August/September 2005

Catching the Wave

By Ruth Sova, MS, ATRIC

Aquatic therapy is growing in popularity, offering therapists numerous ways to effectively provide rehabilitation for a variety of conditions

The popularity of aquatic exercise is growing worldwide at an incredible rate. In the United States alone, aquatic exercise has grown from approximately 500,000 participants 7 years ago to more than 4 million today.¹ With that growth a resurgence in aquatic therapy has occurred.²

Aquatic therapy is being used for patients with, among other conditions, sensory disorders, limited range of motion (ROM), weakness, incoordination or pain, and spasticity and sensory awareness. Balance deficits, motor skill deficiencies, and circulatory insufficiency are also being helped in the pool.

How can water serve so many? There are five primary reasons why aquatic therapy is beneficial.

FIVE BENEFITS
Water diminishes the effect of gravity. When submerged to shoulder depth, the body experiences a 90% apparent weight loss.³ Exercising in a full weight-bearing medium often limits active range of motion. In the water you can exercise without joint stress and increase flexibility because buoyancy assists movements. Limitless joint angles and planes of movement can be accomplished, many of which could not be achieved on land.

Patients rehabing in the water also experience decreased perception of body weight. This makes them feel able to accomplish more.

Because of buoyancy, the pool is perfect for those experiencing pain. Water decreases joint compression forces and force reactions, and therefore lessens arthritic, back, and chronic pain, or pain caused by surgery or injury.⁴

Exercise is also less painful because of hydrostatic pressure, which tends to decrease edema and increase circulation to deep muscle groups.³

Hydrostatic pressure also assists in stabilizing unstable joints. Water supports the body and often eliminates the need for walking aids. It slows a possible fall and therefore allows people with slow reaction time to recover. This ease of movement in the pool is a morale builder and allows for success.

Hydrostatic pressure on the chest wall stimulates chest expansion and deeper ventilation. This increases cardiorespiratory activity.

Muscular strength and tone will improve from working against the variable water resistance. To achieve similar results on land, highly sophisticated weights would be necessary. The more force used against the water, the more "weight" the water carries.^5,6

Moving through the water resistance requires co-contraction of the abdominal and back muscles and therefore teaches central stabilization. Balance, proprioception, and coordination can all be improved.

Exercise in the water can have a positive effect on osteoporosis and bone density. The sensory stimulation of the water increases proprioception, and promotes and allows for greater relaxation.

The pool is the site of normal recreational activity and therapy will be viewed as "fun," not work, for your clients. Much of the pain related to therapeutic movement is gone when working in the pool.

Can you take traditional protocols into the pool and see results? Sure you can, but you will have the best results by using some of the tried-and-true aquatic techniques, such as ai chi, Halliwick, Bad Ragaz, the Burdenko Method, and UCT.

AI CHI
In this exercise, have your patient stand in a wide stance with arms resting easily at the water surface in front of them. Have them inhale diaphragmatically as they horizontally abduct their arms while turning their palms up. Have them exhale as they horizontally adduct their arms while turning their palms down.

The benefits of this technique include improved balance, decrease in stress, and improved cognitive focus.

Ai chi is indicated for patients experiencing pain, limited ROM, balance deficits, and stress-related illnesses.

Ai chi is best done in 88° or warmer water and can be done in groups or one-on-one. The focus is on the breath.

HALLIWICK
In this technique, have your patient lie supine at the water surface. Then have them lift their right hand out of the water without rolling to the right. Then have them return their hand to the water, look to the right without rolling to the right, and return to looking straight up.

The benefits of Halliwick include improved balance. It is indicated for patients with developmental disability, cerebral palsy, and balance deficits. Halliwick is also great for children. It can work with any water temperature, and can be used with groups or one-on-one.

BAD RAGAZ
In this exercise, the patient lies supine with buoyant equipment in necessary places for neutral spine.

The therapist stands at the patient's feet, then places the dorsal aspect of the feet on her abdomen and asks the patient to bend and then straighten their knees. This technique is beneficial because it is pre-weight bearing.

