Intro to hydrotherapy

APTis a programme, using mechanical and thermal characteristics of water during partial or complete immersion, in combination with the effects of movement. It evokes short-term and long-term adaptational mechanisms of a person with a deranged biological system, using specific stimuli to create biological and thus therapeutic effects (NPI, 2005)

EWAC workshop
Aquatic Therapy State-of-the-Art Johan Lambeck , IATF
Djeddah , 11-10-2012

Network in which EWAC participates
Ecebat: 1st European Conference on
Evidence Based Aquatic Therapy
www.aquatherapy2013.org
Aquaoutcome: Erasmus IP
Ewac library: free articles, thesises, aquatic PP
http:www.ewacmedical.nlhtmlindex.php?page_id=133
Indirect connections:
Aquatic Health Benefits group of the WHO
APTI: Aquatic Physical Therapy International of the
WCPT
www.wcpt.orgapti
Association IATF www.halliwicktherapy.org

TH 11 The importance of the right depth.
Th11 is an adequate depth for e.g.
gait training.
The level of Th11 depends on the
length of the patient.

Aquatic (Physical) Therapy (APT)
APTis a programme, using mechanical and thermal
characteristics of water during partial or complete
immersion, in combination with the effects of movement.
It evokes short-term and long-term adaptational
mechanisms of a person with a deranged biological
system, using specific stimuli to create biological and
thus therapeutic effects (NPI, 2005)
A therapy programme utilising the properties of water,
designed by a suitably qualified physiotherapist
specifically for an individual to improve function, carried
out by appropriately trained personnel, ideally in a
purpose built, and suitably heated hydrotherapy pool
(ATACP, 2008)

Science EBM
Practice

Best research evidence
Clinically relevant research, often from the basis of
medicine, but especially from patient-centered clinical
research into the efficacy and safety of therapeutic,
rehabilitative, and preventive regimes.
EWAC library
Aqualit: 1700 references and pdfs about AT (KU
Leuven)

Aquatic exercise for treatment of knee and hip osteoarthritis

Bartels EM et al: Chochrane Library; 2009
Comparison: Aquatic exercise versus control after treatment - mixed
Outcome measure No.
studies No.
participants Effect size
SMD 95%CI
Pain 4 638 0.19 (0.04
0.35)
Function 4 648 0.26 (0.11 0.42)
Walking ability 2 355 0.18 (-0.03
0.39)
Stiffness 2 380 0.14 (-0.06
0.34)
Quality of life 3 599 0.32 (0.03
0.61)
Aquatic exercise appears to have some beneficial short-term effects for patients with hip
andor knee OA while no long-term effects have been documented.
No evidence was found for pain, walking ability or stiffness after end of treatment. No
radiographic evaluation was performed

Effects of aquatic interventions in children with neuromotor impairments
Getz M et al: Clin Rehabil; 2006
11 articles,
no RCT, 5
case reports
There is evidence to suggest that hydrotherapy might improve respiratory function in
children with cerebral palsy
In other aspects of activity and participation, further research of good design is needed

Evidence for effective AT
Hydrotherapy in neurology, e.g. MS, TBI, stroke,
paediatric neurology have received little attention from
researchers to date.
Hands-on techniques were generally not included in the
trials, thus no interactive practice of constantly
reassessing the patients responsive movements and
adjustment of the technique.
J. Geytenbeek, Physiotherapy (2002)

Patient values
The unique preferences,
concerns and expectations
each patient brings to a
clinical encounter and which
must be integrated into
clinical decisions if they are
to serve the patient.
patient is a swimmer

International classification of function, disability and health: ICF
(WHO 2001)
Health problems
Body function
and -structure
Activity
Context
Environmental Context
Personal

AT: level of body function, 1
ROM
Singlemultiple joints: spine and
peripheral joints
Bones: scapula and pelvis
Stability : see ROM
Muscle strength
Isolated groups, trunk, one side of the body, one
limb, all muscles etc

AT: level of body function, 2
Muscle tonus, see strength
Endurance
Isolated muscle groups, all muscles
Involuntary movements
Righting, equilibrium, supporting
Control voluntary movement functions
Complex voluntary movements
Supportive functions of arm or leg

AT: level of activity, 1
Change position
Lying down
Squatting
Kneeling
Sitting
Standing
Bending
Shifting COG
Rolling LRC
Rolling CRC
Maintain position
Lying
Squatting
Kneeling
Sitting
Standing
gliding

AT: level of activity, 2
Moving objects with the legs
Pushing and kicking
Hand and arm use
Pulling and pushing
Reaching and grasping
Walking and moving
Walking short distances, stop
and turn
Different surfaces and around
obstacles

AT: level of activity, 3
Moving around
Entry and exit of the pool
Running and jumping
Swimming
Moving with equipment
Scuba, mask and snorkel
Fins
Wetvest
Respiratory functions
Breathing and blowing

ICF and AT

AT is a stimulus therapy
Mechanical
Flow: turbulence
Buoyancy (pressure)
Waves
Thermal
Chemical

Unloading and resistance
0
10
20
30
40
50
60
70
80
90
100
ASIS Proc. Styl. C-7
stand
slow walk
fast walk
Harrison R, J of Physiotherapy 1987

Epstein, 1997

60
80
100 p0.05
Dry land
Water Dry land Water
120
p0.05
Systolic
(mmHg)
Blood pressure
Diastolic

Head-out Water Immersion
PO2 Expiratory flow rate Pulmonary compliance Efficiency
Central blood volume Chest wall pressure Abdom. compression
Pulmonary Vessel fill Chest circumference Diaphragm height
Diffusion capacity Airway resistance Lung volume & VC

