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Warm Water Pool Therapy for:
Jeffery Allen PT. OCS
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BUILDING AN EVIDENCE-BASED CASE: Aquatic Therapy for the Rheumatology or Arthritic Patient A Five Part Explanation: PART I Part
I However,
it has been suggested that weight-bearing exercise — even exercise
considered "normal" — can aggravate pain and further promote
degeneration in patients with abnormal joints. This
is particularly true if the joints have incongruous articular surfaces,
poor alignment, ligamentous instability, or altered muscle or joint
innervation, as is often the case in patients with immunologic conditions.
Unfortunately,
this diminishes exercise options for the patient with joint degeneration,
which often results in a discontinuation of exercise altogether.
Ironically, the ensuing immobility and lack of dynamic joint loading
further damage joint surfaces leading to a downward spiral of immobility
and degeneration. Throughout
this column, we will test the idea that aquatic therapy is an effective
treatment for the impairments, functional limitations and disabilities
commonly associated with rheumatic diseases. Below,
you will find the aquatic benefits most commonly cited by the anecdotal
press for the treatment of rheumatologic disorders. Each hypothesized
benefit will be examined in turn. Building
a Case Hypothesized
Benefits Hypothesis I.
Hydrodynamic Principles Archimedes'
principle states: "When a body is wholly or partially immersed in a
fluid, it experiences an upthrust equal to the weight of fluid
displaced." This upthrust, or buoyancy, counterbalances gravity and
supports the body, resulting in an apparent reduction in weight bearing
through the spine and lower extremities. Therefore,
exercise in water can produce less spinal and lower extremity joint
compression than the identical exercise performed on land, offering
patients with rheumatologic disorder an environment where it is possible
to exercise aerobically. Hydrostatic
Pressure Pascal's
Law states, "Fluid pressure is exerted equally on all surfaces of an
immersed body at rest at a given depth." Thus we know that pressure
increases as depth increases. Since the density of the fluid in most
therapeutic pools is fixed and unalterable, this pressure gradient can be
used therapeutically.
It
is also important to remember that hydrostatic pressure can restrict chest
wall expansion in individuals with compromised pulmonary systems and thus
serve as a progressive resistive exercise program for respiration. II.
Scientific Research Jentoft
et al examined the effects of pool-based and land-based exercise programs
on patients with fibromyalgia.1 The outcomes were assessed by the
Fibromyalgia Impact Questionnaire, the Arthritis Self-Efficacy Scale, and
tests of physical capacity. After 20 weeks, statistically significant
improvements were seen in both groups in cardiovascular capacity, walking
time and daytime fatigue. The results were mainly unchanged at six months
followup. The researchers concluded that physical capacity can be
increased by exercise, even when the exercise is performed in a warm-water
pool, and that pool programs may have some additional effects on symptoms.
Melton-Rodgers
et al compared the aerobic effects of land-based biking versus water-based
running for subjects with a diagnosis of class II or III adult-onset
rheumatoid arthritis.2 There were no significant differences between the
two training environments for the following factors: peak VO2, maximum
heart rate, perceived exertion (RPE) at 60 percent peak VO2, or pain. Peak
minute ventilation on the bike was 26 percent higher and peak tidal volume
was 48 percent greater than that achieved during water running
(significantly different). Conversely, peak RPE was 7 percent higher and
peak respiration rate was 22 percent greater in the water than during
land-based bicycling (significantly different). The authors concluded that
it was possible to achieve training effects during water running for the
population and parameters studied. Minor
et al examined a group of patients with rheumatoid arthritis or
osteoarthritis who volunteered to be subjects for this study of aerobic
versus nonaerobic exercise.3 Patients were randomly assigned to an
exercise program of aerobic walking, aerobic aquatics, or nonaerobic range
of motion (controls). The researchers showed a significant training effect
over controls by having rheumatologic subjects participate in either land-