Bad Ragaz is indicated for patients with back/trunk stabilization problems, who need muscle reeducation, and who have tone reductions.

Bad Ragaz is mostly used in warm—92°—water and is a one-on-one tecnique for muscle reeducation. Advanced application uses proprioceptive neuromuscular facilitation patterns.

THE BURDENKO METHOD
With the Burdenko Method, the patient lies prone at the water surface, holding a buoyant bar or noodle in two hands—shoulder width apart—in front of their chest, and presses down.

The benefits of this method include strengthening and endurance. It is indicated for athletes, and patients with hip/knee and back/trunk stabilization, and balance, deficits.

The Burdenko Method works fine in warm—92° to 94°—water but is excellent in cooler—86° to 88°—water. It can be used in groups or one-on-one.

UNPREDICTABLE COMMAND TECHNIQUE
In the unpredictable command technique (UCT), the exercise can be performed under the direction of a therapist using a number of movements, such as those in the following sample session:

"Move your left arm out to the side and bend the elbow. Straighten the left elbow as you move your right arm out to the side and turn your head to the left. Bring your right arm forward and look down toward your right armpit. Make a fist with your right hand. Bring the left arm forward and make a fist with the left hand. Look straight ahead. Open your hands and clasp your fingers together. Gently twist your trunk to the left to move your arms. Bring your arms forward and unclasp your hands. Lower your arms. Turn your head to the right and sidestep left two steps. Look down toward your left armpit and sidestep right three steps. Look straight ahead and walk backward five steps. Turn 90° to the right and walk backward. Turn 180° to the right and then walk sideways to the right. Sidestep to the left and turn your head to the left. Keep sidestepping to the left and look to the right. Sidestep to the right, turn your head, and look forward. Keep sidestepping to the right, and shrug your shoulders up and forward. Walk backward and shrug your shoulders up and back. Walk forward and pull your shoulders back and down. Stop walking. Move your left leg out to the left and bring it back to the starting position. Move your right leg forward and bring it back to the starting position. Do a semisquat and return to a standing tall position. Move your left leg back and turn your head to the right. Bring both your feet and head back to the starting position. Move your right leg forward and turn your head to the right. Bring both back to the starting position. Take a deep breath, filling the belly first, then raising the arms and filling the chest. Let the air out as you begin walking backward."

The benefits of UCT include neuro integration of motor skills. It is indicated for geriatric patients and patients who have Parkinson's disease, cerebral palsy, or balance deficits or are recovering from a cerebrovascular accident.

UCT works especially well for clients with motor skill deficits and can be done in any position—sitting, lying, or standing. It can be used in groups or one-on-one.

EDUCATION AND CERTIFICATION
Additional information and education about these aquatic therapy methods are available at the Aquatic Therapy & Rehab Institute's Web site (www.arti.org). To learn about certification in aquatic therapy, go to the International Council on Aquatic Therapy and Rehabilitation Industry Certifications Web site (www.icatric.org).

Ruth Sova, MS, ATRIC, is president of the Aquatic Therapy & Rehab Institute Inc, Port Washington, Wis.

REFERENCES

1. Terret T. History of aquatics fitness. AKWA. July 2002:38-39.
2. Krist P. AEA survey results. AKWA. January 2002:5-6.
3. Ruoti R, Morris DM, Cole AJ. Aquatic Rehabilitation. Philadelphia: Lippincott Williams and Wilkins; 1997:15-55.
4. Meyer R. Deep water exercises and pain management. AKWA. November 1999:16-20.
5. Arient J. Meniscus injuries. Aquatic Therapy Journal. January 2002:23-29.
6. Frank J. The bone density debate. AKWA. November 2000:35-36.

RESOURCES
Becker B. The physical principles behind aquatic therapy. Aquatic Therapy Journal. June 2001:11-17.

La Tourette D, Meno J. Bad Ragaz. Aquatic Therapy Journal. January 2000:13-16.

Taucher G. The Burdenko Method. Aquatic Therapy Journal. January 2001:9-17.

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