the soothing mfects of water

7/28/2019 The Soothing Mfects of Water

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T h e S o o t h i n g M f e c t s o f W a t e rThe role of aquatic therapy in neurorehabilitation.

A q u a t i c th e r a p y i s mo r e th a n r e c r e a t io n a l t im ein the swimming pool . Increas ingly , i t i s p re -scr ibed as part of the physical therapy programfor pa t ien ts with d isab l ing neuro logica l d isor -der s . The buoyancy of wate r a l lows for grea te rf reedom of mo tion . Com orbid i t ies such as a r thr i t is and m usc leinf lammation a re a ided by the sooth ing benef i ts o f warm water .Depe nding on the ir needs , pa t ien ts can benef it f rom rega in ingrange of motion , ba lance , musc le contro l , and improved inde-pendence with func t ion and mobil i ty .

Its multiple benefits can be experienced by patients in pdiatrie,adult, and geriatr ic populations. Children with conditions such ascerebral palsy, muscular dystrophy, and developmental delays mayhave aquatic therapy in their care plans. Among adult and geriatricpopulations, common diagnoses include spinal cord injury, s troke,brain injury, and Parkinson's disease.

At Good Shepherd Rehabilitation Network, we use aquatic thera-py tor both inpatient and outpatient programs. Access is not an issue,making it a therapy that both ambulatory and nonam bulatory patientscan use. If a patient cannot enter the water using stairs, we have ahydraulic chair to get people into the water . Neurorehabilitationpatients often receive therapy on land in combination with aquatictherapy. We spend about an hour with patients in the pool each .ses-sion, but, as with other physical therapy, the benefits extend beyondthe time they spend in the water. Contraindications for aquatic thera-py include incontinence, open wounds, and uncontrolled seizures.

Aq uatic therapy offers ma ny benefits, and th e psychological boostit provides cannot be underestimated. When the fear of falling deterspatients or slows their progress on land, they can feel safe in thewater . For example, therapists may challenge patients ' balance withhigher-level exercises in the water, where falling is unlikely to causeinjury. The accomplishment of more difficult tasks builds confidence

PSYCHOLOGICAL BENEFITSAdditional psychological benefits are noted as patients realize tha

they can perform tasks in the water that they cannot do on land. Even theslightest movement can encourage the patient. Patients recognize thathey can perform activities with less support and experience an increasein independent movement when in the pool. A neurological injury odisease may confine a patient to a wheelchair, presenting a significanlifestyle change. However, they may be able to take a few more steps orreach higher since their movements are aided by the buoyimcY and sup-port of the water. A patient who needs help lifting his knee on land toaccompli.sh activities such as getting dres.sed or taking a step may be ableto do it unaided in the water. The aqua tic therapist w ho chooses activitiesto foster patient success also stimulates motivation and confidence.

When tone reduction has occurred, the rhythmic motion of thewater can help until muscles physiologically relax. Water also isgood to counteract swelling and promotes venous return.

A neurological injury or disease may confine a patient to a wheel-chair , which becomes the pr imary m eans for mobility. Independencewith vertical positioning and dynamic standing activities is of tenrestr icted when on land. In the pool, however , muscle weakness andlimitations in sustaining vertical positioning become less apparent.

A D A P T I N G T H E R A P Y F O R T H E P O O LMany land-based techn iques used by the therapist can be modified

for use in the water, and, with assistance, dynamic activities may beinitiated earlier. Ambu lation trainin g often can begin sooner when it isperformed in the water. A patient who can only stand at parallel barson land may be able to walk using the bars in the pool. For instance,paraplegics may not be functional with standin g activities on land, butcan move in water with the support of parallel bars. The therapist assistswith their stance and facilitates swing. Often, this assistance and cueingreduces or eliminates the need for bracing that is necessary on land. A


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Additional man ual cueing at the pelvis can facili-tate increased weight bearing on the affected sideand equalize steps.

The water is a good environment to practiceother jnctional m ovements, such as squatting andnegotiating a step. For som eone w ho is significant-ly weak, being in the water reduces the amount ofweight-bearing load, and promotes flexion activi-ties such as lifting up the foot and placing it on astep. The therapist may provide manual cueingat the pelvis to facilitate stepping up or steppingdown, so that comp ensatory patterns are not devel-oped. As strength im proves, the patient can m oveto more shallow water where gravity is greater asthey progress toward resuming function on land.