and water-based aerobic exercise. Aerobic capacity, 50-foot walking time,
and physical activity improved after participation in the 12-week exercise
trial. Their findings document the feasibility and efficacy of
conditioning exercise for people who have rheumatoid arthritis or
osteoarthritis. Danneskiold-Samsoe
et al examined the effect of exercise therapy performed in a heated
swimming pool for patients in a non-acute stage of rheumatoid arthritis.4
After two months exercise therapy, the researchers noted a significant
improvement in aerobic capacity in patients with Class II or III
rheumatoid arthritis after participation in a twice/weekly, eight-week
aquatic exercise program. Bacon
et al examined the effects of aquatic therapeutic exercise on
lower-extremity range of motion, gait, balance and functional mobility in
children with juvenile arthritis.5 In this pilot study, patients age 4-13
with lower-extremity joint involvement, diagnosed as functional class
I-III, completed a six-week program of aquatic exercise aimed at
increasing lower-extremity range of motion and strength. The researchers
found a significant reduction in post-exercise recovery heart rate after
patients with juvenile rheumatoid arthritis participated in a
twice/weekly, six-week aquatic exercise program. Researchers felt that
further investigation was warranted to determine fully the effects of
aquatic therapeutic exercise on mobility and fitness in children with
juvenile arthritis. Conclusion This
column attempts to establish the beginning of a hydrodynamic and
scientific basis for the use of aquatic therapy to improve the
cardiovascular health of the rheumatic patient. References 2.
Melton-Rogers, S., Hunter, G., Walter, J., & Harrison, P. (1996).
Cardiorespiratory responses of patients with rheumatoid arthritis during
bicycle riding and running in water. Physical Therapy, 76(10), 1058-1065. 3.
Minor, M., Hewett, J., Webel, R., Anderson, S., & Kay, D. (1989).
Efficacy of physical conditioning exercise in patients with rheumatoid
arthritis and osteoarthritis. Arthritis Rheumatology, 32(11), 1396-1405. 4.
Danneskiold-Samsoe, B., Lyngberg, K., Risum, T., & Telling, M. (1987).
The effect of water exercise therapy given to patients with rheumatoid
arthritis. Scandinavian Journal of Rehabilitative Medicine, 19(11), 31-35.
5.
Bacon, M., Nicholson, C., Binder, H., & White, P. (1991). Juvenile
rheumatoid arthritis: Aquatic exercise and lower-extremity function.
Arthritis Care Research, 4(2), 102-105. 6.
Salzman, A. (2002). aquatic therapy research Bibliography. Aquatic
Resources Network: Amery, WI.
Throughout
this five-part examination, the idea that aquatic therapy is an effective
treatment for the impairments, functional limitations and disabilities
that are commonly associated with rheumatic diseases will be tested. Building
a Case for Treating Rheumatologic Patients with Aquatic Therapy Hypothesized
Benefits Hypothesis
Rapid-velocity
activity and exercise in an aquatic medium lead to:
Mixed-velocity
activity and exercise in an aquatic environment lead to:
Building
an argument to support or negate hypothesis Buoyancy Basically,
buoyancy is an upward thrust which acts in the opposite direction to the
force of gravity. Therefore, a body in water is subject to two opposing
forces: gravity acting through a center of gravity (COG) and buoyancy
acting through the center of buoyancy (COB). These forces, when not
perfectly aligned, create a moment around a pivot point and the body
rotates. When
discussing whether a body or body part immersed in water will sink or
float, it is important to understand the concept of relative density
(alternatively known as specific gravity). Relative
density is "the ratio of the mass of an object to an equal volume of
water". Water has a specific gravity equal to 1. It serves as the
reference point for all objects. Objects with relative density less than
water float, and those with relative density greater than water sink.
Objects with relative density near the value of water hover just below the
surface. The
human body has elements which tend to sink (dense muscle) and elements
which tend to float (fatty tissue and air-filled lungs). This tendency to
float counterbalances gravity and supports the body, resulting in an
apparent reduction in weight. This reduction in weight can provide relief
from compressive forces on painful joints. It
is therefore possible for a person to stand, even walk, with reduced pain
without external support or abnormal protective mechanisms in the water.
