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Spine Rehabilitation and Core Strengthening in the Aquatic Environment
Lori Thein Brody, PT, PhD, SCS, ATC
Lori Thein Brody is currently the Orthopaedic and Sports Science Graduate Program Director for Rocky Mountain University in Provo, Utah. She also works as a Physical Therapist and Athletic Trainer at the UW Health Sportsmedicine and Spine Center in Madison, WI. She has taught in physical therapy education programs at Ithaca College and the University of Wisconsin, Madison. Dr. Brody has lectured extensively across the country on management of orthopaedic and sports related injuries, aquatic physical therapy, arthritis and other connective tissue problems and musculoskeletal primary care. She has numerous articles and chapters to her credit and along with Carrie Hall, she co-authored Therapeutic Exercise: Moving Toward Function, (Lippincott Williams and Wilkins) now in its third edition. She also co-edited Aquatic Exercise for Rehabilitation and Training (Human Kinetics Publishers) with Paula Geigle. She served on the Musculoskeletal Panel for Volume II of the Guide to Physical Therapist Practice, and on the Guide to Physical Therapist Practice Task Force, Volume III. She also served on the American Board of Physical Therapy Specialties, including serving as its chair. She also served on and chaired the Committee for the Credentialing of Post-Professional Clinical Residencies and Fellowships. She is the 2006 recipient of the Ron Peyton Award from the Sports Physical Therapy Section.
Abstract Increasing core muscle strength and function forms the basis of many rehabilitation and conditioning programs, whether the focus is on the ankle, knee, hip, spine or shoulder. The core provides a stable base upon which the limbs and spine produce efficient and coordinated movement. A poorly functioning base can lead to a multitude of problems whether acutely or cumulatively over time. While core muscle activities on land can be robust in producing results, many individuals are unable to effectively train the core due to a variety of factors. The pool provides an alternative environment with numerous opportunities for improving core muscle strength and function. Aquatic activities can improve core function to a level where the client can transition to land, or it can be an alternative training site for those desiring a break from land-based activities. This presentation will discuss a continuum of training activities for the core muscles. Correct exercise performance, as well as examples of modifications for pathology will be discussed. Case examples will serve to demonstrate implementation and integration.
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Aquatic Therapy:
Spine Rehab and Core Strengthening
Objectives
Understand fundamentals of spine structure and related biomechanics
Understand interdependence of hip, pelvis and lumbar spine
Describe how core muscles are activated with various exercises
Design an exercise program to strengthen core for persons of varying abilities
Outline
Introduction Anatomy/mechanics Exercise examples Precautions Conclusions
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 2
Who benefits?
Postural dysfunctionMechanical pain
C, T, LS/p surgerySprain, strainDDD, DJDSpondylolisthesisFracture, osteoporosis
Who?
People who need:– Buoyancy
unloads spine decreases loads across joints
– Assistance allows weaker muscles to move limbs
– Gait assistance Gait retraining in ms/nm conditions Early weightbearing
Why?
Relief of WB Unloading spinal
joints Ease of movement Normalize
movements Normalize gait Relaxation
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 3
Evidence: Core Strength1-4
Decreased core strength:– Risk factor for LE injuries in sports– Assoc. w/ low back pain
Trunk ms activity occurs prior to LE, suggesting that this activity stiffens spine to provide a solid base of support for the LEs
Evidence: LBP6
Recent systematic review found evidence to suggest that therapeutic aquatic exercise potentially beneficial in the treatment of LBP
Evidence: LBP7
Recent RCT in CLBP found that aquatic therapy produced signif greater improvements in many functional measures than land-based
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 4
Rationale
Many people unable to assume positions necessary for ex on land
Initiate rehab sooner
Prevent secondary problems
Functional positions
Anatomy
Cervical and lumbar: convex anteriorly
Thoracic and sacral: convex posteriorly
Anatomy
Intervertebral disc Facet joints Transverse
processes Spinous processes
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 5
Biomechanics
Lumbar spine:– IVD and vertebral
bodies are primary load bearing structures
– Facet joints carry small loads
Biomechanics
As IVD fails, disc height is lost and facet joints increase WB loads
Facet joints loaded in extension and rotation; avoid in facet disease
Biomechanics
Trunk flexion: shifts loads away from facet joints to posterior ligaments & IVD
Slight flexion is preferred posture for those with facet disease
But too much flexion increases pain!
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 6
Biomechanics
IVD failure Bulging or herniated
discs can place pressure on nerve roots
Disc collapse increases facet pressure & DDD
Mechanics application
Flexion increases anterior compression and opens posteriorly, decreasing facet compression, but increases posterior pressure
Mechanics application
Lumbar extension: compresses facet joints; potentially compresses disc herniation,
but used to treat herniation in post acute phases
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Mechanics application
Rotation: loads facet joints, especially in neutral or extension
Rotation accomplished at hips or higher in spine
So should you do rotation exercises?
