Aqua Therapy FOR HIPS:
for Use of Water
There is no question that the water offers a therapeutic environment which
can be harnessed by a skilled therapist to permit activities for the
postoperative patient. This environment is created because of the unique
properties of water and it is both difficult and clinically impractical to
achieve a similar environment on land. Take a moment to examine these
Archimedes' principle states: "when a body is wholly or partially
immersed in a fluid, it experiences an upthrust equal to the weight of
this upthrust, or buoyancy can be used to provide either assistance or
resistance to movement of the body. It all depends on the position of 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.
reduction in weight can provide relief from compressive forces on painful
joints. It is therefore possible for the postoperative patient to stand,
even walk, with reduced pain without external support or abnormal
protective mechanisms in the water.
the patient can initiate "normal" weight bearing tasks such as
gait, transfers, and balance drills immediately after surgery and offset
any deconditioning effects of immobility or reduced movement.
better? This reduction in compression creates an environment in which
weight bearing and joint compression can be applied in a graded or
progressive manner by the therapist. Weight bearing may be systematically
reduced by increasing the amount of the body submerged.
(standing) immersion at the level of the anterior superior iliac spine (ASIS)
reduces weight 40%-56% of normal. Be careful though: all bets are off when
the patient moves. During slow walking, patients must be immersed to the
clavicle to reduce weight bearing to 50%, and during fast walking,
patients must be immersed deeper than the xiphosternum in order to reduce
weight that much.
conclusion, buoyancy can be used to create:
decrease in weight bearing through joints; |
decrease in joint stress; |
decrease in splinting or guarding of antigravity muscles; |
increase in freedom of movement. |
can also promote ease of handling of the large or heavy patient and allow
access to body parts which would be inaccessible if the patient was
positioned on a plinth or chair.
Pascal's Law states that "Fluid pressure is exerted equally on all
surfaces of an immersed body at rest at a given depth".
essence, hydrostatic pressure increases the pressure on the outside of an
immersed standing body, resulting in:
reduction in edema in the lower extremities (by providing graduated
pressure at greater depths); |
offsetting of blood pooling in lower extremities (and thus a reduction
in the risk for postoperative clotting); |
desensitization effect (by constantly stimulating phasic receptors). |
means the postoperative patient can be relieved of some of the potential
for swelling and clotting problems associated with surgery.
Viscosity is nothing more than the inherent friction that exists between
molecules of a liquid which cause a resistance to flow. Water is more
viscous than air , thus, it takes more force to push through water
molecules than to push through air molecules.
the faster an object is pushed through the water, the more turbulence is
created and this creates additional resistance to movement.Keep in mind
that the postoperative patient has probably already lost a great deal of
proprioception for a number of reasons.
his joint has been worn-down, perhaps to bone-on-bone and has lost its
normal weight-bearing feedback capacity.
the joint is further traumatized by surgical intervention (perhaps even
sacrificing additional Golgi tendon organs and muscle spindles to the
surgeon's blade). It seems likely that movement in water can offer
patients exaggerated input from the environment -- perhaps resulting in
When an object moves through a fluid, there is an increase in the pressure
in the front of an object combined with a reduction in pressure in the
back. This results in the water wanting to move from an area of high
pressure to an area of lower pressure.
area of "negative pressure" is known as the wake. Eddy currents
form in this wake and "drag" 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
principle of flow can be used therapeutically to increase (or decrease)
the force necessary to push through the water. This property can be used
to create a progressive resistive exercise program that is
three-dimensional, velocity-specific, and safe to perform.
Refraction is the prism effect that is evident when looking from an air
medium to a water medium. Light bends when its rays move from a more dense
to a less dense substance.
of the "therapeutic" effects of refraction are negative.
Refraction decreases depth perception and makes the pool seems shallower.
It alters visual cues for both patient and provider. Patient's limbs seem
distorted (bent away), and items seem high and to the right, thus making
visual feedback and monitoring is more difficult.
the postoperative patient, it is possible to use refraction
therapeutically. For instance, while immersed, a patient with a habitual
visual method of joint placement (e.g. someone who looks at his feet to
walk) may be forced to use his proprioceptive system instead.
At temperatures above "thermoneutral" (approximately 93°
Fahrenheit at rest), body temperature increases due to the reduced ability
of the body to dissipate heat through the skin. Thermal energy (heat) is
exchanged between water and the body and between air and the body.
exchange between a submerged body and the water occurs through both
convection and conduction. 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.
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, FluidotherapyŽ and moist heat.
in thermoneutral water will produce a generalized relaxation effect
similar to that experienced with swaddling or bundling of a body part.