Thus, the patient can initiate "normal" weight bearing tasks
such as gait, transfers, and balance drills in the water and offset any
deconditioning effects of immobility or reduced movement. As
already mentioned, the relative density of water has been arbitrarily set
at 1 (RD = 1). It follows then that if an object has a relative density
greater than 1, the object will sink. There
are many factors which will increase the relative density of an object:
If
relative density is less than 1, an object will float on the surface.
There are many factors which decrease the relative density of an object:
ź
So,
how can "buoyancy" create a therapeutic environment? For one,
exercise in water produces less spinal and lower extremity joint
compression than the identical exercise performed on land. This reduction
in compression creates an environment in which weight bearing and joint
compression (of the lower extremities and spine) can be applied in a
graded or progressive manner by the therapist. In
conclusion, buoyancy can be used to decrease the fight against gravity's
downward thrust by producing:
Buoyancy
can also promote ease of handling of the large or heavy patient, allow
access to body parts which would be inaccessible if the patient was
positioned on a plinth or chair, and allow progression of resistance in a
logical, graded fashion, from:
Viscosity
It
is possible to use viscosity therapeutically. Water is more viscous than
air, and resistance to flow through water is greater than resistance to
flow through air. Thus, it takes more force to push through water
molecules than to push through air molecules. Additionally,
the faster an object is pushed through the water, the more turbulence is
created and this creates additional resistance to movement. Flow The
area of "negative pressure" is known as the wake. Eddy currents
form in this wake and "pull" the object back. The negative
pressure (or drag) behind a moving object (the wake) is responsible for
90% of the impedance of movement. Surprisingly, the bow wave (the positive
pressure in front of the object) is only responsible for 10% of the
impedance. In
a streamlined flow of a liquid, a thin layer of fluid molecules slide over
one another. Resistance is directly proportional to the velocity of
movement and no eddy currents are created. In unstreamlined (turbulent)
flow of a liquid, there is an irregular, rapid, random movement of fluid
molecules. Resistance is directly proportional to the velocity of movement
squared and eddy currents are created. The
principle of flow can be used therapeutically to increase (or decrease)
the ease of movement by creating positive and negative drag. Resistance
can be altered by:
It
is also possible to use the concepts of flow to decrease resistance by
taking advantage of the "pull" of wake or by performing
movements in a more streamlined position. II.
Scientific research Dial
and Windsor examined the combined effects of an 8-week health
education/water exercise class for 12 adults with rheumatoid arthritis.
[1] Self-report tools indicated that the subjects had improved in
functional status, pain, mobility, tenderness in joints, joint movement,
number of recent flare-ups and treatment expectations. There was no
significant improvement in ADL outlook. Objective findings showed
significant improvement in the following: shoulder, elbow and wrist AROM,
ability to flex digits to palmer crease, hip and knee AROM, and timed
tests for arise-walk-sitting, walking 50 feet times, and donning-removal
of shirt. The subjects did not show significant improvement in grip
strength, morning stiffness, ankle AROM or MCP extension. In
a study by Danneskiold-Samsoe et al, subjects diagnosed with functional
class II or III participated in an aquatic exercise program 2x/week for 2
months. [2] After 2 months of exercise participation, maximal isometric
and isokinetic strength of the quadriceps increased by 38% and 16%,
respectively. Bacon
et al examined the effects of an aquatic exercise program on individuals
diagnosed with JRA (functional class I-III). [3] There were significant
ROM improvements in bilateral hip internal rotation, and right hip flexion
with knee extended. Trends toward increased plantar flexion ROM were also
noted but not significant. There were no significant improvements in
balance or timed tasks. There were no significant differences (although a
trend was evident) toward increased gait cadence, velocity and stride
length. Templeton
et al examined the objective changes in joint flexibility and functional
ability in rheumatologic populations after participation in an aquatic
therapy program. [4] Measurements of joint ROM and functional ability
measured by the Functional Status Index (FSI) were determined pre- and
post-aquatic exercise. Psychosocial factors were emphasized by encouraging
members to share benefits, joys, and accomplishments prior to each class
session. Following the eight week aquatic program, joint ROM measurements
and functional ability (FSI) significantly improved. Aquatic therapy was
identified as an effective treatment for improving quality of life in this
population. There was no significant improvement in the subjects' ratings
of "need for assistance" with daily functional tasks. Stenstrom
et al examined the effects of a 1x/week aquatic exercise class for 30
subjects with class II RA over a 4 year span. [5] After four years of
training 1x/week, the following significant improvements were evident in
the training group: grip strength, frequency of exercise and frequency of
hospitalization in the Department of Internal Medicine. Additionally, the
control group attended supplemental physiotherapy visits more often than
the training group (34 visits and 21 visits, respectively). At the
two-year follow-up, the training group remained significantly more active
and more likely to exercise than the control group. A majority of the
training group continued to independently perform intensive, dynamic water
training even though this was not offered as a service through the study.