As with most things in life: “it depends”
Rotation
Important in most aspects of function
Mechanics application
What about hip extension exercises?
Normal = 15 degrees
0ver 15 degrees is spine
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 8
Leg lifts backwards
Watch hip extension ROM
Anything beyond 15 degrees (normal) is coming from spinal extension
Closing/compressing facets
Avoid pelvic rocking A to P during leg lifting
Keep hip ext ROM small in upright
standing
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 9
Spine/Core Training & Mobility
Why is mobility important?
What mobility should I emphasize?
Importance of Mobility
The body is designed to move Trunk, hip and pelvis must rotate for
normal movement, esp. gait If the spine lacks sufficient movement
for any reason, it must be made up elsewhere
Therefore “steal” motion from adjacent joints
Mobility activities
Directed at adjacent joints
Combination of static and/or dynamic
Combine with awareness of posture/ms activity
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National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 11
Buoyant equipment can be placed anywhere along limb to adjust the amount of stretch
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 12
Knee lift with or without trunk rotation
Walking with an exaggerated stride can enhance dynamic mobility
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 13
Core Strength
The neuromuscular ability to control the lumbopelvic region and protect the spine from injury
Requires strength, power & endurance of superficial & deep muscles
Aquatic Stabilization Ex
Rationale: spine is partially unweighted, allowing movement with less compressive force
Torque w/ less pain
Aquatic Stabilization Ex
Arm movements create turbulence that must be resisted by core– AP– Lateral– Rotational
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 14
Aquatic Stabilization Ex
Bilateral shoulder flex/ext– Creates AP sway, shorter lever– Can shorten even further by performing
elbow flex/ext
Horizontal ab/ad– Creates AP sway, longer lever
Aquatic Stabilization Ex
Shoulder abduction– Creates lateral sway when performed with
a single arm– Bilateral is simply a shoulder ex in the
absence of resistance
Reciprocal shoulder flex/ext– Creates rotation
Aquatic Stabilization Ex
Key is to resist the forces generated by holding core still
Requires nm control and kinesthetic sense of posture first
Can’t train if you can’t recruit
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 15
Progressions
Depends upon goals– Strength– NM control– Balance– Controlled mobility
Depends upon comorbidities– Shoulder problems– Trunk mobility
Video….
Progressions
Increased speed Increased surface
area Narrow base of
support Asymmetrical Eyes closed
Examples….
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 16
Adding resistance to AP sway
Wide base to….
Narrow base
Resisted walking with the addition of gloves isometrically or isotonically in a
variety of directions
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 17
Adding buoyancy-resisted exercises in a variety of patterns
to recruit core
Increasing surface area to increase resistance
Stabilization occurs on stance limb, as it stabilizes pelvis for
moving limb
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Bow & arrow ex with wide base & wide elbows OR
narrow base and arms in create different emphasis
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Long lever trunk rotation, wide BOS
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National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 21
Leg movement on fixed pelvis working
bottom up
Supine abs and hip extension
Ab press down
Supine ab curl with fixed legs
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 22
Buoyant dumbbell pull down in a variety
of postures; use w/ CV training
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 23
Leg movements in a variety of directions keeping pelvis stable
Resistive walking with plow
DW Stabilization sequence
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To ensure pelvic control prior to NWB activities
Wonder board activities
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 25
Lifting task with board
Deep water diamonds or XC
ski
Higher level activities
Mimic functional activities Hop, stick, direction changes Push-pull Complex movement patterns Lifting Advance cardio
Add more exercises Increase repetitions Increase resistance Add more sets Decrease rest interval Increase frequency
Exercise challenges Increase task complexity Change muscle contraction type Change exercise speed Change exercise mode Decrease stability of BOS Reduce feedback Alter the environment Alter exercise sequence Vary start and end position Reduce cognitive control
Progressions…..
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 26
Chronic Pain
Fibromyalgia Chronic LBP Chronic fatigue syndrome Stenosis/DDD/DJD Chronic regional pain syndrome
Chronic Pain
Pool ideal place to work
Warmth of water Unloading due to
buoyancy Ease of movement
Considerations
Avoid overwork Short lever Decreased surface
area Side step Slow movements Relaxation
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 27
Considerations
Find exercises they tolerate Balance frontal resistance vs. buoyancy Alternate exercises
– Small muscle group– Large muscle group– Upper extremity – Lower extremity– Core
Only a few reps of each
Considerations
Stick with exercises tolerated– If many, only a few reps of each– If only a few, a few reps and more sets
Increase by increasing total exercise time
Give frequent rest– Walk, relax, unweight, float
Issues
Avoid overwork Start with short
sessions Gradually increase Add resistance last
National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 28
Precautions
Overwork Effects of WB or
frontal resistance Compensatory
postural stresses
Thanks! Questions?
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National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 29
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