Case directed therapeutic aquatic exercise in
musculoskeletal diseasesUrs N. Gamper, PT, CH-ValensInternational Congress 2016Comprehensive Aquatic Therapy put into PracticeSantiago de Querétaro, October 31, 2016
Topics
� Characteristics of musculoskeletal diseases� Assessments and measurements� Attendant treatment in msk diseases� Delayed and protective muscle activity� Why water � Actual evidence for aquatic exercises in msk
diseases� Characteristics of fascia's and how we can treat it’s
with Bad Ragaz Ring Method®
Musculoskeletaldiseases
specific undifferentiated non specific
specific intervention
like: SurgeryDMARD
Antibiotics
Diagnosticchallenge:Teamwork Doctors
Therapists
non specificintervention
like:Multidimen-
sionalapproach
Chronic musculoskeletal diseases in aquatic therapy
� Low back pain� Osteoarthritis� Osteoporosis� Rheumatoid Arthritis� Spondylitis ankylosans� Fibromyalgia� Myofascial pain syndrome
Pain and pain related limitations of daily
activities and participation
Maintaning functional capacity over life course
Health problem
Rehabilitatio n
Integrated behavioural on neuromuscular explanation of activity limitations in musculoskeletal diseases
Neuromuscular model
Behavioural model
Pain during activity Psychological distress
Avoidance of activity
Muscle and soft tissue weakness
Pain during activity
Poor proprioception
Laxity/Stiffness
Accessory movement
Activity limitationsAdapted from Dekker J: Springer 2014
International classification of functioning, disability and health (ICF) and aims of interventions in muskuloskeletal-diseases
Reduction of symptomsReduce painImprove mobility
- Joint / Nerves- Soft tissue
Improve enduranceImprove muscle forceImprove postural control
Reduction of ADL limitationsImprove mobility
- Changing and maintaining body positions- Walking and moving
Improve self careImprove domestic life
- Household tasksImprove major life areas
Source: WHO http://apps.who.int/classifications/icfbrowser/
Rehab Cycle and outcome measurements
Identify problems and needs
Relate problems to modifiable and limiting factors
Define target problems and target mediators, select appropriate measuresPlan, implement and
coordinate the interventions
Measure the effect
Measurements has to measure on:� Body function
� Activity and Participation
Measurements must be:� metric
� sensitive
� reliable
Stucky G, Sangha O, Principles of Rehabilitation. In: Klippel JH, Dieppe PA, eds. Rheumatology, 2nd ed. Mosby:1998
Pain neuroscience education (PNE)
13 RCT, PEDro Scala 7-10
Content of PNE:� Neurophysiology of pain� Nociception and nociceptive pathways� Synapses and action potentials� Spinal inhibition and facilitation� Peripheral and central sensitization� Plasticity of the nervous system� Psychosocial factors and beliefs contributing to pain
� No reference of anatomic or patho-anatomic models� No discussion of the emotional or behavioural aspects of pain
The efficacy of pain neuroscience education on musculoskeletal pain: A systematic reviewLouw A et al. Physiotherapy Theory Practice, 2016; 32: (5), 332-55
The efficacy of pain neuroscience education on musculoskeletal pain: A systematic reviewLouw A et al. Physiotherapy Theory Practice. 2016;32(5),332-55
A key element of “teaching people about pain” appears to be the combination of education with active/movement strategies. A conceptual framework of kinesthetic education must be consistent with and reinforces pain neuroscience education. They also provide some specific guidance for integrating pain neuroscience education with exercise and movement in a more congruent manner, enhancing the effectiveness of specific movement approaches such as graded exposure techniques. What is often overlooked, however, is the consistency between the messages of pain neuroscience education and those of other therapeutic interventions, including movement therapies. The addition of guided purposeful movement performed in a manner consistent with pain neuroscience education may be vital to the desired behavioral changes, and when inconsistent messages are delivered between education and movement interventions, outcomes may be adversely impacted.