All but one subject in the training group rated the long-term benefits of
the 1x/week training as "important" or "rather
important." Jentoft
et al [6] examined the effects of pool-based (PE) and land-based (LE)
exercise programs on patients with fibromyalgia. The outcomes were
assessed by the Fibromyalgia Impact Questionnaire, the Arthritis
Self-Efficacy Scale, and tests of physical capacity. After 20 weeks,
greater improvement in grip strength was seen in the LE group compared
with the PE group, although both improved. The results were mainly
unchanged at 6 months follow-up. Green
and colleagues [7] assessed the treatment effectiveness of home exercise
alone versus the effectiveness of home exercises plus hydrotherapy for
osteoarthritis of the hip. The authors examined range of motion
(goniometry) muscle strength (dynamometry), and functional abilities
(transfer times, walking speed and number of steps required for a fixed
distance, and stairclimbing/descent speeds). Weeks 0-6 were used to
establish a baseline. There was no significant difference of any
parameters over this period. Weeks 9-12 were used to examine treatment
effects compared to the baseline information. Subjects in both Group 1 and
2 showed highly significant improvement in the combination of parameters
tested. Final visit: This improvement continued over the next 6 weeks and
the final assessment (week 18) showed marked improvement over control
values for both the land only and the aquatic plus land groups. The
elements most effected by both interventions were joint stiffness, hip
external rotation, hip abduction power/endurance, the number of steps
necessary to travel a distance and to ascend/descend a set of steps. The
authors found no significant difference in the treatment results obtained
by the self-treatment group and the self-treatment plus hydrotherapy
group. However, this was not a comparative study. Conclusion References 2.
Danneskiold-Samsoe B, Lyngberg K, Risum T, Telling M. The effect of water
exercise therapy given to patients with rheumatoid arthritis. Scand J
Rehabil Med . 1987; 19(11): 31-35. 3.
Bacon MC, Nicholson C, Binder H, White PH. Juvenile rheumatoid arthritis:
aquatic exercise and lower-extremity function. Arthritis Care Res. 1991;
4(2): 102-105. 4.
Templeton MS, Booth DL, O' WD. Effects of aquatic therapy on joint
flexibility and functional ability in subjects with rheumatic disease. J
Orthop Sports Phys Ther. 1996; 23(6): 376-381. 5.
Stenstrom CH, Lindell B, Swanberg E, Swanberg P, Harms-Ringdahl K,
Nordemar R. Intensive dynamic training in water for rheumatoid arthritis
functional class II - a long-term study of effects. Scand J Rheumatol.
1991; 20: 358-365. 6.
Jentoft ES, Kvalvik AG, Mengshoel AM. Effects of pool-based and land-based
aerobic exercise on women with fibromyalgia/ chronic widespread muscle
pain. Arthritis Rheum. 2001; 45(1): 42-47. 7.
Green J, McKenna F, Redfern EJ, Chamberlain MA. Home exercises are as
effective as out-patient hydrotherapy for osteo-arthritis of the hip. Br J
Rheumatology. 1993; 32(9): 812-815.