Considerations for the Patient who has Undergone Hip Surgery
Even though the water is an ideal
environment to tackle many problems inherent in the postoperative
population, there are still considerations of which must be considered.
We always take a moment to examine the following to ensure you will
have the best care with your aqua therapy program.
There are many potential precautions to consider for the s/p hip surgery
patient. Here are several things to consider when taking this population
into the pool:
you are uncomfortable or anxious in water, the resulting muscular
bracing and splinting may make pain worse. |
you have undergone total hip replacement surgery with a posterior
approach, extreme caution must be taken to avoid contraindicated
positions (hip internal rotation, adduction, and flexion above 90°).
The freedom of movement possible in water may allow the patient to
perform movements which should not be performed.
Any aqua therapy program for a THA patient must be approved by
the referring surgeon. |
the patient has a surgical suture site or an open wound, they will not
be permitted in the
pool. If the
patient's skin is delicate and in danger of maceration, there must be
a very compelling reason (benefit) to taking the patient into the
pool. If the wound is clean and healing and is covered with a
bio-occlusive dressing (such as Tegaderm or Op-site), there is little
risk involved in taking the patient into the pool so the benefit does
not have to be as great. If the patient is immersed, care must be
taken to thoroughly dry (via "patting" not rubbing) the
surgical site after immersion. |
and Specifics for Designing Programs
Therapists must treat the patient who has just undergone hip surgery
carefully. There are many considerations when designing an aquatic therapy
program for this population. For example:
start any new patient in water that is no deeper than he can
comfortably stand. Remember that fear can contribute to muscle
guarding which can increase pain. Provide equipment for
buoyancy-assistance (such as an aqua-stick or a floatation barbell) so
the patient does not require the assistance of the therapist to feel
provide more warm-up time at the beginning of each treatment to allow
injured/repaired joints to "warm up" (from the synovial
fluid bathing the joint). We make sure you increase progressive
resistive exercise (PRE) gradually to prevent delayed onset muscle
soreness or dislocation of a new hip. Increases in
weight-bearing are progressive by moving the patient shallower
to return the patient to functional (land-based) status as soon as
| Water temperature is least 92° Fahrenheit (thermoneutral)
for pain palliation. |
| Aerobic conditioning is not neglected in as there is a
strong relationship between aerobic exercise and pain palliation.
However, it is important to understands that your target heart rate
zone for aquatic exercise is at least 12 - 17 beats per minute lower
than its land-based counterpart. |
for Aquatic Therapy
The therapist who is not familiar with working with patients who are s/p
hip surgery may set unrealistic goals. It is important to realize that
exercise in water can be a powerful tool for the rehabilitation of hip
that would be appropriate for hip patients:
of traumatized tissues by applying graded and progressively more
taxing stresses on injured tissue; |
in strength or prevention of muscle atrophy; |
in flexibility or prevention of contractures; Improvement in posture
(upright stance through terminal hip extension); |
in ability to perform ADLs; |
in fatiguability; |
in exercise tolerance; |
in work tolerance or duration; |
of loss of cardiovascular fitness immediately after surgery; |
in complaints of pain; |
in gait parameters; |
in balance, reaction time, and safety during ambulation; |
of lower extremity blood stasis or clots. |
of Aquatic Therapy
Therapists cannot choose to place patients in the water simply because
they believe in the "power of the pool". It is important for
therapist to demonstrate through documentation that they have a solid
rationale for placing the s/p surgical patient in the water. Typical
of weight-bearing in a graded or progressive manner; |
of synovial fluid bathing of joints which decreases joint stiffness
and pain; |
of circulation which promotes healing of musculoskeletal injuries;
Retardation of muscle atrophy and contractures which may occur in the
absence of exercise; |
of the loss in cardiovascular fitness which often accompanies surgery;
in proprioceptive awareness during exercise and functional task
of resistance in a graded or progressive manner; |
of stretch of scarred tissue (s/p surgery); |
in limb movements against gravity (assisted by buoyancy); |
in joint compression forces during exercise; |
in muscle splinting and guarding from pain; |
of socialization in a "normal" recreational environment. |
Therapists who combine
excellent manual therapy skill with work in the water, have the best of
both worlds to offer patients with hip dysfunction. You see the
possibilities inherent in gravity, yes; but you delight in the
possibilities intrinsic to buoyancy, viscosity, turbulence and pressure.
The universe expands: you can offer our patient air and water, an
integration of effort and ease.
Salzman, MS, PT 1997
Allen Physical Therapy
"Hands on Treatment, Every Patient, Every Visit"
South Lyon, Michigan
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