By Cathy H. Ciolek, PT, GCS, and Paula Richley Geigle, PT, PhD
Age and Water Do Mix Age-related deficiencies in the cardiopulmonary, neuromuscular, and musculoskeletal systems can be effectively addressed with aquatic physical therapy In the next 30 years, a near doubling of the population over 65 is expected. With this significant increase, the elderly are expected to represent 20% of the entire United States population.1 Among the elderly in 1997, only 4.5% resided in nursing homes.2 Thus, 95% of this population still live in the community and may seek outpatient (including aquatic) physical therapy services for impairments resulting from normal aging and/or pathology.2 Cardiopulmonary Opportunities Normal aging changes of decreased arterial circulation, heart volume, cardiac output, and maximum stroke volume may be positively impacted by using hydrodynamic principles. Hydrostatic pressure increases circulatory system return, and buoyancy acts to reduce gravity forces, affording the client cardiopulmonary opportunities that might be difficult to complete on land.3 Immersion in warm water facilitates peripheral circulatory dilation, which may increase blood flow to the extremities with less pump pressure. Buoyancy provides support for trunk and extremity movements that do not exist on land, allowing increased cardiopulmonary opportunities for clients with limited physiologic reserve. The constant of hydrostatic pressure that exists as a principle of the water can be helpful in assisting in edema reduction but in clients with decreased vital capacity of less than 1.5, the constant hydrostatic pressure can exceed the ability of the lungs to stay inflated and the patient's lung or lungs could collapse. Spirometry or more advanced lung function testing is needed for individuals who have limited vital capacity prior to going into the pool or these patients should be treated in supine-floating with face up instead of prone or vertical position, so the hydrostatic pressure does not press on the lungs, eg, the chest rises and falls against air, not water.4 To address limited cardiopulmonary function, many aquatic interventions are possible such as Halliwick,5 Bad Ragaz6 therapeutic exercise, and functional activities. The most important aquatic component is to incorporate activities that include active and/or active assisted movements to provide cardiopulmonary opportunities by optimally using hydrodynamic principles. Boosting Neuromusculature Decreased motor neurons, decreased neural glucose utilization, decreased reaction times, and altered level of neurotransmitter production may be addressed in an aquatic program via buoyancy, hydrostatic pressure, and viscosity. Buoyancy support along with the sensory input from hydrostatic pressure and viscosity promote potential increased neural firing while providing an environment that is more stable and facilitates increased client neuromotor efforts. With practitioner direction, a client is able to focus on timing and recruitment of muscle groups during functional activities with increased sensory input from the aquatic environment. The turbulence of the water creates an incongruency between the vestibular and visual systems. For clients with mild to moderate difficulty achieving collaboration of these two systems, the aquatic environment appears to encourage a unified functional outcome. The most obvious physical improvement is typically seen in client upright stability. A precaution does exist with clients who demonstrate severe vestibular dysfunction. Turbulence, even mild, may be overwhelming for involved vestibular systems and may cause nausea and/or vomiting. Therapeutic exercise, Bad Ragaz,6 functional activities7, core stabilization, and balance activities may be used individually or in combination to treat neuromuscular issues. Stressing the Musculoskeletal System A decrease in muscle mass, muscle fibers, and muscle strength (all greater in type II fibers) can create a functional weakness for aging clients. In addition, a loss of functioning motoneurons, decreased efficiency at neuromuscular synaptic junctions, and a decrease in bone density can also occur with normal aging. The physical therapist applying hydrostatic pressure, turbulence, and buoyancy principles in an aquatic treatment regime may minimize these aging changes by providing opportunities to therapeutically stress the musculoskeletal system in a supportive but challenging environment. In addition, submersion in warm water provides thermal opportunities to address the decreased length of ligaments and tendons while functioning in proper alignment and with reduced velocity. Therapeutic exercise,8 Bad Ragaz,6 Halliwick,5 functional activities, core stability, and balance activities are potential intervention choices to address the aging musculoskeletal changes. Outcome Measures All aquatic physical therapy interventions require land-based outcome measures. As with land-based outcome measurement, each assessment tool is selected to optimally measure specific changes in function. For clients with cardiopulmonary limitations, outcome tools could include but are not limited to the Borg perceived exertion scale (RPE), vital signs, the 6 minute walk test, O2 saturation, and peak expiratory flow rate (PEFR).9 All of these tools provide time- and cost-efficient means to investigate the outcome of aquatic intervention. Potential outcome tools for neuromuscular involvement include timed functional activities, handheld dynamometers, isokinetics, stand and reach, Berg balance scale, get up and go, balance master, gait mat, Tinetti, foam and dome, and Wisconsin gait scale.9 To assess intervention impact on musculoskeletal issues, the Oswestry, shoulder assessment form, Harris hip scale, dynamometers, Western Ontario and McMaster osteoarthritis index, Barthel, Fugel-Meyer, functional abilities confidence scale, and sickness impact profile are possible outcome measurement tools.9 Selection of outcome measurement tools for all three of these preferred practice categories is an essential component of the patient/client management model. The intent of aquatic physical therapy with an elderly population parallels the Healthy People 2010 goals of: increasing quality and years of life and eliminating health disparities (between generations).10 References 1. Administration on Aging, US Department of Health and Human Services. A profile of older Americans: 2000. Available at: www.aoa.dhhs.gov. 2. Health, United States, 1999 With Health and Aging Chartbook. Hyattsville, Md: National Center for Health Statistics; 1999. 3. Becker BE, Cole AJ, eds. Comprehensive Aquatic Therapy. Newton, Mass: Butterworth-Heinemann; 1997. 4. Cirrullo JA. Considerations for pool programming and implementation. Orthopedic Physical Therapy Clinics of North America. 1993;3:95-110. 5. Lambeck J, Stanant FC. The Halliwick concept, part II. Journal of Aquatic Physical Therapy. 2001;9(1):7-12. 6. Ruoti RG, Morris DM, Cole AJ. Aquatic Rehabilitation. Philadelphia: Lippincott-Raven Publishers; 1997. 7. Simmons V, Hansen P. Effectiveness of water exercise on postural mobility in the well elderly: an experimental study on balance enhancement. Journal of Gerontology: Medical Sciences. 1996;51(A):M233-M238. 8. Schrepfer RW, Babb RW. Manual techniques of the shoulder in aquatic physical therapy. Journal of Aquatic Physical Therapy. 1998;6(1):11-16. 9. Lewis CB. Tool Box I and II. McLean, Va: Learn Publications Inc; 1997. 10. US Department of Health and Human Services. Healthy People 2010. Available at: www.health.gov/healthypeople/default.htm. Cathy H. Ciolek, PT, GCS, is clinical physical therapist with Kendal-Crosslands Communities in Kennett Square, Pa. Paula Richley Geigle, PT, PhD, is a faculty member at the Institute for Physical Therapy Education, Widener University, Chester, Pa, and a clinician for Therapy Services of Delaware, Hockessin, Del.