Part
III (back
to top) Throughout
this five-part series, we will test the idea that aquatic therapy is an
effective treatment for the impairments, functional limitations and
disabilities commonly associated with rheumatic diseases. Building
a Case for Treating Rheumatologic Patients with Aquatic Therapy Hypothesized
Benefits Hypothesis Building
an argument Thermal
energy (heat) is exchanged between water and the body and between air and
the body.4 Energy exchange between a submerged body and the water occurs
through both convection and conduction.4 Convection
creates thermal shifts more rapidly than does conduction, but requires
movement of water across the skin or movement of the body through water to
occur. Convection
transfers heat in the direction of the lower temperature. If the water
temperature is warmer than thermoneutral, thermal energy is transferred to
the skin or "outer shell" of the body and is then shuttled to
the thorax or "core" via the venous system. Conduction,
unlike convection, occurs due to physical contact between the water and
the body, and does not required movement within the water to occur.
Immersion alone in water warmer than the skin results in conduction of
thermal energy from the water to the body's shell, and eventually, to its
core. Thermal
energy is also exchanged between the body and the air through radiation
and evaporation — methods which become more critical if the total body
is immersed and the water temperature prevents heat dissipation from
occurring during aquatic exercise.4 Immersion
in water warmer than the skin will result in a rise in superficial tissue
temperature which creates a palliative effect like that experienced during
the therapeutic use of paraffin, Fluidotherapy® and moist heat.5 The
mechanism of pain relief may come from one of several phenomena. The
application of external heat may: 1)
Create reflex mechanisms by stimulating cutaneous afferents, creating a
"soothing counterirritant effect;"1,5 2)
inhibit gamma motor (efferent) firing, which lowers the stretch on the
muscle spindle, which then reduces the afferent firing from the spindle.1
The reduction in the "walled off effect" or muscle guarding
would permit blood flow to restore normal oxygenation of tissues and
removal of chemical irritants (wastes) which would enhance nutrition,
diminish stiffness, and decrease ischemia-induced pain;6,7 3)
penetrate the surface deep enough to elevate the temperature of muscle
spindles and golgi tendon organs, thus decreasing their firing rate (via a
reduction in discharge of secondary muscle spindle afferents).1 The
reduction in the "walled off effect" or muscle guarding would
permit blood flow to restore normal oxygenation of tissues and removal of
chemical irritants (wastes) which would enhance nutrition, diminish
stiffness, and decrease ischemia-induced pain;6,7 4)
stimulate thermal receptors which create impulses which then travel on A
delta and C nerve fibers to the spinal cord. This thermal input inhibits
pain impulses (traveling on the same A delta and C fibers) before pain
input reaches synapses in the spinal cord; 5)
accelerate both metabolic functions (of cells) and circulation of blood
and lymph.1 This increases oxygenation of ischemic muscles and promotes
elimination of the chemical irritation of waste which then decreases
muscle ischemia and toxemia and decreases sensation of pain.6,7 II.
Clinical research Green
and colleagues assessed the treatment effectiveness of home exercise alone
versus the effectiveness of home exercises plus hydrotherapy for
osteoarthritis of the hip.8 Subjects had a median age of 67 years. Group 1
received instruction in home exercises only. These 5 exercises were: leg
swinging (flexion/extension and abduction/adduction), an internal rotation
hip stretch, resisted standing hip abduction, and "raising the trunk
upwards off the affected leg." Group 2 received the same home
exercise instruction, but additionally attended hydrotherapy 2x/week.