Is there a role for transversus abdominis in lumbo-pelvic stabilityHodges PW. Manual Therapy. 1999;4(2):74-86
Adapted from: Cresswell AG et al. Exp Brain Res. 1994;98:336-41
unexpectedexpected
Leg muscles movement
Back muscle dysfunction during remission from recurrent back painMacDonald D et al: Pain. 2009, 142(3):183-88
Healthy
LBP
Shoulder Flexion Shoulder Extension
○ □ healthy people● ■ recurrent episodes unilateral low back pain
SF
SF
LF
LF
Gait parameters and muscle activation patterns afte r 3, 6, 12 month after total hip arthroplastyAgostini V et al. J Arthroplasty. 2013;29(6):1265-72
arthroplasty sound
Why Aquatic Therapy
Physical properties
Water is a newenvironment (Tasks)
Rules of exercise physiology
Patient needs
Patho-physiology
� Buoyancy� Hydrostatic pressure� Viscosity� Waves� Turbulences� Temperature
Physical properties
Harrison RA et al. Physiotherapy Practice. 1987,3:60-63 and Physiotherapy.1992;78(3):164-66
0
10
20
30
40
50
60
70
80
90
100
ASIS Proc. Styl. C-7
stand
s. walk
f. walk
Percentage of weight-bearing during partial immersion in the hydrotherapy pool
How we can influence muscular activity in the pool?
� Turbulences
� Waves
� Flotation aid
� Depth
� Surface
� Body shape
� Radius
� Speed
� Problem solving strategy- Change in neuro-motor behaviour- Different compensation strategy (land/water)- Balance reactions (strategy and time)
� Increase of sensory input� No risk to fall
Water as a new Environment (new tasks)
Aquatic Therapy is recommended in several clinical Guidelines
� EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritisFernandes L et al. Ann Rheum Dis. 2013;72:1125-1135 doi:10.1136/annrheumdis-2012-202745
� EULAR revised recommendations for the management of fibromyalgiaMacfarlane GJ et al. Ann Rheum Dis. 2016; doi:10.1136/annrheumdis-2016-209724
� 2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitisJ Braun, et al. Ann Rheum Dis. 2011;70:896-904 doi:10.1136/ard.2011.151027
� An updated overview of clinical guidelines for the management of non-specific low back pain in primary careKoes BW et al. Eur Spine. 2010;19(12):2075–2094 doi:10.1007/s00586-010- 1502-y
Systematic Review
Aquatic exercise for the treatment of knee and hip osteoarthritisBartels EM et al. Cochrane. 2016;3: doi:10.1002/1465858.CD005523.pub3
13 RCs 1190 participants, mean duration OA 6.7 y, mean duration aquatic exercise 12 weeks (6-20)
Paracetamol SMD 0.18 (0.11-0.25), NSAR SMD 0.37 (0.26-0.49)McAlindon TE et al. Osteoarthritis and Cartilage. 2014:22(3):363-88
doi:10.1016/j.joca.2014.01.003.
Total 538 537 -0.31 (-0.47, -0.15)
Outcome: Pain
Aquatic exercise for the treatment of knee and hip osteoarthritisBartels EM et al. Cochrane. 2016;3: doi:10.1002/1465858.CD005523.pub3Disability
QoL
Total 529 530 -0.32 (-0.47, -0.17)
Total 493 478 -0.25 (-0.49, -0.01)
Effectiveness of aquatic exercises for musculoskeletal conditionsBarker AL et al. Arch Phys Med Rehabil 2014;95:1776-86
OA
RA
FM
LBP
-0.31 (-0.5,-0.13)
0.00 (-0.47,0.47)
-1.02 (-1.65,-0.38)
-0.74 (-1.68, 0.20)
Total (95%CI) 586 603 - 0.37 (-0.56,-0.18)
Pai
n: A
quat
ic e
xerc
ise
vs. n
o ex
erci
ses
Aquatic exercise no exercise
Effectiveness of aquatic exercises for musculoskeletal conditionsBarker AL et al. Arch Phys Med Rehabil. 2014;95:1776-86
Out
com
e P
hysi
cal F
unct
ion:
aqu
atic
vs.