Stroke patients sometimes pose special chal-lenges in the aquatic environment, where buoy-ancy must be counteracted to reduce tone in theantigravity muscles. When hip and knee extensorcontrol is poor, the patient may develop increased flexor tone in the poolin the affected lower extremity. Applying an ankle weight may help. Thetherapist also may need to provide manu al cueing for weight shifting andweight acceptance to help the patient stand on the involved leg. On land,patient progress can be affected by how much body weight can be sup-ported, but in the pool weight bearing is reduced to about 50% when thepatient is at waist depth.

If the therapist is unable to challenge a patient to work in an uprightposition, or needs to further isolate affected muscle groups, the supinefloating position can be utilized as in the Bad Ragaz Ring Method (a

Physical the rap y p afien f Kim Krafczyk infhe faci ii fy's warm w afer fhe rapy p o o i .

form of active or passive aquatic therapy moafter the principles and movement patterKnupfer exercises and proprioccptive neurcular facilitation). For example, weakness hip abductors can be facilitated and resistthis position, by perlbmiing uiiiping jacmovements . Common compensa t ions sutrunk lateral flexion can be discouraged easthe patient is focusing solely on one movenot a combination as is done when s tanAbdom inal stabilization can be challenged berally swaging the patient throu gh the waterverbal cues to tighten the trunk an d the hipstherapist's hold may be moved from the hthe ankles, or from the scapula to the elbowsthe shoulders abducted, to increase difficult

Working with children in the pool is lar to working with adults . Many deficittreatme nt objectives are the same; however,

ments need to incorporate creative play activities In order for chito remain interested and be compliant. Often, using the concepts odevelopmental sequence during treatments is helpful.

Whether working with children or adults , there are tools thaenhance rehab i l i ta t ion p rocess . For example , to enhance res istraining, webbed gloves can be used, as well as resistive tubing, hdumbbells , and weights . Strengthening and balance programs caaugmented by introducing the use of foam rollers, noodles , hydro band floatation belts. Underwater treadmills and bikes also add dimeto a therapeutic regimen. Whatever the tool or equipment, the ult

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AN EASIER A CCESSs an increasing number of therapists are creating exercise programs fortheir clients to take advantage of the tempered warmth and buoyanq'of aquatic therapies for their musculoskeletal issues, more individuals

such cases, pool accessibility becomes a concern.Fortunately, the A mericans With Di.sahilties A ct's Accessihility Guidelines for

artm ent of Justice, and are slated to go into effect as of March 2011. A s"accessibility" standard s are put info practice, mand ates will affectindividuals with mobility impairments. The complete docum ent,

'c'partmenf of lustice's ADA Standa rds for Accessihle Design (2010), can he readhtlp://\v\vw.acccss hoaid.go v/ada-ab a/ada standards-doj.cfm.

Ill recognition ol fhu new law, swimming pools with less than 300 linear feetprovitle one mea ns of access (in the form of either a pool lift or

iO O linear feet of pool wall must provide

date basic chair lifts, hoists, spinal boar ds, etc. Lifts are available as in-gro und

Product selections are multiple and varied, and p(X)l administra tors in the p ub-plannin g new pool facilities, or existing piwl revisions, must con-

Rogena Schuyler Silvcrman, editor, Rehab Management

Incorpora t ing such fools as weighfed bel fs. dumbbe l ls.and nood les , can enhance an aquaf i c t herapy reg imen.goal of the aquatic therapy program is to return the patient tostrength, mohility, and, ultimately, independence.

Continuing aquatics after patients are discharged from theirtherapy program has benefits for patienfs with neurological di.sorders. lust as fhey can be given exercises to do at home to coniplement physical therapy on land, aquatic therapy patients can con-tinue to work on their own in the ptxil. Patients need to he educatedon progressing in the program, which may include introducingmore challenging exercises for balance or increasing resistanceof current exercises. Family members also can be trained to assistthem. Many times, patients take advantage of joining the pool as afitness member once their therapy is complete, KM

Sara Sommer, MS, PT, is a therapist at Good ShepherdRcluibilitation N etwork in Atlentown, Pa. Somm er has practicedin aquatics for 6 years, working with orthoped ic and neurologiciilpatients. She attended Misericordia University. Formare inforniii-tion, contact R ehabEditorig'aHicd360.com.

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the soothing mfects of water

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