Among other parameters, the authors examined pain (visual analog scale),
descriptive pain scale, and the amount of pain medicine consumed. Subjects
in both Group 1 and 2 showed highly significant improvement in the
combination of parameters tested. Final visit: This improvement continued
over the next 6 weeks and the final assessment (week 18) showed marked
improvement over control values for both the land only and the aquatic
plus land groups. The authors found no significant difference in the
treatment results obtained by the self-treatment group and the
self-treatment plus hydrotherapy group. However, this was not a
comparative study. Meyer
and Hawley examined the relative characteristics of patients who
participated in aquatic exercise versus those who did not.9 Patients who
participated in an aquatic exercise class were in significantly less pain
than those who did not. This phenomenon can be explained with one of two
reasons: 1) the more involved patients (those with a higher baseline of
pain) did not choose to participate in a water-exercise class and thus
were overly represented by the non-exercise group; or 2) the patients who
exercised in the water experienced a subsequent reduction in pain, which
then resulted in a lower pain score than their non-exercising
counterparts. With more study, it will be possible to determine which
reason created the difference. Templeton,
Booth and O'Kelly did find a significant decrease in subjective rating of
pain (ten-point pain scale) over baseline in patients who participated in
a 45-minute, 2x/week, 8-week aquatic exercise class taught in 91d
Fahrenheit water.10 The researchers statistically assessed the effects of
that reduction in pain and found that this reduction was at least
partially responsible for a subsequent significant improvement in hip,
ankle, wrist and shoulder active ROM. The researchers were unsure which
elements of "aquatic intervention" were responsible for the
reduction in pain, and suggested future studies which teased-out the
relative contributions of immersion alone, exercise alone, and alterations
in lifestyle (such as change in medications) which occurred during the
trial period. McNeal
hypothesized that the decreased subjective complaints of pain in
populations with rheumatic diseases result from the additional sensory
input received from the temperature of the water in combination with
turbulence and pressure.11 Furthermore,
the literature indicates that aerobic exercise positively affects mood
(which affects pain) through the mediating effects of beta endorphins and
other factors.12-16 The well-known fragment of amino acids
"61-69" (beta-endorphin) is only one of over 18 molecules found
naturally in the brain which have strong pain palliation effects.17 These
analgesic brain peptides are affected by levels of activity and should
respond similarly to exercise performed in an aquatic- or land-based
setting. As it is possible that the hemodynamic shifts which occur with
immersion may affect brain chemistry, this assumption should be made
cautiously until further research is done. References 2
Christie JL, Sheldahl LM, Tristani FE, Wann LS, Sagar KB, Vevandoski SG,
Ptacin MJ, Sobocinski KA, Morris RD. Cardiovascular regulation during
head-out water immersion exercise. J Appl Physiol. 1990;69(2):657-664. 3
Sagawa S, Shiraki K, Yousef MK, Konda N. Water temperature and intensity
of exercise in maintenance of thermal equilibrium. J Appl Physiol.
1988;65(6):2413-2419. 4
Walsh M. Hydrotherapy: the use of water as a therapeutic agent. In:
Michlovits SL, Wolf S (eds). Thermal Agents in Rehabilitation.
Philadelphia, PA: FA Davis Company; 1986:119-139. 5
Michlovitz SL. Biophysical principles of heating and superficial heat
agents. In: Michlovits SL, Wolf S (eds). Thermal Agents in Rehabilitation.
Philadelphia, PA: FA Davis Company; 1986:99-118. 6
Whitney SL. Physical agents: heat and cold modalities. In: Scully RM,
Barnes MR (eds). Physical Therapy. Philadelphia, PA: JB Lippincott
Company; 1989:848-849. 7
Warren CG. The use of heat and cold in the treatment of common
musculoskeletal disorders. In: Kessler RM, Hertling D. Management of
Common Musculoskeletal Disorders. Philadelphia, PA: Harper and Row; 1983. 8
Green J, McKenna F, Redfern EJ, Chamberlain MA (research article). Goldby
LJ, Scott DL (editorial). Home exercises are as effective as outpatient
hydrotherapy for osteoarthritis of the hip. British Journal of
Rheumatology. 1993;32(9):812-815 and editorial, 771-773 (The way forward
for hydrotherapy). 9
Meyer CL, Hawley DJ. Characteristics of participants in water exercise
programs compared to patients seen in a rheumatic disease clinics.
Arthritis Care Res. 1994;7(2):85-89. 10
Templeton MS, Booth DL, O'Kelly WD. Effects of aquatic therapy on joint
flexibility and functional ability in subjects with rheumatic disease. J
Orthop Sports Phys Ther. 1996;23(6):376-381. 11
McNeal RL. Aquatic therapy for patients with rheumatic disease. Rheum Dis
Clin North Am. 1990;16(4):915-929. 12
Stein PN, Motta RW. Effects of aerobic and nonaerobic exercise on
depression and self-concept. Percept Mot Skills. 1992; 74(1): 79-89. 13
Dua J, Hargreaves L. Effect of aerobic exercise on negative affect,
positive affect, stress, and depression. Percept Mot Skills. 1992; 75(2):
355-361. 14
Coyle CP, Santiago MC. Aerobic exercise training and depressive
symptomatology in adults with physical disabilities. Arch Phys Med Rehabil.