no
xerc
ises OA
RA
FM
Osteoporosis
0.32 (0.10,0.54)
0.22 (-0.25,0.699)
0.63 (0.20,1.00)
0.36 (-0.88,0.16)
Total (95% CI) 581 573 0.32 (0.13,0.51)
No exercises Aquatic exercises
The benefits of a high-intensity aquatic exercise program (HydrOS) for bone metabolism and bone mass of postmenopausal womenMoreira LD et al. J Bone Miner Metab, 2014;32(4): 411-19
Femoral trochanter BMD P1NP (Bone formation marker)
N=108, EG 64, CG 44, CG normal physical statusEG High intense AE 24 weeks 3/w 50-60 min. Intensity mod. Borg Scale 5-9
Early aquatic physical therapy improves function an d does not increase risk of wound-related adverse events for adults after orthopaedic surgeryVillalta EM et al. Arch Phys Med Rehabil. 2013;94:138-48
Effect of ADL
Adverse effect
Total (95% CI) 146 144 0.01 (-0.05,0.079
Start with Aquatic Therapy4 days after surgery
Total (95% CI) 115 119 0.33 (0.07,0.58)
Postoperative Rehabilitation of Patients with Shoul der Arthroplasty ? A Review on the Standard of CareKraus M et al. Intern J Phys Med Rehabil. 2014;S5:001. doi: 10.4172/2329-9096.S5-001
Ideal for individualized Aquatic Therapy
Muscle Test 30°°°°/S 60°°°°/S 90°°°°/S
Supraspinatus LandWater
16.683.93
p=.015
17.465.71
p=0.15
22.7927.32
p=0.73
Infraspinatus LandWater
11.102.28
p=.0325
10.762.89
p=.0524
15.0321.06
p=.5566
Subscapularis Land Water
5.961.49
p=.0072
6.832.26
p=.0346
7.4510.73
p=.2421
Anterior deltoideus
Land Water
15.883.61
p=.0047
18.824.49
p=.0273
22.0932.83
p=.3273
Percentage of maximal voluntary contraction
Shoulder muscle activation during aquatic and dry land exercises in no impaired subjectsKelly B et al. J Orthop Sports Phys Ther. 2000;30(4):204-10
Effects of aquatic resistance training on mobility limitation and lower-limb impairments after knee replacementValtonen A et al. Arch Phys Med Rehabil. 2010;91(6):833-39
N=50, E 26 C 24 unilateral knee replacement, time since surgery: 9 month,2/w 45 progressive aquatic exercises RPE 12-16, HydroBoots, 12 weeks, CG no inervention
Fascial treatment in the
pool?
Sensory findings after stimulation of the thoracolu mbar fascia with hypertonic saline suggest its contribut ion to low back painSchilder A et al. Pain. 2014;155:222-31 doi:10.1242/jeb.112268
12 healthy subjects
Hypertonic saline 5.8%
Fascial adaptation to lifestyle
Schleip R Ed. 2015 Fascia in sport and movement. HandspringMod. after Reeves ND et al. Exp Physiol. 2006;91:483-98
Plyometric training effects on Achilles tendon stif fness and dissipative propertiesFouré A et al. J Appl Physiol, 2010;109:894-54 doi:10.1152/japplphysiol.01150.2009.
n=19, (EG 9, CG 10) 14 w/ 2/w 60 minutes EG diff. jumping exercises CG normal daly activity
EGpretestposttest
CGpretestposttest
Muscle-tendon-unit activity during counter-movement and no counter-movementSchleip R et al. J Bodyw Mov Ther. 2013;17(1):103-15
Kawakami Y et al. J Physiol, 2012; 540.2:635-46 DOI:10.1113/jphysiol.2001.013459
Oscillatory movement with recoil properties
conventional muscle training
Human Achilles tendon plasticity in response to cyc lic strain: effect of rate and durationBohm S et al. J Exp Biol. 2014; 217: 4010-17 doi:10.1242/jeb.112268
Referenc 4x
high strain rate72 jumps
long strain duration1x
14 weeks, 4/w, leg press 90% 1RM)
Reference protocol Long strain duration
*p=0.009ǂp=0.081
*p<0.008
P=0,002
P<0.05
Loading of different facial componentsSchleip R et al. J Bodyw Mov Ther. 2013;17(1):103-15
Effect of fascia training on collagen turnover
Schleip R Ed. in Fascia in sport and movement, Handspring 2015Magnusson SP et al. Nat Rev Rheumatol. 2010;6:262–68 doi:10.1038/nrrheum.2010.43
The pathogenesis of tendinopathy: balancing the response to loadingMagnusson SP et al. Nat Rev Rheumatol, 2010;6:262–68 doi:10.1038/nrrheum.2010.43
a) 36 km runningb) 1 h max. knee kickingc) 10 times 10 repetition
(70% 1 RM)
Fascial training
� Soft tissue stretching� Rebound elasticity
• Tendon: high load, 70% 1 RM oscillatory recoil like slow jumping
• Intramuscular Fascia: low load, 30% 1 RM slow, dynamic, fluidly
� Fascial release• Manual techniques
� Fluid refinement• Free movements in al directions
Schleip R et al. J Bodyw Move Ther. 2013;17(1):103-15 doi:10.1016/j.jbmt.2012.06.007
Fascial training use BRRM ®: soft tissue stretching
Fascial training use BRRM ®: soft tissue stretching
Fascial training use BRRM ®: rebounding elasticity
Fascial training use BRRM ®: soft tissue stretching
Questionsand try it’s in the
pool