spine rehabilitation and core strengthening in the aquatic ... · spine rehabilitation and core...

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.

National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org 1

www.nspf.org

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


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


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


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


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!


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


Lumbar extension: compresses facet joints; potentially compresses disc herniation,

but used to treat herniation in post acute phases



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


What about hip extension exercises?

Normal = 15 degrees

0ver 15 degrees is spine


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


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


Buoyant equipment can be placed anywhere along limb to adjust the amount of stretch


Knee lift with or without trunk rotation

Walking with an exaggerated stride can enhance dynamic mobility


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


Arm movements create turbulence that must be resisted by core– AP– Lateral– Rotational



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


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


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


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….


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


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


Bow & arrow ex with wide base & wide elbows OR

narrow base and arms in create different emphasis


Long lever trunk rotation, wide BOS


Leg movement on fixed pelvis working

bottom up

Supine abs and hip extension

Ab press down

Supine ab curl with fixed legs


Buoyant dumbbell pull down in a variety

of postures; use w/ CV training


Leg movements in a variety of directions keeping pelvis stable

Resistive walking with plow

DW Stabilization sequence


To ensure pelvic control prior to NWB activities

Wonder board activities


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…..


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


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


Precautions

Overwork Effects of WB or

frontal resistance Compensatory

postural stresses

Thanks! Questions?

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between hip muscle imbalance and occurrence of low back pain in collegiate athletes: a prospective study. Am J Phys Med Rehabil. 2001;80(8):572-577.

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4. Leetun D, Ireland M, Willson J, Ballantyne B, Davis I. Core stability measures as risk factors for lower extremity injury in athletes. Med Sci Sports Exerc. 2004;36(6):926-934.

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6. Waller, B., J. Lambeck, et al. (2009). "Therapeutic aquatic exercise in the treatment of low back pain: a systematic review." Clin Rehabil 23(1): 3-14.

7. Dundar, U., O. Solak, et al. (2009). "Clinical effectiveness of aquatic exercise to treat chronic low back pain: a randomized controlled trial." Spine (Phila Pa 1976) 34(14): 1436-1440.


References Nadler S, Malanga G, Bartoli L, Feinberg J, Prybicien M, DePrince M. Hip muscle

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Pollock M, Gaesser G, Butcher J, et al. ACSM Position Stand on The Recommended Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory and Muscular Fitness, and Flexibility in Adults. Med Sci Sports Exerc. 1998;30(6):975-991.

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Kinetics Publishers, 2009


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