1995; 76(7): 647-652. 15
Byrne A, Byrne DG. The effect of exercise on depression, anxiety and other
mood states: a review. J Psychosom Res. 1993; 37(3): 565-574. 16
Moore KA, Blumenthal JA. Exercise training as an alternative treatment for
depression among older adults. Altern Ther Health Med. 1998; 4(1): 48-56. 17
Liska K. Drugs and the Human Body: Implications for Society. 2nd ed. New
York: Macmillan Publishing Company; 1986:117-118
Part
IV (back
to top) Throughout
this five-part series, we will test the idea that aquatic therapy is an
effective treatment for the impairments, functional limitations and
disabilities commonly associated with rheumatic diseases. Building
a Case for Treating Rheumatologic Patients with Aquatic Therapy Hypothesized
benefits Hypothesis Building
an Argument Richley
Geigle et al argue that somatosensory input is increased more by moving an
object through a viscous liquid than by moving through a less viscous gas
(air). They postulate that resistance to movement may "cause
distention or stretch of the skin resulting in stimulation of rapidly
adapting mechanoreceptors, perhaps contributing to better proprioception."1
A
body immersed is surrounded by a viscous fluid which retards the speed of
movement. This viscosity prevents rapid falling and elongates the period
of time in which a patient can respond to a shift of his center of mass
outside his base of support. Additionally,
the natural end result of a loss of balance which is not corrected is a
fall into a compliant fluid (water) and not a fall to a noncompliant solid
(the ground). Thus, the patient may be challenged to move outside his base
of support without fear of traumatic consequences. This
reduction in patient anxiety may encourage the patient to attempt tasks
which he would not attempt on land. It becomes possible to elicit balance
challenges which the patient has both time and mental confidence to
combat. On land, without the assistance of such aquatic properties, the
resultant balance responses may be incomplete or absent. Water
offers a three dimensional environment of both support and resistance. Any
object with a specific gravity of less than one will tend to float toward
the surface of the water. Alternatively, any object with a specific
gravity less than one will sink. According
to Richley Geigle et al, these forces combine to "create multiple
combinations of joint angles and planes of motion which are assisted,
supported or resisted to various degrees. The therapist may use these
combinations in the water to challenge the patient beyond his or her limit
of stability, without the fear of the consequences of falling which are
often present with land-based balance training."1 II.
Clinical Research Conclusion References 2.
Simmons, V., & Hansen, P.D. (1996). Effectiveness of water exercise on
postural mobility in the well elderly: An experimental study on balance
enhancement. Journal of Gerontology, 51A(5), M233-M238.
Part
V (back
to top) Throughout
this five-part series, we will test the idea that aquatic therapy is an
effective treatment for the impairments, functional limitations and
disabilities commonly associated with rheumatic diseases. Building
a Case for Treating Rheumatologic Patients with Aquatic Therapy Hypothesized
Benefits Hypothesis Building
the Case Objects
with specific gravity less than water float, and those with specific
gravity greater than water sink. Objects with specific gravity near the
value of water hover just below the surface. The human body has elements
which tend to sink (dense muscle) and elements which tend to float (fatty
tissue and air-filled lungs). This
tendency to float counterbalances gravity and supports the body, resulting
in an apparent reduction in weight. This reduction in weight can provide
relief from compressive forces on painful joints. It is therefore possible
for a person to stand, even walk, with reduced pain without external
support or abnormal protective mechanisms in the water. Thus, the patient
can initiate "normal" weight bearing tasks such as gait,
transfers, and balance drills in the water and offset any deconditioning
effects of immobility or reduced movement. II.
