lying on floats.

Specific stretches using drag

Muscle group	Starting position
Trunk side flexors	Supine lie
Trunk rotators	Supine lie, therapist adds rotation as the body moves through an arc
Trunk flexors/extensors	Side lie
Hip adductors	Supine lie
Shoulder adductors	Supine lie
Shoulder extensors	Prone or side lie
Pectorals	Standing – walking forwards holding bats in both hands
	– walking in a circle holding a bat in the hand of the arm to be stretched
Elbow flexors	Standing – walking forwards holding bats in both hands
	– walking in a circle holding a bat in the hand of the arm to be stretched