Clinical Algorithm for Aquatic Activity by Heart failure
Cardiomyopathy
Older than 6 weeks
Myocarditis
Older than 6 weeks
Q-wave MI
Functional State?
NYHA lV NYHA ll NYHA lll
No immersion Enjoy the pool
SV 30%
No Ye s
Wait
Ye s
Wait
No
No Ye s
Becker BE: 2010 adapted from Meyer K et al: 2008

Physiologically
high impact
50
70
90
110
130
150
170
190
2.55 2.77 3.02 3.31
HR (bpm)
speed (kmh)
water
treadmill
Whitley & Schoene, 1987

Heart rate differences

Shoulder muscle activation during aquatic and dry land exercises in nonimpaired subjects

Kelly B et al: J Orthop Sports Phys Ther; 2000
Muscle Test 30S 60S 90S
Supraspinatus Land
Water 16.68
3.93
P=.015 17.46
5.71
P=0.15 22.79
27.32
P=0.73
Infraspinatus Land
Water 11 . 1 0
2.28
P=.0325 10.76
2.89
P=.0524 15.03
21.06
P=.5566
Subscapularis Water
Land 5.96
1.49
P=.0072 6.83
2.26
P=.0346 7.45
10.73
P=.2421
Anterior
deltoideus Water
Land 15.88
3.61
P=.0047 18.82
4.49
P=.0273 22.09
32.83
P=.3273
Percentage of maximal voluntary contraction

So: what does water do?
Water:
Provides proprio- en exterosensory input
Provides an equilibrium problem
Offers variation
Stimulates activity
Motivates (often)
Has physiological effects

Advantages
Water is a pain reducing environment
Stiffness of connective tissue decreases
No crutches have to be used
Water gives variable resistance
Water is safe and gives thinking time
Water provides rhythm and directs motion
Impact: mechanically low physiol. high

Aquarobic Effect on BMD, Fitness & Well-being @1 year
-1,2%!
,0%!
5,6%!
16,2%!
7,1%!
8,4%!
-5%!
%!
5%!
10%!
15%!
20%!
Bravo, Gauthier et al, Arch PMR, 78, 1375-80,1997
77 females, ages 50-70, 1 hourday, 3 days per week, 12 months

Osteoporosis
N = 97 healthy menopausal Japanese women
Veterans: 35 months exercising 2-3w
Newcomer: 3.5 w start 2-3w
Control: no exercise
Results:
BMD Veterans Newcomer Control
Start 0.832 gcm 0.766 gcm 0.783 gcm
1 Year +0.27% +0.75% -2.72%
Tsukahara N et al: J Nutr Sci Vitaminol (Tokyo) 1994

Cider A, Schaufelberger M, Sunnerhagen KS, Andersson B, Eu J Heart Failure
5 (2003) 527-535
25 pts with CHF, 8 weeks training at 3 times per week

Case: adult CP diplegia
3wk, 10 weeks vigorous AT
Resistive ex. LE, waterwalking, stretch
Unconditioned, short distance walking with calipers
pretest: 20m Posttest: 140m
Endurance increased with 450%
Walking: farther and faster
Strength increased with 100%
Independent stancewalk without calipers
Functional reach
Pretest 0 inch, no independent stance
Posttest direct: 7 inch
Posttest 11 weeks: 6 inch
Thorpe & Reilly, JAPT 2000

The influence of Ai Chi on balance
and fear of falling among older adults

Rita Teixeira1, Laura Prez2, Johan Lambeck3, Francisco Neto4

Intragroup p-values Intergroup p-values Intergroup ES (d)
Ai Chi Controls
FES 0.306 0.01 1* 0.001* 1.5
POMA total 0.001* 0.254 0.002* 1.3
POMA balance 0.001* 0.230 0.001* 1.4
POMA gait 0.001* 0.202 0.004* 1.1
* = signi fic ant , = 0.05

Inclusioncriteria
for hydrotherapy
There is a generalised problem
with multi-local involvement
No possibility to enhance physical
fitness on dry land
There is a lower extremity
problem, weight reduction is
needed
The autonomous system needs
tuning in a stress inhibiting
environment

Exclusioncriteria
The contract ends
The normvalues have been
reached
The goals have been met
There are new contra-indications

Methods
Halliwick
Bad Ragaz Ringmethod
ATrelax
Conventional
hydrotherapy
Clinical Ai Chi, obstacles
Manipulative therapy in
water
Underwater elongation of
the spine
Fitness in water, incl
swimming
Feldenkrais
Hubbardtanks etc
.

Halliwick Mental
Adjustment

Balance Control

Movement
Water
Specific
Therapy

(Adapted) Aquatics for
Sports and Leisure

Obstacle course Ai Chi

Bad Ragaz Ring M AquaTrelax

Halliwick: Ten Points
Mental Adjustment
Sagittal Rotation Control
Transversal Rot. Control
Longitudinal Rot. Contr.
Combined Rot. Contr
Upthrust
Balance in Stillness
Turbulent Gliding
Simple Progression
Basic Movement
M A and Disengagement
Balance Control and dis
Movement and dis.

Sagittal Rotation Control
Can be used to: facilitate righting reactions
facilitate equilibrium reactions
automatic movements in general
lengthening of the trunk or
stabilization of joints

BIS: oblique abdominal activation

Voluntary and involuntary movements
Hold the kickboard:
Active movement, pre setting,
double task
Hold the kickboard:
Active movement, reactive adaptation to
disturbed balance, double task

Close chain and open chain
Close chain situation:
Five fix points, relative stable position, little
body control
Open chain situation:
No fix point, free movement, full body
control, instable

The Bad Ragaz Ring Method

Aqua-T-Relax

Thank you very much for your attention

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