Clinical research As
the level of immersion increased, both MSA and EMG activity decreased
proportionally as weight bearing diminished. With immersion to the
cervical spine, both MSA and EMG became almost absent. In other words, the
subjects' calf muscles became less active in a buoyant environment. In
effect, the calf muscle responsible for maintaining upright posture in a
gravity-based environment had diminished responsibilities. Additionally,
as the level of immersion was increased, the sympathetic activity of the
skin on the sole of the foot decreased. With immersion to the cervical
spine, the SSA showed a marked and proportional decrease in activity.
Translated, this means that although immersion results in less motor
activity for postural muscles such as the calf, it also results in less
sensory input to the skin (and probably joint) receptors which record
weight bearing. Weight
bearing may be systematically reduced by increasing the amount of the body
submerged.3,4 A study by Harrison and Bulstrode measured static weight
bearing in a pool using a population of healthy adults.3 Results indicated
that weight bearing during immersion was reduced to less than land-based
weight. Immersion to C-7 levels reduced weight bearing to 5.9%-10% of
actual total body weight. Immersion to the xiphosternum reduced weight
bearing to 25%-37% of actual total body weight. Immersion to the level of
the anterior superior iliac spine (ASIS) reduced weight bearing to 40%-56%
of actual total body weight. The researchers reported that variations in
gender, physical build and body composition of subjects only minimally
effect weight bearing values. A
follow-up study by Harrison, Hillma, and Bulstrode compared weight bearing
during immersed standing, slow and fast walking.4 During static standing,
immersion to the groin resulted in up to a 25% reduction of weight
bearing. When immersed to the mid-trunk, subjects experienced between a
25-50% reduction in weight. When immersed to the clavicle, weight bearing
was reduced to between 50-75% of normal. Immersion above the clavicle
resulted in almost complete loss of weight bearing. During
slow walking, subjects had to be immersed to the ASIS before weight
bearing was reduced to 75% of normal. When immersed to mid-trunk during
slow walking, weight was further reduced to 50-75% of normal. Immersion to
the clavicle during slow walking reduced weight bearing up to 50% of
normal values, and immersion above the clavicle resulted in weight bearing
25% of normal or less. During
fast walking, mid-trunk immersion produced weight-bearing up to 75% of
actual weight. Subjects had to be immersed deeper than the xiphosternum
during fast walking in order for weight bearing to be less than 50% and
deeper than C-7 for weight bearing to be less than 25% of normal values.
Harrison, Hillma and Bulstrode warn clinicians to be especially cautious
during rapid water walking which can produce up to 50% weight bearing even
when the patient is immersed to the xiphosternum. Results from their 1992
study showed that the percent weight bearing during walking was much
higher (up to 76% higher) than static standing at the same immersion
level. Conclusion Weinstein
reported that reduced joint compression and reaction forces were partially
responsible for symptom reduction in a population of adults with various
forms of arthritis who participated in a group aquatic exercise class.5 McNeal
suggested that buoyancy provides an environment which allows for decreased
muscle activity promoting muscle relaxation as well as decreased joint
compression.6 It is evident that patients with rheumatic complaints may
find the water a safe and comfortable environment in which to work. References 2
Mano T., Iwase S., Yamazaki Y., Saito M. Sympathetic nervous adjustments
in man to simulated weightlessness induced by water immersion. (1985).
Sangyo Ika Diagaku Zasshi. 7 (Suppl): 215-227. 3.
Harrison R.A., Bulstrode S. Percentage weight bearing during partial
immersion in the hydrotherapy pool.(1987). Physiother Practice. 3: 60-63. 4.
Harrison R.A., Hillma M., Bulstrode S. Loading of the lower limb when
walking partially immersed: implications for clinical practice. (1992).
Physiotherapy. 78(3): 164-166. 5.
Weinstein L.B. The benefits of aquatic activity. (1986). J Gerontol Nurs.
12(2):7-11. 6.
McNeal R.L. (1990). Aquatic therapy for patients with rheumatic disease.
Rheum Dis Clin North Am. 16(4):915-929. Disclaimer Allen Physical Therapy |
